Audit, Compliance, & Risk Committee
June 12, 2015
UVA Health System
Corporate Compliance & Privacy Office
FY16 Medical Center Project Schedule
Corporate Compliance & Privacy Office
FY16 Project Schedule
The Corporate Compliance and Privacy Office proposed project
schedule for the Medical Center for fiscal year 2016 is in your booklet.
The schedule is developed based on:
• required work from federal, state, and other regulatory agencies,
• risk assessment models,
• requests from Medical Center management, and
• analyses of work performed in prior years.
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Corporate Compliance & Privacy Office
FY16 Project Schedule
5 employees:
• 8,840 hours available
Removing hours for:
• professional development
• leave and holidays
• other activities
- office
- personnel administration
- committees
6,870 hours are available for Corporate Compliance and Privacy Office projects
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Corporate Compliance & Privacy Office
FY16 Project Schedule
4,070 Projected Hours Based on Historical Data Adjusted As Needed
Consulting (700 hours):
• Privacy and Compliance Policy and Procedures
• Staff or Management Inquiries
Unscheduled Compliance & Privacy Projects (3,000 hours):
• Federal or State Governmental Investigations or Inquiries
• Management or Staff Requests, Inquiries or Investigations
• Industry Alert Investigations
Training (370 hours):
• Department Focused Compliance or Privacy Training
• Website Documents
• Communications
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Corporate Compliance & Privacy Office
FY16 Project Schedule
2,800 Hours for Scheduled Projects
Outpatient Clinic or Procedure Area Audits (800 hours):
• ~ 3 projects
Inpatient Audits (1200 hours):
• ~ 3 projects
Privacy Site Auditing & Monitoring (400 hours):
• 3 locations per month or 36 visits per year
• medical record audits at each location
Training (400 hours):
• annual new hire privacy,
• annual new hire compliance,
• annual retraining privacy,
• annual retraining compliance, and
• quarterly hybrid privacy training
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Corporate Compliance & Privacy Office
FY16 Project Schedule
6,870 available hours for projects:
• 4,020 hours (59%) - compliance
• 2,850 hours (41%) - privacy
Elements of an Effective Compliance Program
1. Standards & Procedures
2. Oversight
3. Education & Training
4. Monitoring & Auditing
5. Reporting
6. Enforcement & Discipline
7. Response & Prevention
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