Compliance Officer

A.General purpose of the position:
Mục đích chung của vị trí này

• Participate in the FVH Compliance Program, functioning as an independent and objective body that reviews and evaluates compliance issues/concerns within the organization. Ensure the Executive team, top and middle management and employees are in compliance with the rules and regulations of international and local healthcare standards such as JCI hospital standards and MOH; hospital policies and procedures are being followed; and that behavior in the hospital meets the Standards of Conduct.
• As a channel of communication to receive and direct compliance issues to appropriate resources for investigation and resolution, and as a final internal resource with which concerned parties may communicate after other formal channels and resources have been exhausted.
• Monitoring and reporting results of the compliance/ethics efforts of the hospital and in providing guidance for the senior management team on matters relating to compliance. Implement all necessary actions to ensure achievement of the objectives of an effective compliance program.

B.Key duties and responsibilities/Nhiệm vụ và trách nhiệm chính:

Compliance Management Program

The Compliance officer:

- Acts as an independent review and evaluation body to ensure that compliance Issues/concerns within the organization are being appropriately evaluated, investigated and resolved.

- Actively supports and participates in quality improvement projects, quality and safety-related activities, department/committee meetings, programs and other activities related to the identified managerial structures, processes and outcomes.

- Collaborates with other departments (e.g., Risk Management, Collaborative Governance, Medical Services, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution.

- Recommends quality improvement tools and techniques to be used in measuring the hospitals quality performance and variations; and solving quality related problems.

- Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures.

- Designs, schedules, and conducts system and individual patient tracers or quality review audits as appropriate to the facility or service.

- Monitors, and as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.

- Participate, when appropriated, in identifying potential areas of compliance vulnerability and risk; reviewing non-conformances, adverse events, observations. and patient complaints for repetitive trends; developing/implementing corrective action plans for resolution of problematic issues, and providing general guidance on how to avoid or deal with similar situations in the future in order to to improve processes and systems.

- Verifies effectiveness of the actions taken for the identified variances or non-conformances.

- Provides reports on a regular basis, and as directed or requested, to keep the executive management informed of the operation and progress of compliance efforts.

- Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.

- Establishes and provides direction and management of the compliance Hotline.

- Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the Compliance Office; (b) heightened awareness of standards of conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.

- Reviews quality standards and existing hospital policies and procedures, and interviews hospital personnel and patients to evaluate the effectiveness of quality improvement program

- Works with the Human Resources Department and others as appropriate to participate in planning, development, coordination, and presentation of specific trainings and educational programs as appropriate to the quality management and improvement needs of the Hospital, including appropriate introductory training for new employees as well as ongoing training for all employees and managers.

- Monitors the performance of the Compliance Program and relates activities on a continuing basis, taking appropriate steps to improve its effectiveness.

- Has authority to review all documents and other information that are relevant to compliance activities, including, but not limited to, patient records, billing records, and records concerning marketing efforts and arrangements with other parties, including employees, independent contractors, suppliers, agents, and physicians and other professionals on staff.

- Has the full resources of the organization at his or her disposal to carry out these functions and to implement the hospital Compliance Policy

- Other duties and responsibilities assigned from time to time