mbo annual corporate responsibility program (crp) checklist · mbo annual corporate responsibility...

MBO Annual Corporate Responsibility Program (CRP) Checklist

MBO Information

MBO Name and Location Fiscal Year

MBO CRO Title

Signature: Date Prepared

CEO Name Date Approved

CEO Signature

Instructions: Please answer each question completely, with respect to the year-to-date Corporate Responsibility effort as follows:

Yes No N/A

For all Items

The response is "yes" in all cases at the MBO The response is not "yes" in all cases at the MBO (You must provide detail in the "Explanation" section) Item is not applicable to the MBO (You must explain why it is not applicable in the "Explanation" section Please include where documentation can be found to support the response in the "Reference" section

A. Corporate Responsibility Officer

1. Has the MBO Board appointed the current local Corporate Responsibility Officer (CRO)?

Yes No NAReference

Explanation

2. Is there documentation to support the appointment of the current CRO in the Board minutes?

Yes No NAReference

Explanation

3. Does the CRO's job description reflect the CHI minimum required elements for the CRO role?

Yes No NAReference

Explanation

4. Is the CRO a member of the organization's senior leadership team?

Yes No NAReference

Explanation

5. Does the CRO report directly to the MBO CEO? If not, who does the CRO report to?

Yes No NAReference

Explanation

6. Does the CRO participate periodically in senior leadership meetings (a minimum of once a quarter)?

Yes No NAReference

Explanation

B. CRP Board Oversight1. Has the MBO Board appointed the required CRP oversight committee (Finance, Audit and Compliance Committee for MBOs less than $200 million net revenue, Audit and Compliance Committee for MBOs greater than $200 minimum net revenue)?

Yes No NAReference

Explanation

initiator:[email protected];wfState:distributed;wfType:email;workflowId:e31f65d45c1a9b42a2aac2529e41c4e4

MBO Annual Corporate Responsibility Program (CRP) Checklist - of 13

MBO Name and Location Fiscal Year

B. CRP Board Oversight continued

2. Are all of the requirements of the respective board CRP Oversight committee charges being met?

Yes No NAReference

Explanation

3. Does the CRO provide CRP updates to the respective board committee a minimum of twice yearly?

Yes No NAReference

Explanation

4. Does the CRO have an executive session with the respective board oversight committee a minimum of annually?

Yes No NAReference

Explanation

5. Does the MBO CRP Plan agree with the most recent approved CHI Board of Stewardship Trustees (BOST) CRP Plan?

Yes No NAReference

Explanation

6. Has the most recent MBO CRP Plan been adopted by the MBO board as documented in the board minutes?

Yes No NAReference

Explanation

7. Do the MBO board and committee members, officers, directors and applicable employees complete an annual conflict of interest disclosure form as per MBO policy?

Yes No NAReference

Explanation

8. Are the results of the annual conflicts of interest disclosure forms shared with the appropriate board and committee members?

Yes No NAReference

Explanation

9. Are benefits provided to board or committee members (including spouses, children, etc.) tracked and appropriated reported for tax purposes?

Yes No NAReference

Explanation

C. MBO CRP Committee1. Has the MBO established a local CRP committee in compliance with the MBO CRP Plan?

Yes No NAReference

Explanation

2. Does the CRP Committee meet a minimum of three times a year?

Yes No NAReference

Explanation

3. Do the CRP Committee minutes appropriately support meeting activities in accordance with the required CRP elements as defined in the MBO CRP Plan?

Yes No NAReference

Explanation

4. Does CRP Committee membership meet the required representation and attendance requirements as defined by the MBO CRP Plan?

Yes No NAReference

Explanation

MBO Name and Location


Fiscal Year

D. Standards and Procedures - Our Values and Ethics at Work

1. Has the Our Values and Ethics at Work Reference Guide (OVEAW) been distributed to all employees?

Yes No NAReference

Explanation

2. Has the OVEAW been distributed to all new employees within 30 days of hire as evidenced by signed and dated acknowledgment forms?

Yes No NAReference

Explanation

3. Are signed acknowledgment forms on file to support receipt by all employees?

Yes No NAReference

Explanation

4. Has the OVEAW been distributed to all volunteers and auxiliary members (as applicable)?

Yes No NAReference

Explanation

5. Has the OVEAW been distributed to all medical staff members in conjunction with the credentialing and/or recredentialing process and as needed (e.g., as revisions are made)?

