University of Connecticut University of UC Title Fallback Connecticut

CCC Charter

PURPOSE

The UCHC Executive Compliance Committee charges the Clinical Compliance Committee with the purpose of fulfilling its oversight responsibilities in the Clinical Domain. The Clinical Compliance Domain has oversight of issues pertaining to clinical operations in John Dempsey Hospital (JDH), UConn Medical Group (UMG), the Dental Faculty Practice (DFP) and Correctional Managed Health Care (CMHC), as well as compliance with State and Federal regulations, applicable UCHC policies and the Code of Conduct relating to delivery of and appropriate documentation of clinical care.


RESPONSIBILITIES

The committee fulfills its responsibilities by:

  • Reporting to the UCHC Executive Compliance Committee;
  • Providing a forum for communication among various clinical departments of UCHC for issues relevant to audit, compliance or ethics;
  • Reviewing the UCHC Clinical Compliance Plan and other pertinent documents relevant to this Domain of the Program;
  • Maintaining awareness of trends in clinical compliance as they apply to internal processes;
  • Examining internal controls over activities in the Clinical Domain related to legal compliance and ethics;
  • Recognizing, endorsing and establishing educational and operational initiatives that contribute to performance and quality improvement in the clinical domain by promoting adherence with compliance policies, procedures and practices;
  • Ensuring that the Office of Medical Staff carries out its duties to ensure quality of clinical care;
  • Establishing monitoring activities to ensure ongoing attention to specific risk areas;
  • Reviewing compliance activities of the Corporate Compliance Office in the Clinical Domain;
  • Reviewing audits and consultants activities related to Clinical Domain compliance;
  • Updating the committee members on current issues and trends in compliance by:

Discussing summary presentations by Compliance Office staff on UH investigations and other pertinent Office activities;

Participating in educational offerings

Acting as liaisons to JDH, UMG, DFP and CMHC staff/faculty by providing information and consultation on issues of clinical compliance.


COMPOSITION

The Clinical Compliance Committee shall be comprised of members as appointed jointly by the CCIPO and relevant Associate Vice Presidents or Associate Deans for Clinical Affairs. Members are selected by virtue of their roles within the institution in departments/groups with compliance risk. Membership is evaluated, as the Clinical Domain compliance needs change. Generally the following departments/groups are represented:

  • Associate Compliance Officer – Clinical Domain (chair)
  • Case Management
  • Chief of Medical Staff (ex-officio with vote)
  • Collaborative Center for Clinical Care Improvement
  • Correctional Managed Health Care
  • JDH Dental Clinics, Faculty representative
  • Diagnostic Imaging and Therapeutics
  • Emergency Department
  • Health Information Management
  • Information Technology
  • JDH and UMG Billing Services
  • Laboratory Medicine and Anatomic Pathology
  • Medical Staff Office (credentialing representative)
  • Pharmacy
  • Clinical Planning and Decision Support
  • Psychiatry
  • Rehabilitation Services
  • Reimbursement/Managed Care
  • School of Medicine and Dental Medicine Faculty
  • UMG Ambulatory Services administration
  • Coding and Documentation Officer/ Patient Financial Services
  • Compliance Specialist, Coding and Documentation /Compliance Office
  • JDH Quality Programs

Ex officio without vote:

  • Associate Dean for Education and Patient Care – Dental
  • UCHC Compliance and Audit Office (including the following staff):
  • Compliance Education Director / Faculty Liaison
  • CCIPO
  • Associate Compliance Officer – Education/Administration
  • Associate Compliance Officer – Finance
  • Internal Medical Auditor

The UCHC CCIPO has appointed the Associate Compliance Officer for the Clinical Domain to be the Chair of the Clinical Compliance Committee. Committee members shall serve for the time that they represent their department or group compliance concerns. All members of the committee shall have a working familiarity with basic principles of clinical compliance and ethics. Many of the members will have direct responsibility for compliance within their department/group by virtue of their role in the institution. Generally, each committee member shall be independent and free from any relationship, which would interfere with the exercise of independent judgment. However, should an issue arise where any member recognizes a conflict, that member will note such conflict and recuse him/herself from discussions/voting on the topic.

MEETINGS

The committee shall meet at least four times per year, usually quarterly or more frequently as circumstances dictate. A quorum will be satisfied by the attendance of greater than 50% of the voting members. When a quorum is present votes may pass by a simple majority.


DUTIES

To fulfill its duties, the Committee shall:

  • Annually review, discuss and approve of the following:
  • Clinical Compliance Plan, which includes the following areas:
  •            Clinical Compliance Monitoring Program,
  •            Clinical Compliance Policies and Procedures,
  •            Compliance Education Plan;
  • Maintain current their own compliance training;
  • Review the ongoing activities of the Clinical Domain for Compliance;
  • Provide verbal and written reports on selected monitors to the Committee;
  • Report on concerns, risks and trends;
  • Review the integrity of the clinical domain’s internal controls in consultation with the internal auditors, as noted in specific audits;
  • Perform any other activities consistent with this Charter, Hospital and Medical Staff By-laws, By-laws of the Schools of Medicine and Dental Medicine and governing law, as the committee or the UCHC Executive Compliance Committee deems necessary or appropriate;
  • Review and update this charter as conditions dictate, but no longer than every five years.

Approved by the Joint Audit and Compliance Committee on 03/12/08