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Unformatted text preview: By Michael Morrow, Kathryn Dever and Gene DeLaddy, CIA Feature Achieving Consistency in Your Audit Program at a Large Multi-hospital System June 2009 Association of Healthcare Internal Auditors New Perspectives 47 Introduction by Gene DeLaddy The healthcare industry continues to develop appreciation for the importance of an eighth essential element to an effective compliance program—a strong culture of compliance and ethics that permeates throughout the organization. Developing and sustaining a values- based organizational culture does not happen overnight, but we can facilitate the process through an integrated audit program approach that reinforces the attitudes and behaviors reflective of a commitment to and emphasis on doing the right thing. The challenges to achieving the benefits of program consistency are ever more important in the complex environment of a large multi-hospital system. The Carolinas Healthcare System’s (CHS) executive team is responsible for the nation’s third largest public healthcare system, with more than $4 billion in net revenue under management during 2008. CHS is comprised of more than 20 hospitals and approximately 250 other healthcare facilities, including physician practices, surgery centers, diagnostic centers, nursing centers and physical rehabilitation programs. Approximately 1,100 physicians and 25,000 employees provide care for 2.7 million inpatient, outpatient and emergency department cases each year. During the past several years, CHS has expanded throughout the region, bringing other hospitals, physicians and healthcare facilities under the CHS umbrella. The CHS Compliance and Internal Auditing teams make their expertise and experience available to all CHS affiliated clinical and administrative organizations, demonstrating not only their scope, but their breadth of knowledge, as well. Our success in program consistency has largely been the result of program maturation and a shift toward an integrated approach for the areas of Internal Audit, Compliance and Privacy. It has been our experience that the Internal Audit department’s partnership and integration with the Compliance and Privacy functions optimizes all resources available to achieve our Compliance program goals. We believe it is essential to have a strong corporate program that can provide education, training, auditing, and monitoring at the appropriate level for each facility....
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