A copy of the agenda for the Regular Committee Meeting will be posted and distributed at least seventy-two (72) hours prior to the meeting. In observance of the Americans with Disabilities Act, please notify us at 650-988-7504 prior to the meeting so that we may provide the agenda in alternative formats or make disability-related modifications and accommodations. AGENDA Corporate Compliance /Privacy and Internal Audit Committee Meeting of the El Camino Hospital Board Thursday, June 19, 2014, 5:00 – 7:00 p.m. El Camino Hospital, Conference Room F, ground floor 2500 Grant Road, Mountain View, California and via teleconference 330 East Strawberry Drive, Mill Valley, CA 94941 Purpose: The Corporate Compliance/Privacy and Internal Audit Committee is responsible for providing direction for both the Corporate Compliance and Internal Audit programs at all locations of El Camino Hospital (ECH). Responsibilities include providing oversight on compliance issues requiring executive-level interaction, assessing physician relationship risk as it relates to compliance, reviewing HIPAA/Privacy laws as they relate to compliance and directing ECH on compliance strategies. The Committee also serves as the ad-hoc mobilization team for any external investigations and/or actions. Further, additional responsibilities include providing direction and oversight to ongoing internal audit activity and determining appropriate organizational response in order to identify and mitigate organizational risk. AGENDA ITEM PRESENTED BY 1. CALL TO ORDER/ROLL CALL John Zoglin, Chair, Corporate Compliance Committee 5:00 – 5:01 p.m. 2. POTENTIAL CONFLICT OF INTEREST DISCLOSURES John Zoglin, Chair, Corporate Compliance Committee 5:01 – 5:02 3. PUBLIC COMMUNICATION John Zoglin, Chair, Corporate Compliance Committee 5:02 – 5:07 4. CONSENT CALENDAR ITEMS Any Committee Member may pull an item for discussion before a motion is made. Approval: a. Minutes of Corporate Compliance Meeting, April 10 2014 ATTACHMENT 4 John Zoglin, Chair, Corporate Compliance Committee public comment motion required 5:07 – 5:10 5. ERM RISK PROFILE Discussion regarding how Board/Committee discuss overall risk profile and what is recommended structure regarding other board committee risk tolerance discussions John Zoglin, Chair, Corporate Compliance Committee information 5:10 – 5:40 6. KEY PERFORMACE INDICATORS SCORECARD AND TRENDS a. KPI Scorecard b. Trends ATTACHMENT 6 Diane Wigglesworth, Corporate Compliance/ Privacy Officer information 5:40 – 5:45
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A copy of the agenda for the Regular Committee Meeting will be posted and distributed at least seventy-two (72) hours prior to the
meeting. In observance of the Americans with Disabilities Act, please notify us at 650-988-7504 prior to the meeting so that we
may provide the agenda in alternative formats or make disability-related modifications and accommodations.
AGENDA Corporate Compliance /Privacy and Internal Audit Committee Meeting
of the El Camino Hospital Board
Thursday, June 19, 2014, 5:00 – 7:00 p.m.
El Camino Hospital, Conference Room F, ground floor
2500 Grant Road, Mountain View, California
and via teleconference
330 East Strawberry Drive, Mill Valley, CA 94941
Purpose: The Corporate Compliance/Privacy and Internal Audit Committee is responsible for providing direction for both the
Corporate Compliance and Internal Audit programs at all locations of El Camino Hospital (ECH). Responsibilities include
providing oversight on compliance issues requiring executive-level interaction, assessing physician relationship risk as it relates
to compliance, reviewing HIPAA/Privacy laws as they relate to compliance and directing ECH on compliance strategies. The
Committee also serves as the ad-hoc mobilization team for any external investigations and/or actions. Further, additional
responsibilities include providing direction and oversight to ongoing internal audit activity and determining appropriate
organizational response in order to identify and mitigate organizational risk.
AGENDA ITEM PRESENTED BY
1. CALL TO ORDER/ROLL CALL John Zoglin, Chair,
Corporate Compliance
Committee
5:00 – 5:01 p.m.
2. POTENTIAL CONFLICT OF
INTEREST DISCLOSURES
John Zoglin, Chair,
Corporate Compliance
Committee
5:01 – 5:02
3. PUBLIC COMMUNICATION John Zoglin, Chair,
Corporate Compliance
Committee
5:02 – 5:07
4. CONSENT CALENDAR ITEMS
Any Committee Member may pull an item
for discussion before a motion is made.
