Office of Healthcare Compliance

FAQs Regarding Compliance

What is Compliance?

The definition of compliance embraces many things.  It means adhering to laws, rules, regulations, policies, and procedures governing the day to day operations of VUMC.

What is an Effective Compliance Program?

The Department of Health and Human Services and its Office of the Inspector General (OIG) now strongly encourage all health-care providers to implement effective compliance programs.  As a commitment to compliance, the OIG has posted recommendations in the form of Compliance Program Guidance for Hospitals.  These guidelines were actually developed by the United States Sentencing Commission (USSC) in 1991 and are listed in the Federal Sentencing Guidelines, Ch.8.  The USSC developed the Guidelines to promote consistent treatment of individuals and organizations convicted of federal crimes, including fines and restitution, imprisonment and probation, or exclusion from participation in various federally funded programs.  VUMC uses these guidelines which include seven fundamental elements of an effective compliance program:

  • Implementing written policies, procedures and standards of conduct
  • Designating a compliance officer and compliance committee
  • Conducting effective training and education
  • Developing effective lines of communication
  • Conducting internal monitoring and auditing  
  • Enforcing standards through well-publicized disciplinary guidelines
  • Responding promptly to detected offences and undertaking corrective action

Why Do We Have a Compliance Program? Great question!

Because healthcare has become so complex in recent years, the industry is under constant scrutiny.  Having an effective compliance program in place helps to avoid or minimize legal or regulatory penalties and potential civil litigations.  VUMC’s Compliance Program promotes ethical conduct and is designed to establish a culture within VUMC that promotes prevention, detection, and resolution of conduct that does not conform to federal and state law;  federal, state, and private payor health care program requirements; and the hospital’s ethical and business policies. 

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This page was last updated September 26, 2016 and is maintained by