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Physician LeadershipFriday, December 7, 2012

Deidre Ramsey, Managing Director, Regional TPMG Compliance - Moderator

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Goals for Today

Learning Objectives

Actively participate with the speakers in understanding the importance of having an Assistant Physician-in-Chief (APIC) Leader for Compliance partner with the Compliance and Privacy Officer.

Understand the alignment of the APICs for Compliance and Compliance and Privacy Officers within KP.

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Overview of Presentation

Who We Are

Organizational Structures

Role of APIC for Compliance

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Kaiser Permanente Integrated Delivery System

Kaiser Foundation Health Plan

(KFHP)

The Permanente Medical Group

(TPMG)

Kaiser Foundation

Hospitals (KFH)

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Northern California Region

3.4 million members

22 medical centers

7,000 physicians

66,700 employees

Compliance Mission

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TPMG Mission

We partner through education and expert consultation to

mitigate regulatory risk to the organization.

We support an innovative health care delivery system in which

physicians and staff can practice the best possible care.

KFH Mission

To embed a culture that inspires delivery of the KP Promise with the

highest levels of integrity and to mitigate risk to KP by coordinating a

comprehensive and integrated compliance organization that puts

our members and patients first.

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Compliance Vision

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TPMG Vision

TPMG Compliance provides a foundation to build a culture of

compliance, where physicians and staff operationalize regulatory requirements in the delivery of

high quality health care.

KFH Vision

Doing the right thing is in our DNA.

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History of TPMG Compliance

TPMG Board established a Compliance Program and appointed a Chief Compliance Officer in 1998.

In 2011, Barry Scurran, D.P.M. was appointed the TPMG Chief Compliance Officer.

TPMG Chief Compliance Officer reports directly to Dr. Robert Pearl, Chief Executive Officer.

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Current Chief Compliance Officer: Barry Scurran, DPM

History of KFH/KFHP Compliance

KFH/KFHP Board established a Compliance Program and appointed a Chief Compliance Officer in 2002.

KFH/KFHP Board appointed Daniel Garcia, Senior Vice President, as the current KFH/KFHP Chief Compliance Officer.

KFH/KFHP Chief Compliance Officer reports directly to George Halvorson, Chairman and Chief Executive Officer and the Audit & Compliance Committees of the Kaiser Foundation Health Plan and Hospitals Boards.

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Medical Center Compliance Committee - GSAA

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Medical Center Compliance Committee – San Jose

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Medical Center Organizational Structure

KFHP/HCompliance and Privacy Officer

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Executive Compliance Committee Reporting Structure

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How We Communicate

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Support for Assistant Physician-in-Chief for Compliance

Emily Zielske

Legislative Program Manager

Eva Fong

Imaging Services Program Manager

James Rundell

Ancillary Services Program Manager

Kirsten Anderson

Scope of Practice Program Manager

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Assistant Physician-in-Chief for Compliance

The APIC for Compliance is the compliance leader for TPMG at every Medical Center in partnership with the Hospital/Health Plan Compliance and Privacy Officer.

Our Strength is Our Diversity

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Selecting a Physician Partner

Step Three

Physician in Chief selects an APIC for

Compliance to partner with the Medical Center

Compliance Officer

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Working Together

TPMG & KFH work together to review the laws and understand the regulatory impact to staff

and physicians.

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Solving Problems

Physicians help create compliant

solutions

Case study review

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Questions

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Contacts

Dede Ramsey, RN, MBA, CHCManaging Director, TPMG Compliance

– (510) 625-3885

Scott Tafuri, DPM, JDAssistant Physician in Chief, Compliance & Risk

– (510) 248-3538

Merritt Quisumbing Anderson, JD, CHC, CHPCCompliance & Privacy Officer

– (510) 675-5514

Lorna Yamaguchi, MDAssistant Physician in Chief , Compliance/Risk/Medical Legal/HR

– (408) 972-6167

Niraj Singh, MA, MPhil, CHC, CHPCHospital/Health Plan Compliance and Privacy Officer

– (408) 972- 6855

Appendix

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Table of Contents

APIC for Compliance Areas of Focus………………….......……......…3 - 5

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Assistant Physician-in-Chief for Compliance Areas of Focus

1. Changing the Culture &Ongoing Communication

2. Compliance Program Oversight

3. Training and EducatingPhysicians

Provide leadership

Ensure TPMG auditing results are submitted to the Medical Center Compliance Committee

Help resolve issues & report systemic problems or unresolved issues to TPMG Chief Compliance Officer or Regional TPMG Compliance

Co-chair Medical Center Compliance Committee

Distribute department communications

Communicate new regulatory requirements

Celebrate good results

Principles of Responsibility

Ensure physicians receive appropriate compliance training

Deploy required compliance training

Communicate standards and requirements

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5. Understanding Policies 6. Performance Monitoring

Report any offenses detected

Facilitate resolution of compliance issues

Consistently encourage policies to be followed

Ensure regionally approved policies are adopted locally

Ensure policies and procedures are updated

Ensure consistency of policy interpretation

Evaluate compliance controls when remediation is ineffective

Collaborate with Medical Center Leadership to ensure survey readiness

Ensure operations monitor performance through reports and other metrics

Assistant Physician-in-Chief for Compliance Areas of Focus

4. Prompt Response toCompliance Issues

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Assistant Physician-in-Chief for Compliance Areas of Focus

7. Taking Corrective Action8. Conducting Risk

Assessments

Review, approve, and ensure timely completion of Correction Action Plans

Help prevent and detect violations of the law

Consult with Regional TPMG Compliance as needed

Discipline as needed

Be aware of potential risks identified

Communicate with department and review expectations

Elevate compliance issues to the Medical Center Compliance Committee when remediation is ineffective

Conduct risk assessments