Yes No NAReference

Explanation

6. Has the OVEAW been distributed to all board and board committee members?

Yes No NAReference

Explanation

7. Has the OVEAW been distributed to all new board and board committee members as evidenced by signed and dated acknowledgment forms?

Yes No NAReference

Explanation

8. Are signed acknowledgment forms on file to support receipt by all board and board committee members?

Yes No NAReference

Explanation

9. Has the OVEAW been distributed to all medical students and residents, agency staff (or as defined by the terms of the agency contract) and any other person as appropriate?

Yes No NAReference

Explanation

10. Are the standards of conduct, Ethical and Religious Directives and the excluded provider provisions included in all contracts (unless an exception has been approved by CHI Legal)?

Yes No NAReference

Explanation

11. Have the HIPAA Privacy standards been revised and implemented in accordance with CHI guidance?

Yes No NAReference

Explanation

12. Have the IT Security standards been revised and implemented in accordance with CHI guidance?

Yes No NAReference

Explanation



Fiscal Year

D. Standards and Procedures - Our Values and Ethics at Work - continued

13. Does the MBO have a board approved Red Flag policy in place?

Yes No NAReference

Explanation

14. Has the MBO adopted and implemented the Policy Governing Requesting or Accepting Gifts from Business Sources?

Yes No NAReference

Explanation

15. Has the MBO adopted and implemented the CHI Conflicts of Interest (COI) model policy for Board, Officers and Directors ?

Yes No NAReference

Explanation

16. Has the Government Contact Protocol been circulated to key management upon hire and at least once annually thereafter?

Yes No NAReference

Explanation

E. Education, Training and Communication1. Do all new employees receive CHI standard CRP introduction and orientation within 90 days of hire?

Yes No NAReference

Explanation

2. For those employees required to complete annual CRP web-based education, was a completion rate of 95% or greater achieved?

Yes No NAReference

Explanation

3. Do all board and board CRP oversight committee members receive a minimum of one hour of CRP education annually?

Yes No NAReference

Explanation

F. Audit, Monitoring and Risk Assessment

1. Has the annual CRP risk assessment been completed and submitted by the designated due date?

Yes No NAReference

Explanation

2. Has an action plan been developed, reviewed and approved by the MBO CRP committee to address risk areas identified in the CRP risk assessment process, including the IT Security risk assessment?

Yes No NAReference

Explanation

3. Is there a process in place to ensure the action plan developed is monitored for resolution of open items?

Yes No NAReference

Explanation

4. Has the MBO developed internal audit and monitoring processes to assess ongoing compliance with the organization's HIPAA Privacy and Security policies?

Yes No NAReference

Explanation

5. Have action plans been developed and implemented to address identified HIPAA Privacy and Security risks?

Yes No NAReference

Explanation



Fiscal Year

F. Audit, Monitoring and Risk Assessment - continued

6. Has the MBO implemented the required procedural and policy changes as directed by CHI to comply with the new HIPAA regulations within the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009?

Yes No NAReference

Explanation

7. Is billing and coding accuracy reviewed a minimum of annually? (This can be conducted either internally, externally or both.)

Yes No NAReference

Explanation

8. Are deficiencies identified as a result of any coding audit corrected and appropriate education provided to staff?

Yes No NAReference

Explanation

G. Physician Financial Arrangements

1. Has the MBO implemented a Physician Transaction Review Committee (PTRC)?

Yes No NAReference

Explanation

2. Is the PTRC comprised solely of independent board members?

Yes No NAReference

Explanation

3. Does the PTRC review all new and renewed physician contracts prior to execution?

Yes No NAReference

Explanation

4. Is there a process in place to ensure all services provided by or to a physician or physician group: 1) are consistent with the CHI and MBO strategic initiatives and good business practices, and 2) support the CHI and MBO mission and core values?

Yes No NAReference

Explanation

5. Is there a process in place to ensure all services provided by or to a physician or physician group are consistent with fair market value?

Yes No NAReference

Explanation

6. Is there a process in place to ensure all blanks within a physician contract are fully completed, all exhibits are attached and that each party's signature has been obtained?