Approval:
a. Minutes of Corporate Compliance
Meeting, April 10 2014
ATTACHMENT 4
John Zoglin, Chair,
Corporate Compliance
Committee
public
comment motion required
5:07 – 5:10
5. ERM RISK PROFILE
Discussion regarding how Board/Committee
discuss overall risk profile and what is
recommended structure regarding other board
committee risk tolerance discussions
John Zoglin, Chair,
Corporate Compliance
Committee
information
5:10 – 5:40
6. KEY PERFORMACE INDICATORS
SCORECARD AND TRENDS
a. KPI Scorecard
b. Trends
ATTACHMENT 6
Diane Wigglesworth,
Corporate
Compliance/ Privacy
Officer
information
5:40 – 5:45
Agenda: El Camino Hospital Corporate Compliance/Privacy and Internal Audit Committee Meeting June 19, 2014 Page 2
AGENDA ITEM PRESENTED BY
7. FY: 15 COMMITTEE GOALS
ATTACHMENT 7
John Zoglin, Chair, Corporate Compliance Committee
information 5:45 – 5:46
8. ADJOURN TO CLOSED SESSION 5:46
9. POTENTIAL CONFLICT OFINTEREST DISCLOSURES
John Zoglin, Chair, Corporate Compliance Committee
5:46 – 5:47
10. CONSENT CALENDARAny Committee Member may pull an itemfor discussion before a motion is made.
John Zoglin, Chair, Corporate Compliance Committee
Number of statement of deficiencies issued to ECH 4 5 4
Number of Actual/Realized Sanctions, fines or penalties 0 0 $ 100.00
Monitoring and Audit Findings May. 2014Jul - May.
FY:2014
FY:13
Actual
Total number of Audit Findings 8 36 96
Number of findings identified has high severity 2 2 14
1 of 1
Separator Page
Attachment 6b Corporate Compliance Scorecard
Trends.pdf
Corporate Compliance
2
1
2
1
7
2
6
8
5
1
4
2
1
2 2
8
2
4 4
8
2
3
1
2
1
3
1
2 2 2
1
2
1
2
3
1
3 3
1 1
0
2
4
6
8
10
Jul -12 Aug -12 Sep -12 Oct -12 Nov -12 Dec -12 Jan -13 Feb -13 Mar -13 Apr -13 May -13 Jun -13 Jul -13 Aug -13 Sep -13 Oct -13 Nov -13 Dec -13 Jan -14 Feb -14 Mar -14 Apr -14 May -14
Nu
mb
er
of
Inst
an
ces
Policies & Procedures
Non-Compliance with Policies / Disciplinary Action Following Investigation of Non-Compliance
# Reports of Non-Compliance with Policies # Disciplinary Actions Following Investigation of Non-Compliance
14
2 2 2 13
1 2 2 2 31
52
51 1
3 31
3 0
53
31
31 4
2
1
2
41
1 24
1 2
12 13
7
1311
23
14 1416
23
1513
97 7 8
23
7
1210
23
13 12
0
5
10
15
20
25
30
Jul -12 Aug -12 Sep -12 Oct -12 Nov -12 Dec -12 Jan -13 Feb -13 Mar -13 Apr -13 May -13 Jun -13 Jul -13 Aug -13 Sep -13 Oct -13 Nov -13 Dec -13 Jan -14 Feb -14 Mar -14 Apr -14 May -14
Nu
mb
er
of
Inst
an
ces
Investigations: Total Investigations / Hotline Activity
Hotline Reports Substantiated Hotline Reports Not Substantiated Total # of Investigations
Jul -12 Aug -12 Sep -12 Oct -12 Nov -12 Dec -12 Jan -13 Feb -13 Mar -13 Apr -13 May -13 Jun -13 Jul -13 Aug -13 Sep -13 Oct -13 Nov -13 Dec -13 Jan -14 Feb -14 Mar -14
Nu
mb
er
of
Inst
an
ces
Incidents Requiring Report to Outside Entity
HIPPA Reports Privacy Breaches Self Reported by ECH to CDPH
0
4
8
12
16
Nu
mb
er
of
Inst
an
ces
Anti-Kickback/Stark EMTALA Billing or Claims Conflict of Interest HIPPA Security Breaches
6/10/2014 F:\Clineff\ANNE\Ad Hoc Projects\Diane W\Corporate Compliance Scorecard FY14 Totals/Graphs
Separator Page
Attachment 7 - Goals for Compliance Committee
CCPIAC FY 15.doc
Corporate Compliance/Privacy and Audit Committee
Goals FY 2015
Purpose
The purpose of the Corporate Compliance/Privacy and Audit Committee (“Compliance and Audit Committee”) is to advise and assist the El Camino Hospital (ECH) Hospital Board of Directors (“Board”) in its exercise of oversight by monitoring the compliance policies, controls and processes of the organization and the engagement, independence and performance of the internal auditor and external auditor. The Compliance and Audit Committee assists the Board in oversight of any regulatory audit and in assuring the organizational integrity of ECH in a manner consistent with its mission and purpose.
