Regulatory and Accreditation Compliance

The Joint Commission

  • Centers for Medicare & Medicaid Services (CMS)
  • The Joint Commission
  • Recovery Audit Contractor (RAC) audit
  • FTC Red Flags Rule
  • Health care fraud and abuse
  • "Anti-Kickback" law-Stark I and II
  • ACR radiology performance measures
  • ACR Appropriateness Criteria ®
  • OIG- professional courtesies/vendor contracts
  • EPA
  • Sarbanes-Oxley Act of 2002

    Corporate Compliance

  • Program development
  • Audit tools and training

  • Standard survey readiness/tracer methodology
  • Standard interpretation and resource tools
  • Board and executive leadership training
  • Leadership Structure Standards
    • Leadership and medical staff relationships
    • Organizational culture and system performance
    • Conflict of interest
    • Conflict management

Medical Staff structure evaluation:

  • CMS and TJC compliance review
  • Peer-review process, medical case review
  • Ongoing and focused professional performance evaluation (OPPE and FPPE)

Adverse Event Disclosure
Alternative Dispute Resolution (ADR)

Bioethics Program

  • Standardized adverse event disclosure process
  • Disclosure simulation physician team training
  • ADR strategies, benefits and early intervention strategies

  • Bioethics committee program development
  • Bioethics case consultation
  • Medical staff training
  • IRB evaluation
  • Medical mediation and conflict resolution