Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

(B3) Managing Hotlines SCCE Higher Education Compliance Conference 2008

231 views

Published on

(B3) Managing Hotlines SCCE Higher Education Compliance Conference 2008

Published in: Education
  • Be the first to comment

  • Be the first to like this

(B3) Managing Hotlines SCCE Higher Education Compliance Conference 2008

  1. 1. 2008 © UPMC | University of Pittsburgh Medical Center. All Rights Reserved. 1 Managing Hotlines Ann G. Mathias Director Research Policy and Compliance Office of Sponsored Programs and Research Support Prepared April 2008
  2. 2. 2008 © UPMC | University of Pittsburgh Medica2 Hotlines • Why you should establish a compliance hotline • Considerations in establishing and managing a hotline • Survey on Hotlines
  3. 3. 2008 © UPMC | University of Pittsburgh Medica3 What • A telephone line dedicated to receiving calls from employees (and others) who want to report a compliance concern, sometime anonymously.
  4. 4. 2008 © UPMC | University of Pittsburgh Medica4 Why • US Sentencing Commission Guidelines • Sarbanes Oxley Act Section 301 • Support open communication
  5. 5. 2008 © UPMC | University of Pittsburgh Medica5 Why continued • US Sentencing Commission Guidelines – (a) To have an effective compliance and ethics program, for purposes of subsection (f) of §8C2.5 (Culpability Score) and subsection (c)(1) of §8D1.4 (Recommended Conditions of Probation - Organizations), an organization shall— • (1) exercise due diligence to prevent and detect criminal conduct; and • (2) otherwise promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law.
  6. 6. 2008 © UPMC | University of Pittsburgh Medica6 Why continued • US Sentencing Commission Guidelines – The organization shall take reasonable steps. . . . • “to have and publicize a system, which may include mechanisms that allow for anonymity or confidentiality, whereby the organization’s employees and agents may report or seek guidance regarding potential or actual criminal conduct without fear of retaliation
  7. 7. 2008 © UPMC | University of Pittsburgh Medica7 Sarbanes Oxley • Doesn’t apply to non-profits but many are following guidelines • Requires a mechanism for anonymous reporting of questionable practices
  8. 8. 2008 © UPMC | University of Pittsburgh Medica8 Why continued • Open communication
  9. 9. 2008 © UPMC | University of Pittsburgh Medica9
  10. 10. 2008 © UPMC | University of Pittsburgh Medica10 Internal vs. External • Cost • Functionality • Confidence level
  11. 11. 2008 © UPMC | University of Pittsburgh Medica11 Cost • Cost for internal service: – Establishing dedicated phone line – Staffing • Cost for external service: – Per month – Per FTE
  12. 12. 2008 © UPMC | University of Pittsburgh Medica12 Functionality • Internal – Concerns about confidentiality – Availability of staff to answer – Staff training – ability to elicit information – If answering machine – effectiveness • External – Confidentiality – Live person – Opportunity for ongoing communication
  13. 13. 2008 © UPMC | University of Pittsburgh Medica13 Publicize • New employee orientation • Employee handbook • Posters throughout building • Periodic reminders in newsletters • Website for employees • Notice of Privacy Practices • Website for the public • Compliance training • E-mail
  14. 14. 2008 © UPMC | University of Pittsburgh Medica14 Supporting Policies & Processes • Compliance Program • Non-retaliation • Confidentiality • Investigation
  15. 15. 2008 © UPMC | University of Pittsburgh Medica15 Compliance Program • Program encourages open communication, reporting of concerns through chain of command and other avenues • Hotline is just 1 element
  16. 16. 2008 © UPMC | University of Pittsburgh Medica16 Non-retaliation • Consistent with state and federal laws on whistle - blowing • Provide protection from retaliation for “good-faith reporting” of concerns • Retaliation is prohibited • Encourage use of chain-of-command • Discourage false allegations
  17. 17. 2008 © UPMC | University of Pittsburgh Medica17 Confidentiality • Protect the confidentiality of callers to the extent possible – Investigation could lead to identification of the caller
  18. 18. 2008 © UPMC | University of Pittsburgh Medica18 The Call • Script • Ongoing communication • Reporting to the entity for follow-up
  19. 19. 2008 © UPMC | University of Pittsburgh Medica19 Script • Advise caller that they may remain anonymous – Advise of risk that investigation may reveal their identity • If willing to be identified gather as much information as possible: – name, department, phone number, location, etc.
  20. 20. 2008 © UPMC | University of Pittsburgh Medica20 Script continued • Ask if they have reported the issue to anyone already • If not, may want to encourage them to do so • Try to identify calls that should go elsewhere (such as Human Resources)