Yes No NAReference

Explanation

7. Does the MBO ensure physician contracts are signed after being approved by the PTRC?

Yes No NAReference

Explanation

8. Is there a process in place to ensure signature authority procedures are followed as defined by MBO policy and the CHI physician contracting policy?

Yes No NAReference

Explanation

MBO Annual Corporate Responsibility Program (CRP) Checklist -


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Fiscal Year

G. Physician Financial Arrangements9. Are payments to physicians or physician groups supported by a fully executed contract or fall within an applicable Stark or Physician Contracting Policy exception?

Yes No NAReference

Explanation

10. Is there a process in place to ensure that payments made to and received from physicians or physician groups are timely and in accordance with provisions of a fully executed contract?

Yes No NAReference

Explanation

11. Have all signed physician contracts been entered into the MediTract contracts management system in accordance with the physician contracting policy?

Yes No NAReference

Explanation

12. Has the MBO implemented the CHI Physician Contracting Policy?

Yes No NAReference

Explanation

13. Does the MBO maintain an accurate mechanism to track deminimus non-monetary benefits or services to physicians?

Yes No NAReference

Explanation

14. Do individuals involved in the physician contracting process receive initial and ongoing education and training regarding the risks associated with physician contracting?

Yes No NAReference

Explanation

15. Is there a process in place to ensure a review of physician family arrangements as defined by Stark is conducted?

Yes No NAReference

Explanation

H. Rewards, Discipline and Enforcement1. Does the MBO have a process to recognize and reward employees whose contributions related to CRP activities support an ethical culture?

Yes No NAReference

Explanation

2. Does the performance evaluation process include adherence to OVEAW and an understanding of the CRP?

Yes No NAReference

Explanation

3. Is documentation maintained to support disciplinary action taken in response to violations of OVEAW and/or the CRP?

Yes No NA

Reference

Explanation

4. Does the MBO conduct employee exit interviews to determine potential compliance issues?

Yes No NAReference

Explanation

5. Are compliance issues identified as a result of exit interviews entered into EthicPoint and tracked through resolution?

Yes No NAReference

Explanation

MBO Annual Corporate Responsibility Program (CRP) Checklist -


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Fiscal Year

I. Hotlines and Other Reporting Mechanisms1. Are Ethics at Work Line calls, reports filed through the internet and issues reported directly to the local CRO handled in accordance with the CRP Manual?

Yes No NAReference

Explanation

2. Are all CRP and HIPAA related matters brought to the attention of the CRO, HIPAA Privacy and Security officials entered into EthicsPoint?

Yes No NAReference

Explanation

3. Is the initial investigation of Ethics at Work Line calls, reports filed through the Internet and internal complaints (including HIPAA Privacy and Security) completed within 30 days?

Yes No NAReference

Explanation

J. Background Checks/Exclusions Screening

1. Are all new employees checked against the OIG and GSA exclusion databases as defined in the CHI excluded provider policy?

Yes No NAReference

Explanation

2. Is a criminal background check performed for new employees as per MBO policy?

Yes No NAReference

Explanation

3. Are all medical staff applicants and other non-credentialed providers checked against the OIG and GSA exclusion databases as part of the credentialing process as defined in the CHI excluded provider policy?

Yes No NAReference

Explanation

4. Are all vendors/contractors checked against the OIG and GSA exclusion databases within 30 days of initiation of contracted service as defined in the CHI excluded provider policy?

Yes No NAReference

Explanation

5. Are all existing employees, medical staff and contractors checked against the OIG and GSA exclusion databases on an annual basis as defined in the CHI excluded provider policy?

Yes No NAReference

Explanation

CRP Checklist Glossary The glossary corresponds to the checklist and outlines how to measure each item for effectiveness.

Item How to MeasureA. Corporate Responsibility Officer

A1 Has the MBO Board appointed the current local Corporate Responsibility Officer (CRO)?

Documentation of the appointment is supported in the board minutes.

A2 Is there documentation to support the appointment of the current CRO in the Board minutes?

Documentation of the appointment is supported in the board minutes.

A3 Does the CRO's job description reflect the CHI minimum required elements for the CRO role?

The CRO job description includes the minimum job requirements as defined in the CHI CRP Manual. A sample job description can be found on the CRP team community at http://collab.catholichealth.net/gm/folder-1.11.128981

A4 Is the CRO a member of the organization's senior leadership team?

