Compliance Programs Matrix

 




Organization
MD Anderson Cancer Center
Trillium Health, Inc


How internal monitoring and auditing is conducted
The chief compliance and ethics officer (CCEO) facilitates 

internal auditing and monitoring at MD Anderson Cancer Center (MDAnderson.org, n.d.). The

CCEO works in concert with specific members of the executive institutional compliance committee (EICC). The audits are done periodically and aim to evaluate the adherence to organizational policies and relevant federal laws. Both interviews and documentation review are used in the auditing process.
The compliance officer 

conducts internal auditing and monitoring at Trillium Health, Inc.


How compliance and practice standards are implemented
At MD Anderson Cancer Center, the CCEO works in concert with organizational compliance committees to implement the compliance and practice guidelines 

(MDAnderson.org, n.d.).
The chief compliance officer and the compliance committee at Trillium Health, Inc. 

collaborate to implement compliance and practice guidelines. The committee’s major role is to

provide pertinent guidance and advice to the chief compliance officer (TrilliumHealth.org, n.d.).

This team evaluates regulatory requirements and policies to ensure that they are harmonious

with each other.


The designated compliance officer (or the person designated to be the contact for compliance matters), who that person reports to, and their relationship to the organization’s governing board
The Chief compliance and ethics officer (CCEO) is the designated compliance officer at 

MD Anderson Cancer Center. The CCEO holds the position of the vice president of the EICC

(MDAnderson.org, n.d.). The CCEO reports directly to the president of the EICC. Furthermore,

the CCEO reports administratively to the chief regulatory officer, who holds the position of the senior vice president of the EICC (MDAnderson.org, n.d.).
The chief 

compliance officer (CCO) is the designated compliance officer at Trillium Health, Inc

(TrilliumHealth.org, n.d.). The CCO is the vice president of regulatory and compliance affairs.

The CCO reports directly to the compliance committee and board of directors.


How employees are trained and educated to model compliant behaviors
Employees at MD Anderson Cancer Center must undergo a compulsory annual training 

program. To enforce compliance, attendance records and educational material are kept and

updated (MDAnderson.org, n.d.). Employees who fail to fulfill the annual educational programs

are subjected to corrective action.
Employees at Trillium Health, Inc. should 

complete designated educational programs annually upon hiring and continuous medical

education programs (TrilliumHealth.org, n.d.). The CCO enforces compliance.


How violations or offenses are detected, reported, and corrected
The CCEO initiates the investigation of violations and offenses at MD Anderson 

Cancer Center. The other stakeholders involved in these investigations are legal experts.

After that, the findings from the investigations are reported to the EICC. Recommendation from

the investigative team and approval by the EICC determines the corrective action

(MDAnderson.org, n.d.). Corrective actions are stipulated in the organization’s practice standard.
Supervisors and managers initiate investigations at Trillium Health, Inc. 

Findings from these investigations are presented to the CCO, who may work in concert with legal

experts to establish the severity of the offense (TrilliumHealth.org, n.d.). Organizational

procedures are used to enforce corrective action.


How lines of communication with employees are developed
MD Anderson Cancer Center’s compliance plan has not developed an elaborate line of communication with employees 

(MDAnderson.org, n.d.).
Trillium Health, Inc. has adopted an open line of communication with employees. Both 

verbal and non-verbal communication is used to convey information. Additionally, employee

anonymity is maintained. Trillium Health, Inc. has embraced open communication via email,

fax, and telephone (TrilliumHealth.org, n.d.).


How disciplinary standards are enforced
Supervisors, managers, and human resource managers implement 

disciplinary standards at MD Anderson Cancer Center based on its policies.
Disciplinary standards are enforced within thirty days after receiving the findings of the 

investigation at Trillium Health, Inc. The supervisor and vice president of human resources

enforce disciplinary standards (TrilliumHealth.org, n.d.). Additionally, the president and the

chief executive officer may suspend an employee to avert the infringement of the standard of

conduct during investigations. Disciplinary action includes dismissal, counseling, warning, or

suspension.