  21. 21. 2008 © UPMC | University of Pittsburgh Medica21 Script continued • Elicit information – Location – Dates – People involved – Business units involved – Ongoing activity or history
  22. 22. 2008 © UPMC | University of Pittsburgh Medica22 Script continued • Does caller want to remain in contact? • Provide code so that caller can call back for continued communication and update
  23. 23. 2008 © UPMC | University of Pittsburgh Medica23 Investigating Allegations • All allegations should be reported to central office – preferably the Compliance Office • Authority to conduct investigation • Timely • Thorough
  24. 24. 2008 © UPMC | University of Pittsburgh Medica24 Investigating • Identify all that need to be notified • If an area other than compliance is investigating be clear about importance of a through and timely investigation – give a deadline, offer assistance • Require a written response • Document
  25. 25. 2008 © UPMC | University of Pittsburgh Medica25 Response • Critical that calls are not “swept under the rug”
  26. 26. 2008 © UPMC | University of Pittsburgh Medica26 Action • Is this an isolated incident? • Is education necessary? • Do policies need to be changed or clarified? • Is disciplinary action appropriate? • Does communication need to back to the hotline?
  27. 27. 2008 © UPMC | University of Pittsburgh Medica27 Analyzing • Track calls • Trends? – Department – Activity – Individuals
  28. 28. 2008 © UPMC | University of Pittsburgh Medica28 Reporting • Inform the leaders of the organization • Tone at the top
  29. 29. 2008 © UPMC | University of Pittsburgh Medica29 Mini-Survey • Survey sent to Compliance Officers in Hospitals that are members of the Hospital Council of Western Pennsylvania • Received 10 responses • Organization size varied – 1,000 – 2,499 employees: 6 – 2,500 – 4,999 employees: 2 – Over 10,000 employees: 2
  30. 30. 2008 © UPMC | University of Pittsburgh Medica30 Survey Results • Who manages your hotline? – In-house staff: 4 – External: 6 • If outsourced, what is the payment arrangement? – Annual fee: 5 – Per call fee: 1
  31. 31. 2008 © UPMC | University of Pittsburgh Medica31 Survey Results continued • How do you publicize your hotline? – New employee orientation: 10 – Employee handbook: 9 – Posters throughout building: 8 – Periodic reminders in newsletters: 8 – Website for employees: 7 – Notice of Privacy Practices: 4 – Website for the public: 2 – Patient handbook: 1 – Other: Annual compliance training: 3
  32. 32. 2008 © UPMC | University of Pittsburgh Medica32 Survey Results continued • What percentage of calls fit into the following categories? – Human Resource issues: 100, 90, 66, 55, 50, 47, 46, 40, 25, 22% – Allegations of unethical conduct: 50, 10, 5% – Allegations of illegal conduct: 10, 5% – Conflict of Interest concerns: 5, 5, 4% – Allegation of mis-use of organizational resources: 10% – Allegation of fraud: 50, 15% – Quality of Care concern: 25, 24,18,4%
  33. 33. 2008 © UPMC | University of Pittsburgh Medica33 Survey Results continued • Other types of calls: – Privacy and security: 62, 50, 8% – Policy Violation: 20% – Conditions of facilities or equipment: 13% – Billing issues: 11% – Theft: 10% – Workplace violence: 6%
  34. 34. 2008 © UPMC | University of Pittsburgh Medica34 Survey Results continued • What percentage of calls result in the following actions: – Retraining/Education: 98, 90, 50, 33, 15, 10, 7% – Disciplinary action: 50, 50, 33, 10, 5, 2%
  35. 35. 2008 © UPMC | University of Pittsburgh Medica35 Survey Results continued • Who in the organization is responsible for managing the hotline calls: – Chief Compliance Office: 9 – Compliance staff: 1 – Other: Internal audit; call initially received by the CEO’s secretary and sent to the appropriate person
  36. 36. 2008 © UPMC | University of Pittsburgh Medica36 Survey Results continued • Do you report hotline call activity to: – Board of Directors: 9 – President / CEO: 8 – Compliance Committee: 7 – Other: HR director
  37. 37. 2008 © UPMC | University of Pittsburgh Medica37 Survey Results continued • Do you find the hotline to be a valuable tool? – Yes: 8 – No: 2
  38. 38. 2008 © UPMC | University of Pittsburgh Medica38 Survey Results continued • Why: Yes: – Calls have resulted in identification of serious issues – Calls have resulted in identification of issues that may not have been known otherwise – Important to have a means for anonymous reporting – Easily used
  39. 39. 2008 © UPMC | University of Pittsburgh Medica39 Survey Results continued • Why: No: – Too often hotline is used as a form of retaliation against others – Legitimate issues are already reported directly to managers, vice presidents or to compliance officer directly
  40. 40. 2008 © UPMC | University of Pittsburgh Medica40 Questions?
  41. 41. 2008 © UPMC | University of Pittsburgh Medica41 References • US Sentencing Commission http://www.ussc.gov/guidelin.htm • Ethics Resource Center, National Nonprofit Ethics Survey http://www.ethics.org/

×