Staff: Diane Wigglesworth, Director of Corporate Compliance
The Director, Corporate Compliance/Privacy and Audit Committee shall serve as the primary staff support to the Committee and is responsible for drafting the Committee meeting
agenda for the Committee Chairs consideration. Additional members of the executive team or outside consultants may participate in the Committee meetings upon the
recommendation of the Director, Corporate Compliance/Privacy and Internal Audit Committee and at the discretion of the Committee Chair.
Goals Timeline by Fiscal Year
(Timeframe applies to when the Board approves the recommended action from the Committee, if applicable.)
Metrics of Success Achieved
Review and evaluate Hospitals proposed FY 2015 Internal Audit Work Plan based on the current risk assessment.
Q1 2015
Committee Reviews FY 2015 Internal Audit Work Plan Developed by Staff in August and provides report to the Board in September 2014.
Participate in staff developed education session regarding Government Audit Programs. (i.e. MIC, MAC, ZPIC and RAC)
Q2 2015 Committee to receive education by 12/31/14.
Review Enterprise-Wide Risk Assessment and action plan for identified risks and validate the top four risks under each domain.
Q3 2015 Committee Reviews ERM Risk Assessment and approves Hospital’s action plan for identified risks and recommends plan to the Board for approval in March 2015
Review and evaluate Hospital’s risk mitigation plan for Research Compliance.
Q4 2015 Committee presents risk mitigation plan to the Board by June 2015.
Submitted by: John Zoglin, Chair, Corporate Compliance/Privacy and Compliance Committee Diane Wigglesworth, Executive Sponsor, Corporate Compliance/Privacy and Compliance Committee
Separator Page
Attachment 16 - Goals for Compliance Committee
CCPIAC FY 14.doc
Corporate Compliance/Privacy and Audit Committee
Revised Goals FY 2014
Purpose
The purpose of the Corporate Compliance/Privacy and Audit Committee (“Compliance and Audit Committee”) is to advise and assist the El Camino Hospital (ECH) Hospital Board of Directors (“Board”) in its exercise of oversight by monitoring the compliance policies, controls and processes of the organization and the engagement, independence and performance of the internal auditor and external auditor. The Compliance and Audit Committee assists the Board in oversight of any regulatory audit and in assuring the organizational integrity of ECH in a manner consistent with its mission and purpose.
Staff: Diane Wigglesworth, Director of Corporate Compliance
The Director, Corporate Compliance/Privacy and Audit Committee shall serve as the primary staff support to the Committee and is responsible for drafting the Committee meeting
agenda for the Committee Chairs consideration. Additional members of the executive team or outside consultants may participate in the Committee meetings upon the
recommendation of the Director, Corporate Compliance/Privacy and Internal Audit Committee and at the discretion of the Committee Chair.
Goals Timeline by Fiscal Year
(Timeframe applies to when the Board approves the recommended action from the Committee, if applicable.)
Metrics of Success Achieved
Review and evaluate Hospitals proposed FY 2014 Internal Audit Work Plan based on the current risk assessment for recommendation to Hospital Board.
Q2 2014 - Completed – Board approved 10/2013
Committee Reviews FY 2014 Internal Audit Work Plan Developed by Staff in September and Recommends Plan to Board for Approval at October Board meeting.
Review FY: 2014 OIG Work Plan and evaluate suitability of Hospitals proposed response plan to the report.
Q2 2014 – Completed – Board approved 5/2014 Committee Reviews Hospital’s Proposed Response Plan to OIG Work Plan in February and Recommends Plan to the Board for Approval at March Board Meeting.
Develop ERM Guidance for Board on Structure, Reporting and Governance Oversight
Q3- Q4 2014 – On target to complete with Presentation to the Board on June 11, 2014
Committee Recommends Process for Evaluation of ERM to the Board for Approval Not Later Than May 2014 Board Meeting.
Goals Timeline by Fiscal Year
(Timeframe applies to when the Board approves the recommended action from the Committee, if applicable.)
Metrics of Success Achieved
Develop a Process for Oversight of New Policies and Changes to Existing Policies
Q4 2014 – Complete – Approved by the Board 5/2014
Committee Recommends Process for Policy Oversight to Board for Approval Not Later Than June 2014.
Submitted by: John Zoglin, Chair, Corporate Compliance/Privacy and Compliance Committee Diane Wigglesworth, Executive Sponsor, Corporate Compliance/Privacy and Compliance Committee Status to Complete as of 5.22.14