Compliance

What is Compliance?

Compliance is how Erlanger works to meet its legal and ethical obligations. Erlanger is committed to complying with all legal and regulatory requirements, and to meeting high standards of ethical behavior in all of its business, operational, and treatment decisions. Erlanger’s Office of Compliance and Privacy Services works with every department and facility across the health system to help make sure we fulfill our ethical responsibilities to our patients, our business partners, and the community. 

The healthcare industry is governed by a vast array of laws, rules, and regulations. Erlanger’s governing and regulatory bodies include agencies you might expect, like state boards of nursing and medical examiners, the Department of Health and Human Services, and the Drug Enforcement Agency. They also include agencies you might not expect, like the Federal Aviation Administration, the Nuclear Regulatory Commission, and the Environmental Protection Agency.

How does Erlanger work to help ensure compliance with laws, regulations, and ethical standards?

The Office of Compliance and Privacy Services, led by the Chief Compliance and Privacy Officer, maintains responsibility for Erlanger’s Compliance Program, which promotes a culture of compliance at Erlanger and works to ensure Erlanger meets its legal, regulatory, and ethical obligations. The Compliance Program does this in several ways:

1. Implementing written policies, standards, and procedures: We develop and maintain policies describing Erlanger’s legal and regulatory obligations and provide guidance to colleagues, associates, and vendors about how to meet them.
2. Compliance leadership and oversight: The Compliance Program is overseen by the Chief Compliance and Privacy Officer, along with the Executive Compliance Committee and the Compliance and Quality Committee of the Erlanger Board of Directors. Regular meetings between these oversight bodies help ensure that areas of risk are identified and discussed, that legal and regulatory changes are understood, and that the Compliance Program is effective.
3. Providing training and education: Erlanger Colleagues are required to complete online training about Erlanger’s legal, regulatory, and ethical expectations. Training is provided at onboarding and annually thereafter. Additional education and training is developed and provided regularly, reflecting specific risk areas or relevant legal or regulatory changes.
4. Maintaining effective lines of communication: Open lines of communication for the reporting of compliance or ethical concerns are a fundamental part of ensuring that Erlanger maintains an effective Compliance Program. Anyone with such concerns is expected and encouraged to report them, by whatever means is most convenient. The Office of Compliance and Privacy Services maintains a 24/7 Integrity Line for the reporting of concerns, offering anonymity should the individual request it. Erlanger does not tolerate retaliation of any kind for good faith reports of ethical or compliance issues.
5. Conducting risk assessments, auditing, and monitoring: We work with departments across the health system to monitor areas of risk to the organization, from cybersecurity to changing Medicare requirements to issues involving patient safety. We then schedule routine audits and reviews based on those risks and conduct for-cause reviews as necessary help ensure that issues are appropriately identified and remediated as they arise.
6. Enforcing standards: In collaboration with Erlanger leadership, we work to establish incentives for helping ensure compliance with regulatory and ethical standards and also consequences for failing to do so. We investigate issues identified through reports of compliance concerns and through the auditing and monitoring functions.
7. Responding to offenses and developing corrective action: When a violation of our legal and/or ethical obligations is substantiated, we work with relevant stakeholders to develop and implement an appropriate corrective action plan. This may include things such as recommending disciplinary action for the individual responsible for the violation; reporting to affected individuals and/or appropriate government agencies; initiating a refund of overpayments; modifying policies and procedures; and developing new training and education.

Erlanger employees and associates are expected to provide the best service possible to our patients and visitors, and to deal with our business partners in a fair and ethical manner. The Compliance Program helps Erlanger provide the best service and care possible by helping ensure our staff comply with the laws, rules and regulations governing the jobs they perform within the healthcare system.  

How to report a suspected compliance violation to the Office of Compliance and Privacy Services

The Office of Compliance and Privacy Services is concerned by any situation which may reflect a violation of our legal or ethical standards. If you suspect that a compliance violation has occurred, please report the suspected violation via one of the following means:

Erlanger Integrity Line: 1-877-849-8338

The Office of Compliance and Privacy Services: 423-778-7703
compliance@erlanger.org

privacy@erlanger.org

By mail:
Erlanger Health, Inc.
Office of Compliance and Privacy Services
975 East Third Street
Chattanooga, TN  37403

In order to determine whether a compliance violation has occurred, please ensure that any reported concern or request for review contains as much detailed specific information as possible. While we welcome anonymous reports, if we are unable to follow up with the reporter to obtain additional information, it can make investigation much more difficult.