There are a lot of barriers in compliance.In this installment of Compliance Conversations, I chat with Erick Dominguez, the chief compliance officer at Emerus, a management company that specializes in healthcare systems. Part of the services they provide to these joint ventures is a compliance program.
Implementing compliance has its difficulties and Dominguez talks about common hurdles he regularly faces.
“Some of the compliance challenges are more around our alignment with the partners. It’s a challenge and at the same time, it’s really a great opportunity for growth. In the compliance space, obviously there’s, you know we’ve got the elements of an effective compliance program, but it’s not prescriptive, and you’re able to use either different processes, job aids, tools, to be able to make sure the company has a culture of compliance. It’s great to have that opportunity with partners, but at the same time, it can be a challenge, why, because we all feel like our compliance program is, especially when it was built from scratch, is our baby if you will. We made it, we created it, and it’s been great. So why would we need to change anything?”
Dominguez and I also had a fascinating discussion about micro-hospitals, otherwise known as neighborhood hospitals, and the many compliance challenges specific to these organizations.
So how do Dominguez and his group manage? And how can we get better at it ourselves?
Tune into this episode of Compliance Conversations, How the Pros Implement a Compliance Program, with Erick Dominguez to learn how to tackle compliance like a large hospital group, manage the unique challenges of micro-hospitals and navigate policies and procedures for hospital licensing.
CJ: Hello everybody, this is CJ Wolf, Healthicity’s Sr. Compliance Executive. Welcome to another episode of Compliance Conversations. Today's guest is a good friend of mine, both personally and professionally, Erick Dominguez. Welcome, Erick.
Erick: Hi! Thank you, CJ. I’m happy t be here.
CJ: Thank you. And Erick I believe is joining us from Texas today, is that right?
Erick: Correct. I’m based out of the good old big D, Dallas, Texas.
CJ: Awesome. I’m going to let Erick start. We’ve got some good questions, I know Eric in his current role, I’m going to let him introduce his title and a little bit about himself, how he ended up in compliance. We all have unique ways; none of us is a kid saying we want to be a compliance officer. We say we want to be an astronaut or a policeman, something cool. He’ll give us an abbreviated version on how he came to compliance, Eric please introduce yourself.
Erick: Sure, thank you. Thank you, CJ. I’m Erick Dominguez as CJ mentioned. I’m the Chief Compliance Officer for Emerus. Emerus is a management company. We come together with large healthcare systems and create the joint ventures, and part of the services that we provide to these joint venture facilities and partnerships is a compliance program. That’s what I lead. I’ve been doing this for seven years, and it’s been a great experience.
CJ: Wow, the time has flown. I didn’t realize it’s already been it’s been seven years for you in this one role.
Erick: It has been. I can only think back and think it’s just a few weeks ago you and I were meeting in a conference room and you were telling me to present something CJ.
CJ: Tell us a little bit about how you got to compliance.
Erick: Sure. I decided that I really wanted to go to medical school. I went to my undergrad at Brigham Young University in Provo, Utah. I pursued the track of pre-med. I was fortunate enough to go through that process and be accepted to Baylor College of Medicine. I also was perusing a business degree in conjunction, so an MBA in Healthcare Management. Around the time between medical school and the MBA degree, I met CJ, and we started talking. I asked him two questions about what he did, and he was actually at MD Anderson, and the University of Texas Amber Cancer Center, and I was very intrigued with what he had done and also with the different areas that he was working in, in a compliance department. I had no idea what a compliance department was, but I then was able to, again, get that understanding, and I had the opportunity to start working at the Institutional Compliance Department at MD Anderson, and that’s how I got into compliance. Kind of the rest is history. So, I’ve been doing this in healthcare for about 19 years, on and off in different positions, but compliance, it’s been roughly ten or eleven years.
