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BENCHMARKING YOUR POLICY MANAGEMENT PROGRAM

Exclusive Health Care Research Study Results

October 21, 2015

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Agenda

Introduction by Sean Jolie, AHA Solutions, Inc.

Benchmarking Your Policy Management ProgramExclusive Health Care Research Study Results

Mary Bennett, R. Ph.,Vice President, Advisory Services,NAVEX Global

Question and Answer Session

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AHA SOLUTIONS, INC. – WE KNOW HOSPITALS.

As a subsidiary of the American Hospital Association, AHA Solutions, Inc. is focused on improving the operational performance of our nation’s hospitals. Through a broad variety of services, we provide hospitals with field leadership, education and research.

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ABOUT THIS WEBINAR

This educational event has been developed by AHA Solutions, Inc. together with NAVEX Global. We thank this organization for its willingness to share its expertise.

Policy & Procedure Management Software & Services from NAVEX Global have earned the exclusive Endorsement of The American Hospital Association

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P R E S E N T E D B Y

Vice President, Advisory Services NAVEX Global

Mary Bennett, R.Ph. is vice president of NAVEX Global's Advisory Services team and a pharmacist by training. Mary previously served as vice president in the Compliance and Integrity office at Caremark, where she implemented the requirements of one of the first government agreements in healthcare. Mary works across all industries for the Advisory Services team, creating and facilitating award-winning training programs, conducting large and small program assessments, developing compliance communications and helping clients develop best practice programs from the ground up.

Mary Bennett, R.Ph.

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B E N C H M A R K R E P O R T

Benchmarking Your Healthcare Policy Management Program

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Agenda

The Status of Policy Management in Healthcare

Hidden Costs of Policy Management

Key Findings• The State of Policy Management Today in Healthcare

Organizations

• Processes & Tools for Policy Management

• Addressing Legal & Regulatory Policy-Related Risks

Key Takeaways

Q&A + Additional Resources

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SNAPSHOT

Policy Management Benchmark Report Statistical• First and largest report of its kind by an independent research company• Collected anonymously• 179 respondents from healthcare providers and healthcare services

companies (no respondents from pharma)• Respondents include:

C-Suite (12%) Senior Managers/Directors (36%) Managers (33%) Non-Managers/Other (18%)

• Respondents represent small, medium and large companies (roughly 1/3 of each)

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Learning Objectives of Our Policy Management Research

• What are E&C professionals in healthcare doing to manage policies today?

• Are some approaches more effective than others?

• Is there a best way?

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Our Ethics & Compliance Ecosystem

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Our Ethics & Compliance Ecosystem

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Policy Lifecycle Process Should be Efficient, Repeatable, Auditable and Defensible

PUBLISH / ARCHIVECREATE

Draft Reviewers Approval Distribute Certification

Queue for Later Release Publish

Document owner

Archive

Policy draft Subject Matter Experts Approver

Users

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Role of Policy Management in Healthcare Today

• Policy management is a maturing business function.• Policy programs not only control compliance risk, but support

patient safety.• In healthcare, a robust policy management program is no longer

optional, it is essential

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Hidden Costs of Policy Management

• Policy Training and Communication

Delivering training sessions Policy sign-off attestation

• Increased Risk of Fines & Legal Costs

Cost of regulatory actions Litigation and settlement costs

• Policy Management Document creation/ editing Reviews /approvals Audit/ accreditations Data collection, analysis,

and reporting

• Current Process Costs Searching & retrieval time IT cost reductions

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Survey Question

What is your top policy management challenge? Improving version control, reducing policy

redundancy and inaccuracy Meeting the demands of legal compliance with

regulations/aligning policies with regulations Training employees on policies Providing quick & easy access to the most current

policies and procedures Creating and updating documents easily Other

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Top Policy Management Challenge: Training

Source: NAVEX Global's 2015 E&C Healthcare Policy Benchmark Report

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Best Practice: Training on Policies

• Training is especially difficult in healthcare organizations where time away from clinical responsibilities may impact patient care.

• The most successful organizations create multiyear education plans—a roadmap

• Microlearning can also help by delivering laser-focused training on key issues without using up too much seat time.

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33% of Respondents Don’t Have a Dedicated Policy Management Budget

Source: NAVEX Global's 2015 E&C Healthcare Policy Benchmark Report

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Survey Question

Do you have a designated owner for your policy management Program?

Yes No I don’t know

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Policy Management Budget Owners Vary

Source: NAVEX Global's 2015 E&C Healthcare Policy Benchmark Report

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Best Practice: Defined Budgets & Ownership are Imperative

• If your policy management program or budget has no specific owner consider advocating for a dedicated budget and an owner.

• This will allow the owner to: calculate program ROI, and advocate with leadership to

ensure the program has the resources it needs to succeed.

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Survey Question

Do you currently use an automated policy management system in your organization?

Yes, we do No, it has not been a priority No, but it is now a priority

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46% of Respondents Use Policy Management Software

Source: NAVEX Global's 2015 E&C Healthcare Policy Benchmark Report

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Best Practice: Centralized, Automated Approach Creates Peak Effectiveness

• Piecemeal or patchwork approaches cannot achieve ambitious policy program goals.

• While better than manual processes, tools that are not built expressly for policy management can introduce unnecessary risk into policy management processes.

