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Compliance Program Effectiveness: Tracking Reports In Real Time, By Type and Method

To advance its risk assessment and compliance effectiveness reviews, WellSpan Health in York, Pennsylvania, has developed a standardized method to track reports of potential concerns and compliance questions in real time across the entire system. Compliance Audit Coordinator Frank Mesaros, who engineered the tools, said they generate more actionable, standardized information by the type of compliance issues (e.g., billing/coding, conflict of interest) and method of reporting (e.g., hotline, email). All compliance employees enter reports in the details spreadsheet, which is summarized in the summary spreadsheet (data below is fictional). “If we have a lot of questions about a particular area, it may tell me we need to do more education,” added Wendy Trout, director of corporate compliance. Everyone has access to the Excel spreadsheets, but they can only enter data in the detail tab. “They fill out standard fields, and then they have free text to write what the question or concern was and what follow-up was done,” Trout said. The hotline summary table shows what percentage of the total hotline calls received by the health system went to each hospital and what percent were managed by the “appropriate department” (e.g., HIPAA security). “It helps me see what facility is pulling in the most calls,” Mesaros said. “Table menus are a way of standardizing the inputs on the details tab,” Trout said. When all staff enter certain data in the same standard way, it helps in reporting meaningful information. “It really is for the person building the spreadsheets and ultimately the summary spreadsheet. It also provides a central location for updates, such as adding a new facility. Having someone on your team who can do this is fantastic.” Trout and Mesaros said these and other dashboards that aren’t shown here have allowed WellSpan to keep tabs on its risk areas and improve its biennial reviews of the effectiveness of the compliance program. They share the results with their compliance risk assessment team, compliance steering committee and the boards. They said 24 compliance staffers use the tools. Contact Trout at and Mesaros at

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