Quality and compliance: the dual responsibilities of the chief medical officer.

You are the chief medical officer of a 300-bed teaching hospital.1 At your bi-weekly meeting with the chief compliance officer, you are shown a patient’s physician bill. The patient complained that the physician never saw her on two of the dates billed. The bill was sent to the CCO from the CEO as a billing complaint with the message: “fix it.” Quality of care and compliance ref lect the organization’s core values, especially its integrity. But their inter-relationship is such that the chief medical officer of a provider organization must have considerable accountability for both. The other key players in the direct oversight of quality and compliance are the chief compliance officer and the formal legal adviser to the organization. The CEO and CMO each have a fiduciary responsibility for the proper utilization of resources with an implication that the interests of the patient are first. Compliance, on the other hand, is defined by adherence to regulations as promulgated by federal or state regulatory bodies, certifying organizations and various payers. Regulatory and legal expectations are such that the board is ultimately responsible for both the compliance and quality programs. Medicare’s “Conditions of Participation for Hospitals” states: “The hospital must have an effective governing body legally responsible for the conduct of the hospital as an institution” (§482.12). The American Health Lawyers Association/OIG white paper “Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors” (2007) states: “The fiduciary duties of directors ref lect the expectations of corporate stakeholders regarding oversight of corporate affairs.... This oversight (of quality of care) obligation is based upon the application of the fiduciary duty of care board members owe the organization and, for non-profit organizations, the duty of obedience to charitable mission.” (http:// oig.hhs.gov/fraud/docs/complianceguidance/040203CorpResp RsceGuide.pdf ) The board usually delegates responsibility of quality to the medical staff via the medical staff bylaws while it looks to the administration of the organization for compliance and margin matters. The CMO serves both the medical staff and the administration and works closely with physician and administrative leadership, and thus should have strong oversight function for quality and compliance. Physician leaders are well versed in quality. Many, however, are unaware of their role in compliance—and, in fact, may be left out of the compliance loop by an equally unaware administration.