The CRO is reflected as part of the leadership team and documented as such on the organizational chart. The CRO actively participates in leadership activities and discussions.

A5 Does the CRO report directly to the MBO CEO? If not, who does the CRO report to? The MBO organization chart supports this reporting relationship.

A6 Does the CRO participate periodically in senior leadership meetings (a minimum of once a quarter)?

Minutes from senior leadership meetings support periodic attendance and involvement of the CRO.

B. CRP Board Oversight

B1

Has the MBO board appointed the required CRP oversight committee (Finance, Audit and Compliance Committee for MBOs less than $200 million net revenue, Audit and Compliance Committee for MBOs greater than $200 million net revenue)?

The CHI BOST approved Audit and Compliance Committee or combined Finance and Audit and Compliance Committee charter has been implemented and approved by the MBO governing body and is on file with the MBO.

B2 Are all of the requirements of the respective board CRP oversight committee charter being met?

The respective charter meets the CHI requirements as defined in the July 1, 2006 communication. Minutes support compliance with the respective charter requirements.

B3 Does the CRO provide CRP updates to the respective board committee a minimum of twice yearly?

The minutes of the governing body reflect a minimum of semiannual CRP updates in accordance with the requirements as defined in the CHI CRP Manual and the governing body charter.

B4 Does the CRO have an executive session with the respective board oversight committee a minimum of annually?

Documentation supports that the CRO had an executive session with the respective board oversight committee.

B5 Does the MBO CRP Plan agree with the most recent approved CHI Board of Stewardship Trustees (BOST) CRP Plan?

The MBO CRP Plan agrees with the CHI template. Any variances from the board approved CHI CRP Plan have been approved by the CHI CRO and is evidenced by supporting documentation. The current CHI CRP Plan can be found at: http://collab.catholichealth.net/gm/folder-1.11.120198

B6 Has the most recent MBO CRP Plan been adopted by the MBO board as documented in the board minutes?

The minutes of the respective board meeting denotes approval of the most recently revised CRP Plan.

B7Do the MBO board and committee members, officers, directors and applicable employees complete an annual conflict of interest disclosure form as per MBO policy?

Conflict of interest disclosure statements for board members and committee members, officers, directors and applicable employees are completed annually as evidenced by signed and dated statements.

B8Are the results of the annual conflicts of interest disclosure forms shared with the appropriate board and committee members?

Documentation exists to support that annual conflict of interest statements are shared with appropriate board and committee members and any conflicts are appropriately addressed and reported.

B9Are benefits provided to board or committee members (including spouses, children, etc.) tracked and appropriately reported for tax purposes?

Benefits provided to board or committee members (including spouses, children, etc.) are tracked and appropriately reported for tax purposes as evidenced by supporting documentation.

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CRP Checklist Glossary - continued of 13

Item How to MeasureC. MBO CRP Committee

C1 Has the MBO established a local CRP committee in compliance with the MBO CRP Plan?

The CRP Plan outlines the establishment, membership and responsibility of the CRP committee.

C2 Does the CRP Committee meet a minimum of three times a year?

The CRP Committee meets three times a year as evidenced by committee minutes.

C3Do the CRP Committee minutes appropriately support meeting activities in accordance with the required CRP elements as defined in the MBO CRP Plan?

Meeting minutes, agendas and other documentation comply with the minimum requirements as defined in the CHI CRP Manual.

C4Does CRP Committee membership meet the required representation and attendance requirements as defined by the MBO CRP Plan?

The CRP charter/plan defines the CRP Committee membership and includes the representatives as defined in the program elements. The minutes reflect that all CRP Committee members attended at least two of the required meetings annually.

D. Standards and Procedures - Our Values and Ethics at Work (OVEAW)

D1 Has the Our Values and Ethics at Work Reference Guide (OVEAW) been distributed to all employees?

Documentation exists to support the initial and ongoing distribution of OVEAW to all employees.

D2Has the OVEAW been distributed to all new employees within 30 days of hire as evidenced by signed and dated acknowledgment forms?

