Create a Culture of Privacy and Security 1) Creating a culture of privacy and security is one of the biggest challenges facing healthcare providers today. 2) Privacy and security are best achieved when the overall atmosphere in your office emphasizes confidentiality and of patient information. Leaders that develop this culture will: A) Consistently communicate your expectations that all members of your workforce protect patients’ health information B) Guide your staff to comply with, implement, and enforce your privacy and security policies and procedures C) Remind staff why keeping health information confidential is so important to patients and your practice in staff meetings or whenever the opportunity to instruct arises. 7 Steps to HIPAA Compliance Understand the rules – review the regulations and learn about HIPAA Assign Responsibility – appoint compliance officers Make a list of your ePHI – identify your information systems Conduct a Risk Analysis – assess vulnerabilities, prioritize risks, identify security measures Implement Policies and Procedures – document all policies and procedures, document method to address security policies, select security controls to match policies Deliver a compliance training program – train all employees and document training, conduct initial and on-going training Monitor and document ongoing HIPAA progress and compliance – audit, monitor, and test privacy and security programs, integrate privacy complaints and security incidents

1. Create a Culture of Privacy,
Security, & Safety

2. Finished files are the re-
sult of years of scientif-
ic study combined with the
experience of many years.

3. Lance King
Vice President, Sales
Healthcare Compliance Solutions
Phone (801) 947-0183
lking@hcsiinc.com

6. What
to
expect
1) Five Most Common Reasons for an Audit
2) Timeline if Audited
3) Creating a Culture of Compliance
4) 7 Steps to HIPAA Compliance
5) How to Conduct a Self Audit
6) Compliance Solutions

7. FUNSTAFF ACCOUNTING COMPLIANCEPATIENTS FRONT DESK

10. Patient
Problem
Physician
Plan
Proposal
Produces…
Positive
Negative

12. 5 COMMON CIRCUMSTANCES FOR AN AUDIT
1. Disgruntled ex-employee
2. A self-reported breach
3. Employee activists
4. Patient’s fear of breach
5. Random OCR visit

13. Day 1 Day 10 Day 30/90 Dependent on Completion of Fieldwork
Timeline

14. CREATING A CULTURE OF COMPLIANCE
• Patient-provider relationship
• Training on PHI safeguards
• Easy reference of Policies and
Procedures
• Addressing staff
• Re-assessing job functions

15. CREATE A CULTURE OF PRIVACY &
SECURITY
• Communicate
• Guide
• Remind

16. 7 STEPS TO HIPAA COMPLIANCE
1. Understand the rules
2. Assign Responsibility
3. List your PHI systems
4. Conduct a Risk Analysis
5. Implement Policies and Procedures
6. Training program
7. Ongoing HIPAA progress and compliance

17. Casting the Vision

19. “The art of communication is the language of
leadership.”
James Humes

20. Communication

23. Guide

24. “Nearly all men can stand adversity, but if you want to
test a man’s character, give him power.”
Abraham Lincoln

25. Case Study #2

27. “You must have love in your heart for the people
under your leadership.”
John Wooden

28. • Educate staff about process
• Make security a high priority
• Have an action plan
• Involve your EHR developer
• Specific to your practice
REMIND

29. Self Audit!

30. Compliance
Health
Check-up
Policies
& Procedures
Ongoing
Docs
Training
BA
Contracts
Risk Analysis
& Risk
Management
Action Plan
Security
Incident &
Breach
Management

32. Violation Category Penalty per Violation
Did not know what to do $100 - $50,000
Reasonable cause $1,000 - $50,000
Willful neglect, then corrected $10,000 - $50,000
Willful neglect, not corrected $50,000
Penalties for HIPAA
Violations

33. Physician
Problem
Protection
Plan
Proposal
Produces…
Positive
Negative

35. SECURITY
RISK
ANALYSIS

37. Options
Consultant
In-house
Online
_____________________________(-)(+)

38. What to Expect with HCSI
1. Membership Website Portal
2. Compliance Binders
3. Ongoing Support

39. Training
(New Employee & Retraining)
• HIPAA Privacy
• HIPAA Security
• OSHA
• Medicare
• Employment Law

40. Manuals
• Reference Guide
• Compliance Plans
• Certificate Binder

41. Consultation and Support
• Weekly and Monthly Updates
• Quarterly Newsletter
• Phone and E-mail Support
• Quarterly Assessment

42. Customizable Forms
• Notice of Privacy Practices
• Business Associate Agreement
• All HIPAA Privacy
• All HIPAA Security
• Gap/Risk Analysis
• HIPAA HITECH Breach Notification
• All OSHA
• All Medicare
• Employment Law
• RAC
• Posters

43. “Our HIPAA/OSHA compliance was a huge concern in our office, especially
after one of our employees filed a complaint with OSHA.
We started using HCSI 4 years ago and couldn't be happier with the program.
It's simple to set up and easier to use.
Do yourself a favor and sign up, it will make your life easier!”
-Dr. Kody Krause, DDS
Comfort Dental Thompson Valley, CO
Customer Testimonial

44. “HCSI kept my fanny out of the hoosekow with a cranky (bit
weirdo/psycho) patient who thought we had been naughty in multiple
ways.
Our association with you all made the difference. We passed the
inspection with flying colors and OCR told the "patient" to bug
off!! Loved It!”
-Lee Mecham Thrall, Clinic Administrator
Old Farm Obstetrics & Gynecology, L.L.C
Customer Testimonial

45. 30 Day Money Back Guarantee!

46. Price Breakdown
• Compliance Officer Training ($250)
• Employee Training ($500)
• Risk Analysis ($250)
• Customized Compliance Plans ($1250)
• Customizable Forms ($100)
• Posters ($100)
• Compliance Updates: E-mail & Newsletters ($50)
• Phone & E-mail Support ($500)

47. 24 HOUR DISCOUNT
•5 Years: $2600 base+$3/employee
•1 Year: $1189 base+$3/employee
***$300 OFF: E-mail within 24 Hours to receive a
$300 Discount Code.
E-mail: lking@hcsiinc.com

48. Compliance Officer Training
“Compliance Officer”

49. Customized Policies & Procedures

50. Quarterly Assessment Support Calls

51. Lance King
Vice President, Sales
Healthcare Compliance Solutions
Phone (801) 947-0183
lking@hcsiinc.com

52. Create a Culture of Privacy,
Security, & Safety