CJ: I think that you sharing that resonates with a lot of us, because we’ve all had our own unique paths, it’s always interesting to hear. We have some colleagues that come from a legal background, some from a business background, some from a clinical. I share a little bit with you because I went to medical school, and then got into compliance, so I think we kind of share a little bit of those types of ideas. You’ve been doing this now for a long time, and so I wanted to ask you, and you’re in a unique environment with Emerus. I wanted to ask you, as the chief compliance officer for a growing company like that, it’s growing, I know you’re in many states, and maybe you can speak to that. As you’re growing in these different states and markets, what are the major compliance challenges that you see today in the environment that you’re in?
Erick: Sure. Some of the compliance challenges are more around our alignment with the partners. It’s a challenge and at the same time, it’s really a great opportunity for growth. In the compliance space, obviously there’s, you know we’ve got the elements of an effective compliance program, but it’s not prescriptive, and you’re able to use either different processes, job aids, tools, to be able to make sure the company has a culture of compliance. It’s great to have that opportunity with partners, but at the same time, it can be a challenge, why, because we all feel like our compliance program is, especially when it was built from scratch, is our baby if you will. We made it, we created it, and it’s been great. So why would we need to change anything?
Erick: One of the challenges has been to work with partners, where partners are very clear on this is the way we do, this is the way we want to see it done in these facilities, until we come and share what the program is that we have, the compliance program that we have to use in these facilities. There are certain elements that we take from their program and we add it to our program, and it’s a great opportunity to grow, but initially, it’s a challenge most of the time, that’s one area.
CJ: Tell us a little bit about the kind of facilities you’re talking about. I don’t know if the right term is micro-hospitals, is that the right term? Tell us a little bit about the kinds of facilities that you’re frequently dealing with.
Erick: Sure. So, the facilities that we build in these joint ventures, and these are ventures, are small, kind of thirty thousand, to sixty thousand square feet facilities. That’s both including a first and second floor. These facilities normally have an inpatient unit, and an outpatient, or an emergency department. The Emergency department usually has anywhere from six to eight exam rooms, and the in-patient side usually about eight to ten inpatient beds. These are smaller, right in the middle of these facilities. The two units run parallel in the hospital. In the center we have everything that we use for both the outpatient and the in-patient units, so we have labs, we have imaging, pharmacy, we have the different requirements that we need to have there. Storage, you name it, the different areas. They are in the middle for two reasons, we have a door on each side, so we’re able to use the same departments, or the same rooms, for both units, and so it really, or the term you used was Micro-Hospital, we actually coined that term, Micro-Hospital, although a few years back we decided it was in our best interest, from a business and patient standpoint, to use the term Neighborhood Hospitals, as opposed to Micro Hospitals.
CJ: Yeah, because you’re really situated in neighborhoods as opposed to, a lot of us might work and think about medical centers as this little mini-city within a city, where it’s research institutions, but you guys are in the neighborhoods, right?
Erick: That’s exactly right, and because we’re out in the neighborhoods where people live and play, and sometimes they even work in those areas. Rather than having them drive to downtown or a big box hospital, or a bigger general hospital, we have services, kind of a health plex, if you will, out in the neighborhoods close to home. That’s the biggest reasons we had to put this model out there for consumers.
CJ: I may have cut you off when I was asking you about challenges you see today in this environment, were there any others that you wanted to touch on?
Erick: Yeah, so because of the uniqueness of the model. Having these amounts of beds, usually you think about a hospital, you aren’t thinking about anything less than one hundred to one hundred fifty inpatient beds. Some go up to five hundred or such, and we’re only talking about eight to ten. What we do, another challenge, because we’re a smaller hospital, what we do is we have multiple hospitals. So really with one partner, we can have anywhere from four to seven of these neighborhood hospitals in the different area’s surrounding the city. Although there is the main provider or the main hospital, these other hospitals are off-site, or satellites of this main hospital. So, putting all those together we’re looking at anywhere from forty to sixty, seventy, inpatient beds. What the challenge is, in September of 2017, there was clarification from CMS that to be able to be the definition of a hospital for the social security act, we must be engaged, primary in inpatient care. We’ve always had those be ED, patients come into our ED, then as needed we either discharge them from our inpatient’s unit, or we transfer them depending on the level of the patient's needs. Where the challenge came in, was first, before September of 2017 we didn’t have a lot of clear guidelines on what that really means. Does it mean we need to have more inpatient beds than outpatient beds, what does it mean? So, for years we were under that challenge, well in September of 2017 there was clarification. There was clarification, and really it was interpretive guidelines is what they gave us. What that led to was to say, you must have an average daily census of two patients. You must have an average length of stay of two, and you must have at least two inpatients at the time of any state or federal survey.
