Compliance Policy #905
Boulder Community Hospital will take steps to communicate effectively its compliance standards policies, and procedures to all employees and other agents by requiring regular participation in training programs and/or by
disseminating publications that explain in a practical manner what is required.
Responsibility: All Hospital Employees
General Compliance Education
Existing and new employees will be required to attend an education program regarding the Hospital's compliance plan and shall be informed of the Hospital's compliance standards and policies. Copies of the policies shall be
available in all department of the Hospital. This general education and training program shall include, but not be limited to, the following topics:
- The Hospital's compliance philosophy and general commitment to compliance.
- General compliance policies and standards applicable to all employees.
- The employee's obligation to adhere to all applicable laws, regulations and Hospital standards of conduct and the consequences for violations.
- The employee's obligation to report any suspected illegal or improper conduct and the procedures for making such reports.
- Identification of the Compliance Officer and his or her authority and responsibility and identification of other persons in the Hospital and the employee's department responsible for overseeing compliance.
The general education program shall be conducted by the Compliance Officer or a designee of the Compliance Officer who has sufficient knowledge and training to conduct the program.
Specific Training and Education
In addition to the general compliance education and training all employees receive, employees who are required to adhere to specific compliance standards or perform duties which require specific compliance training shall receive additional training and education in the relevant areas.
Each department director or manager, in consultation with and subject to the approval of the Compliance Officer will develop a list of the positions whichrequire additional training and education and the topics to be included in the training. The list of positions requiring training and the training topics will be reviewed at least annually by the Director and the Compliance Officer.
Each Director shall prepare or obtain the training materials for the training programs conducted in the department, subject to review and approval by the Compliance Officer.
Specific training and education shall be conducted in each department annually, and more frequently if necessary. Circumstances which may warrant more frequent training and education include changes in applicable laws or
regulations, identification of specific risk areas, issuance of new government directives or discovery of areas of noncompliance.
The Compliance Officer shall be responsible for overseeing the training and education of Hospital employees and agents with respect to compliance issues. Training and Education for Physicians, Agents and Independent Contractors
The Compliance Officer, in consultation with members of senior management and the department directors, shall identify those subcontractors and other agents of the Hospital who are required to adhere to specific Hospital compliance standards or perform duties on behalf of the Hospital which require specific compliance training. These individuals shall receive education and training regarding the Hospital's general compliance standards and the specific compliance standards applicable to the duties the individuals perform for the Hospital.
The Compliance Officer shall coordinate with the Department of Medical Affairs and the leadership of the Medical Staff to provide education and training to members of the medical staff and other credentialed practitioners who perform duties which affect compliance. Physicians who are employees or independent
contractors of the Hospital shall receive specific education and training with respect to the functions they perform on behalf of the Hospital.
Requirements for Training and Education Requirements
The following requirements shall apply to all training and education conducted pursuant to this policy:
1. The person(s) responsible for conducting a training and education program shall document the attendance at the program, as well as the topics covered.
Any written materials provided at the program shall be retained and attached to the attendance list. A copy of the attendance list and training materials shall be provided to the Compliance Officer.
2. The training and education may take place using publications, through lectures, videos, and other interactive activities designed to effectively communicate the information to employees and agents of the Hospital. Training
materials shall be designed to be understandable by all levels of employees who receive the materials.
3. All training and education programs shall include a component to verifythat persons receiving the training and education understand the materials provided.
4. Training instructors shall be knowledgeable in the specific area and may come from inside or outside the Hospital.
5. In lieu of internal training programs regarding specific compliance issues, employees may attend external training seminars with the approval of the department director and/or Compliance Officer.
6. All training materials shall be reviewed and updated as necessary at least annually by the director of the applicable department and/or the Compliance Officer.
The training and education required by this policy is a condition of employment or contractual relationship with the Hospital. No employee or agent shall perform functions which require adherence to compliance standardsReturn to Top
without receiving the required training, unless written permission is obtained from the Compliance Officer.