The OVEAW has been distributed to all new employees as evidenced by a review 10% or 30 randomly selected new employee files (whichever is smaller) to verify that OVEAW Acknowledgment and Certification card is signed and dated within 30 days of hire. (NOTE: Files should be from employees hired between July 1st and March 31st. For MBOs with multiple facilities in which distribution of OVEAW was done separately, 10% or 30 new employee files will be randomly selected and reviewed from each facility. If the OVEAW distribution was done in a centralized fashion, the review may include a combined sample from all facilities.)

D3 Are signed acknowledgment forms on file to support receipt by all employees?

The OVEAW has been distributed to all employees as evidenced by a review 10% or 30 randomly selected employee files (whichever is smaller) to verify that OVEAW Acknowledgment and Certification cards are present and signed.

D4 Has the OVEAW been distributed to all volunteers and auxiliary members (as applicable)?

The OVEAW has been distributed to all volunteers and auxiliary members (as applicable) as evidenced by a review 10% or 30 randomly selected volunteer files (whichever is smaller) to verify that OVEAW Acknowledgment and Certification cards are present and signed.

D5

Has the OVEAW been distributed to all medical staff members in conjunction with the credentialing and/or recredentialing process and as needed (e.g., as revisions are made)?

Documentation exists to support the initial and ongoing distribution of OVEAW booklets for all medical staff members in conjunction with the credentialing and/or recredentialing process and as needed.

D6 Has the OVEAW been distributed to all board and board committee members?

Documentation exists to support the initial and ongoing distribution of OVEAW to all board and board committee members.

D7Has the OVEAW been distributed to all new board and board committee members as evidenced by signed and dated acknowledgment forms?

Documentation exists to support the distribution of OVEAW to all new board and board committee members as evidenced by receipt of signed and dated OVEAW Acknowledgment and Certification cards.

D8 Are signed acknowledgment forms on file to support receipt by all board and board committee members?

Documentation exists to support that signed OVEAW Acknowledgment and Certification cards are received and maintained for all board and board committee members.

CRP Checklist Glossary - continued of 13

Item How to Measure

D9Has the OVEAW been distributed to all medical students and residents, agency staff (or as defined by the terms of the agency contract) and any other person as appropriate?

Documentation exists to support the initial and ongoing distribution of OVEAW for all medical students and residents, agency staff and any other person as appropriate.

D10Are the standards of conduct, Ethical and Religious Directives and the excluded provider provisions included in all contracts (unless an exception has been approved by CHI Legal)?

The standards of conduct, Ethical and Religious Directives and excluded provider provisions are included in contracts as evidenced by a review 10% or 10 randomly selected contracts (whichever is smaller).

D11 Have the HIPAA Privacy standards been revised and implemented in accordance with CHI guidance?

Documentation exists to support revision and implementation of the HIPAA Privacy standards.

D12 Have the IT Security standards been revised and implemented in accordance with CHI guidance?

Documentation exists to support adoption and implementation of the IT Security standards.

D13 Does the MBO have a board approved Red Flag policy in place? Documentation exists to support the board has approved a Red Flag Rule policy.

D14 Has the MBO adopted and implemented the Policy Governing Requesting or Accepting Gifts from Business Sources?

Documentation exists to support evidence of adoption and implementation of the Policy Governing Requesting or Accepting Gifts from Business Sources.

D15 Has the MBO adopted and implemented the CHI Conflicts of Interest (COI) model policy for Board, Officers and Directors ?

Documentation exists to support evidence of adoption and implementation of the CHI Conflicts of Interest model policy.

D16 Has the Government Contact Protocol been circulated to key management upon hire and at least once annually thereafter?

Documentation exists to support circulation of the Government Contact Protocol to key management.

E. Education, Training, and Communication

E1 Do all new employees receive CHI standard CRP introduction and orientation within 90 days of hire?

Attendance of CRP introduction and orientation by new employees within 90 days of hire is evidenced by a review of 10% or 30 randomly selected new employee files (whichever is smaller) or by review of orientation logs or sign-in and sign-out sheets.

E2For those employees required to complete annual CRP web-based education, was a completion rate of 95% or greater achieved?

A 95% completion rate is reached as evidenced by the June 30 web-based completion report.

E3 Do all board and board CRP oversight committee members receive a minimum of one hour of CRP education annually?