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In-Person Training Top Choice for Ensuring Policy Comprehension

Source: NAVEX Global's 2015 E&C Healthcare Policy Benchmark Report

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Best Practice: Ensure Comprehension Using a Variety of Methods Related to Risks & Roles

• Use a variety of methods to ensure that those with the highest risks understand the policies that relate to their role.

• Integrate policies into… – Training – Hotline/Web Intake

Reporting Processes – Case Management

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55% of Respondents Do Not Measure Policy Management Program Effectiveness

Source: NAVEX Global's 2015 E&C Healthcare Policy Benchmark Report

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Best Practice: Implement Effectiveness Strategy

Measurement is key for: – Making a case to auditors &

regulators that your program is actually working

– Proving the value of your program— and getting the necessary resources for program excellence

– Continuously improving

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Survey Question

Do you currently have guidelines for creating and distributing policies?

Yes No I don’t know

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26% of Respondents Have No Guidelines for Creating & Distributing New Policies

Source: NAVEX Global's 2015 E&C Healthcare Policy Benchmark Report

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Nearly Half of Respondents’ Policies are Reviewed Regularly for Compliance with Laws & Regulations

Source: NAVEX Global's 2015 E&C Healthcare Policy Benchmark Report

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Best Practice: Control Policy Creation & Revision with Documented Guidelines

• Organizations without guidelines risk creating a decentralized web of policies that cannot be updated, enforced or overseen.

• This creates massive risk, and can result in a dangerously confusing experience for employees and others.

• Likewise, a set review schedule is critical. Policies must keep up with changing laws, regulations, organization size, technology, clinical guidelines and work habits.

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Survey Question

How many of your policies are reviewed by legal counsel?

Some Most All I don’t know

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Only 15% of Respondents Indicate Their Legal Team Reviews All of Their Policies

Source: NAVEX Global's 2015 E&C Healthcare Policy Benchmark Report

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41% of Respondents: Policies Have Come Under Review in Legal or Regulatory Action or Defense

Source: NAVEX Global's 2015 E&C Healthcare Policy Benchmark Report

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Best Practice:Be Prepared for Legal Action

• Every organization must be prepared to face legal action related to its policies.

• This includes establishing consistent processes for input from legal counsel, record keeping and documentation and regular policy review and attestations.

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66% of Respondents Require Attestation on Policies from Internal Employees

Source: NAVEX Global's 2015 E&C Healthcare Policy Benchmark Report

Initial Attestation Re-Attestation by Employees

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Best Practice:Attestations

• Healthcare organizations may be behind the curve in recognizing that the legal risk of misconduct vendors and employees is comparable.

• Attestations help prove that employees received and understood a policy, but also demonstrate commitment to a strong compliance culture

• Attestations also help establish key defenses if violations occur.

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Comparing Program Effectiveness With & Without Software

Policy Program Imperatives

Rated Program Excellent or Very Good

With Software

Rated Program Excellent or Very Good

Without SoftwareDifferential

Defensibility 34% 7%Those with software

rated themselves 5 times as effective

as those without.

Compliance 51% 11%

Workflow 36% 7%

Access 69% 29%Those with software

rated themselves 2 times as effective

as those without.Communications 33% 17%

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Best Practice:Policy Management Software

• Respondents indicated that policy management software has a significant, positive impact on their programs.

• While the presence or absence of policy management software alone is not a predictor of an effective program, the data indicates that organizations should consider policy management software as a way to improve their overall policy management efforts.

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Data-Driven Key Takeaways

• Define a comprehensive, ongoing, risk-based approach• Understand your universe of risks• Assess your vulnerabilities• Track program effectiveness• Establish training on policies that address key risk areas• Align resources with policy management efforts• Be ready to handle legal action• Implement automated software

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Survey:I’d Like to Talk With an Expert About…

Assessing the effectiveness/defensibility of my current program. Getting an estimate of what my current policy management approach is

costing my organization. Training on policies/integrating policies into training. Integrating policies into my case management system. Determining whether my policies are aligned with my risks/reviewing my

current code of conduct or key policies. Managing policy risks related to third parties/vendors. Other compliance program challenges (optimizing training, third party

due diligence, case management, or other issue).

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WE INVITE YOUR QUESTIONS!

To submit a question, please type your question on the left-hand side of your presentation screen.

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Additional Thought Leadership Resources

Policy Management Thought Leadership www.navexglobal.com/resources>>

• eBook: The Definitive Guide to Policy Management for Healthcare

• On-Demand Webinar Series: AHA Policy Management Bootcamp

• Blog Article: How Do I Know If My Policy Management System Is Working?

Policy Management Software SolutionsLearn about our best-in-class policy management software solution, PolicyTech www.navexglobal.com/PolicyTech>>

Expert Consulting Solutions

Get help addressing policy and program gaps with our experts: www.navexglobal.com/AdvisoryServices>>

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Contact Information

Mary Bennett, R.Ph.Vice President, Advisory ServicesNAVEX Global(760) 798-4505 mbennett@navexglobal.com

• Sean Jolie AHA Solutions, Inc. 312.895.2538 sjolie@aha.org

For more information on AHA Solutions or NAVEX Global please visit www.aha-solutions.org

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Additional Resource from the AHA

• Health Career Center™ is brought to you by the American Hospital Association to connect healthcare employers and top talent in all disciplines through its online job board network.

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