Executive Summary
The matrix stated above compares the compliance program documents of two healthcare facilities: Trillium Health, Inc., found in New York, and MD Anderson Cancer Center, found in Texas. Data demonstrates that internal auditing and monitoring at MD Anderson Cancer Center is accomplished by the chief compliance and ethics officer (CCEO) (MDAnderson.org, n.d.). The CCEO collaborates with members of the Executive Institutional Compliance Committee (EICC) to conduct periodic auditing and monitoring. On the other hand, internal auditing and monitoring are accomplished by the compliance officer at Trillium Health, Inc. (TrilliumHealth.org, n.d.). The compliance officer partners with stakeholders in all departments to identify significant deviations to be addressed promptly. Both auditing and monitoring programs are effective. The program by Trillium Health, Inc. is most likely to yield better outcomes because it engages stakeholders at the departmental level.

Auditing and monitoring at both healthcare facilities facilitate the implementation of compliance and practice standards. In both facilities, interdisciplinary collaboration is key to the implementation of these standards. The designated compliance officer is responsible for implementing these standards in both facilities. MD Anderson Cancer Center’s CCEO works harmoniously with compliance committees to implement the compliance and practice standards (MDAnderson.org, n.d.). Additionally, the CCEO reports directly to the president of the EICC and the chief regulatory officer. On the other hand, the chief compliance officer (CCO) and the compliance committee facilitate the implementation of compliance and practice guidelines at Trillium Health, Inc. The CCO reports directly to the compliance committee and board of directors. In the context of implementing compliance and practice standards, the compliance committee offers an advisory role to the CCO.

Further evaluation indicates that perpetual employee training equips them with relevant knowledge and skills. Notably, training and education enable employees to comply with organizational codes of conduct, policies, protocols, and federal and state regulations (TrilliumHealth.org, n.d.). The training program should be offered in different languages to eliminate the possibility of language barriers (MDAnderson.org, n.d.). Additionally, elaborate training programs should specify the mandatory sessions to be covered. For example, MD Anderson Cancer Center enforces mandatory annual training and education programs, whereas Trillium Health, Inc. enforces mandatory annual training upon hire and as needed via continuous medical education programs. The institution of corrective actions helps to increase compliance levels.

Adopting an open line of communication creates an honest and trustworthy environment in the workplace. It allows stakeholders at various levels of the organization’s hierarchy to give their perspectives on the compliance program. As such, prompt actions are taken to address any concerns (TrilliumHealth.org, n.d.). This averts the likelihood of conflict among stakeholders and promotes interdisciplinary collaboration. Open communication can be achieved using various strategies. For example, Trillium Health, Inc. uses email, fax, and telephone and upholds employee anonymity and confidentiality to create and sustain an open line of communication.

Non-adherence to the compliance program warrants disciplinary action. Thorough investigations should be conducted before taking disciplinary action. Organizational policies should have disciplinary standards to be enforced strictly to avoid the risk of bias. For example, Trillium Health, Inc. enforces disciplinary standers that include dismissal, counseling, warning, or suspension. Additionally, these standards are enforced within 30 days of receiving investigative findings.

In contemporary practice, healthcare facilities should develop a compliance program that fosters perpetual employee training and education. This will create a competent workforce that adheres to the policies and procedures of the organization (The University of Texas at Dallas.edu, n.d.). Additionally, open communication creates an honest environment and promotes interdisciplinary collaboration (The University of Texas at Dallas.edu, n.d.). Disciplinary action should be executed uniformly based on the policies and standards.
References
MDAnderson.org. (n.d.). MD Anderson Institutional Compliance. https://www.mdanderson.org/content/dam/mdanderson/documents/about-md- anderson/about-us/compliance-program/Hospital%20Compliance%20Plan.pdf