Documentation exists to support that MBO board and board CRP oversight committee members received annual CRP education. In addition, documentation exists to support that members who were not present for the annual board CRP education are provided the education at a later date during the fiscal year.

F. Auditing, Monitoring and Risk Assessment

F1 Has the annual CRP risk assessment been completed and submitted by the designated due date?

Documentation exists to support the timely submission of the annual CRP risk assessment.

F2

Has an action plan been developed, reviewed and approved by the MBO CRP committee to address risk areas identified in the CRP risk assessment process, including the IT Security risk assessment?

An action plan was developed, reviewed and approved by the CRP committee as documented in the CRP committee meeting minutes

F3 Is there a process in place to ensure the action plan developed is monitored for resolution of open items?

Action items and implementation dates defined in the CRP risk assessment action plan are met as evidenced by documentation in the CRP committee meeting minutes or other supporting documentation.

CRP Checklist Glossary - continued

Item How to Measure

F4Has the MBO developed internal audit and monitoring processes to assess ongoing compliance with the organization's HIPAA Privacy and Security policies?

Documentation exists to support evidence of ongoing compliance with the organization's HIPAA privacy and security policies.

F5 Have action plans been developed and implemented to address identified HIPAA Privacy and Security risks?

An action plan addressing identified HIPAA Privacy and Security risks was developed, reviewed and approved by the CRP committee as documented in the minutes.

F6

Has the MBO implemented the required procedural and policy changes as directed by CHI to comply with the new HIPAA regulations within the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009?

Documentation exists to support the MBO implemented the required procedural and policy changes as directed by CHI to comply with the new HIPAA regulations within the HITECH Act of 2009.

F7Is billing and coding accuracy reviewed a minimum of annually? (This can be conducted either internally, externally or both.)

Documentation is on file to support that 30 random inpatient and 30 random outpatient billing and coding accuracy reviews are completed annually. (This random sample should be selected from federal and state funded programs. This may include: CHAN audit reports, other external consultant reports, internal audit reports, etc.)

F8 Are deficiencies identified as a result of any coding audit corrected and appropriate education provided to staff?

Documentation is on file to support that action is taken to correct deficiencies and rebill identified errors. Documentation is on file to support education provided to staff (i.e., department meeting minutes).

G. Physician Financial Arrangements

G1 Has the MBO implemented a Physician Transaction Review Committee (PTRC)?

Documentation exists to support adoption and implementation of the PTRC. If a separate PTRC is not in place, explain the physician transaction review process.

G2 Is the PTRC comprised solely of independent board members?

Documentation supports that committee membership is comprised solely of independent board members (specifically, ensure the committee membership does not include the CEO or any credentialed or referring medical staff/ providers).

G3 Does the PTRC review all new and renewed physician contracts prior to execution?

The PTRC minutes document the review and approval of all new and renewed physician contracts prior to execution as evidenced by a review of 30 randomly selected physician contracts executed during the fiscal year. (Or if less than 30 physician contracts exist, a review all physician contracts.)

G4

Is there a process in place to ensure all services provided by or to a physician or physician group: 1) are consistent with the CHI and MBO strategic initiatives and good business practices, and 2) support the CHI and MBO mission and core values?

As evidenced by the review of contracts listed in G3.

G5Is there a process in place to ensure all services provided by or to a physician or physician group are consistent with fair market value (FMV)?


G6Is there a process in place to ensure all blanks within a physician contract are fully completed, all exhibits are attached and that each party's signature has been obtained?


G7 Does the MBO ensure physician contracts are signed after being approved by the PTRC? As evidenced by the review of contracts listed in G3.

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CRP Checklist Glossary - continuedItem How to Measure

G8Is there a process in place to ensure signature authority procedures are followed as defined by MBO policy and the CHI physician contracting policy?


G9Are payments to physicians or physician groups supported by a fully executed contract or fall within an applicable Stark or Physician Contracting Policy exception?


G10Is there a process in place to ensure that payments made to and received from physicians or physician groups are timely and in accordance with provisions of a fully executed contract?


G11Have all signed physician contracts been entered into the MediTract contracts management system in accordance with the physician contracting policy?


G12 Has the MBO implemented the CHI Physician Contracting policy?

Adoption and implementation of the CHI Physician Contracting policy is documented.

G13 Does the MBO maintain an accurate mechanism to track deminimus non-monetary benefits or services to physicians?

Documentation exists to support the tracking of deminimus non-monetary benefits/services to physicians.

G14Do individuals involved in the physician contracting process receive initial and ongoing education and training regarding the risks associated with physician contracting?

Provision of education and training to individuals associated with the physician contracting process is documented.

G15 Is there a process in place to ensure a review of physician family arrangements as defined by Stark is conducted?

Documentation exists to support that physician family arrangements are reviewed prior to the execution of a physician contract.

H. Rewards, Discipline and Enforcement

H1Does the MBO have a process to recognize and reward employees whose contributions related to CRP activities support an ethical culture?

Documentation exists to support how rewards and recognition are integrated into the CRP process.

H2 Does the performance evaluation process include adherence to OVEAW and an understanding of the CRP?

Documentation exists to support that the employee evaluation process includes adherence to OVEAW and an understanding of CRP.

H3 Is documentation maintained to support disciplinary action taken in response to violations of OVEAW and/or the CRP?

Documentation of any disciplinary actions involving a breach of the standards of conduct as defined in OVEAW is maintained.

H4 Does the MBO conduct employee exit interviews to determine potential compliance issues?

Documentation exists to support that the MBO conducts employee exit interviews to determine potential compliance issues.

H5 Are compliance issues identified as a result of exit interviews entered into EthicsPoint and tracked through resolution?

Documentation exists to support that compliance issues identified as a result of an exit interview are entered and tracked into EthicsPoint.

I. Hotlines and Other Reporting Mechanisms

I1Are Ethics at Work Line calls, reports filed through the internet and issues reported directly to the local CRO handled in accordance with the CRP Manual?

Responses to and actions taken as a result of Ethics at Work Line calls/reports comply with the documented process in the CRP Manual as evidenced by a review of 10% or 10 randomly selected Ethics at Work Line calls or reports (whichever is smaller).

CRP Checklist Glossary - continued

Item How to Measure

I2Are all CRP and HIPAA related matters brought to the attention of the CRO, HIPAA Privacy and Security officials entered into EthicsPoint?

Documentation supports that all CRP and HIPAA related matters brought to the attention of the CRO, HIPAA Privacy and Security officials are entered into EthicsPoint.

I3Is the initial investigation of Ethics at Work Line calls, reports filed through the Internet and internal complaints (including HIPAA Privacy and Security) completed within 30 days?

The initial investigation is completed within 30 days as evidenced by a review of 10% or 10 randomly selected EthicsPoint reports (whichever is smaller).

J. Background Checks/Exclusions Screening

J1Are all new employees checked against the OIG and GSA exclusion databases as defined in the CHI excluded provider policy?

All new employees are checked against the OIG and GSA exclusion databases as evidenced by a review of 10% or 30 (whichever is smaller) randomly selected new employee files. Documentation exists to support that appropriate actions were taken by the MBO if exclusionary status was identified.

J2 Is a criminal background check performed for new employees as per MBO policy?

Criminal background checks are performed on all new employees per MBO policy as evidenced by a review of 10% or 30 (whichever is smaller) randomly selected new employee files.

J3

Are all medical staff applicants and other non-credentialed providers checked against the OIG and GSA exclusion databases as part of the credentialing process as defined in the CHI excluded provider policy?

Medical staff applicants and other non-credentialed providers are checked against the OIG and GSA exclusion databases as evidenced by a review of 10% or 30 randomly selected medical staff applicant files (whichever is smaller) and 5% or 10 randomly selected non-credentialed providers ordering services within the MBO (whichever is smaller).

J4Are all vendors/contractors checked against the OIG and GSA exclusion databases within 30 days of initiation of contracted service as defined in the CHI excluded provider policy?

All new vendors/contractors are checked against the OIG and GSA exclusion databases as evidenced by a review of 10% or 30 (whichever is smaller) randomly selected new vendors/contractors, excluding HealthTrust Purchasing Group and other CHI nationally negotiated contracts.

J5Are all existing employees, medical staff and contractors checked against the OIG and GSA exclusion databases on an annual basis as defined in the CHI excluded provider policy?

Documentation exists to support annual exclusion screening is performed for existing employees, medical staff and vendors/contractors. Documentation exists to support resolution of any potential matches.

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