Erick: What happened there was, we’ve always been providing inpatient services, but we didn’t have an exact number to go off. So, the challenge that came to us was, what do we need to do to make sure we’re meeting those requirements to be able to keep these neighborhood hospitals open as hospitals and maintain our CMS certification numbers because we are fully licensed as a hospital, although they are smaller hospitals.
CJ: I see, I can see where that can be challenging. Let me ask you too then, you’re partnering with a lot of different entities. Maybe give us a sense of the scope, I think you have facilities in Idaho, Nevada, Texas, and maybe on the east coast. So, you’re in different geographic areas of the country, and you’re partnering with different healthcare entities. Anything from a compliance standpoint that stands out from certain regions of the country or from certain states?
Erick: Oh yes. We opened most of our hospitals here in Texas, in Dallas, Houston, the Austin area, San Antonio and El Paso. We do have partnerships in Oklahoma and Nevada, Las Vegas, Washington, Washington State, and Pennsylvania as well. In Colorado and Idaho, we also have partnerships there. What you touched on, on one of the other challenges CJ, is that when we’re, we were very well versed in everything Texas. We opened our first little, it was like, our little baby, our little facility that we opened first for this company was in Tomball, it was a free-standing ED. It was not a neighborhood hospital. It then became a neighborhood hospital as we added the inpatient side. Then we went to Dallas, we went to San Antonio, then Austin, then El Paso. We knew everything Texas. As we went out, the first place we went out to was Colorado. That came with its own challenges. We had to basically learn a similar type of regulation, but it had its nuances, then it had some other areas based on geographical location and patient population, there were different needs in that area or those areas. We had to learn and adjust our policies or procedures to be able to meet the needs of, again, the population the geographical area and then, of course, the partner, and what they were expecting from us.
CJ: Do licensing requirements, I mean licensing for hospitals is granted by the state, even though you may be getting a CMS certification to be able to submit claims to CMS, but correct me if I’m wrong, licenses come from the state, right? Are those requirements significantly different from state to state?
Erick: You’re right, the license comes from the state to open the actual hospital. When we hit twenty, it was twenty inpatients. Now just recently they changed that to thirty inpatients, once we hit that thirty inpatients then we reach out to our crediting agency, for us it’s DMD, and we notify them that we’re ready for them to come out and review based on the minimal standards, which really is almost verbatim the conditions of participation, and then they come out for the CCM which then allows us to, it has a medical number, again the CCM, the number, and be able to get paid for that. Then, of course, a lot of other things trickle off that, but back to the state license, the state license is one that we needed to, they are somewhat different. The state regulations in Texas are different than the ones in Colorado and Oklahoma and other states.
Erick: What we do, as part of my team, specifically I have hospital compliance officers that are over certain markets. What they do is, them and I, I have them go line item by line item, making sure that we have policies, procedures, documents, agreements, orientation, sign-in sheets, schedules, you name it. Everything line item by line item, then we meet, the HCO and I, we meet together, we review that content, and I have my surveyor hat on, we go through everything, I’m asking every question in those regs, I’m reading off the regs. Then we meet with leadership, our CEO, our CNO, our leadership there. We have sessions in preparation for these surveys, and then when the surveyors come out, we’re ready. We’ve asked all the questions, we have all the documentation in place, or we know where to get them. I can tell you it’s been great to go through that process. When we opened the first one, those surveys should last one to two days. They normally take about five hours. The next hospital it goes down to four, three, two, and the last one is an hour, they are in and out, because it’s the same policies and everything, and we have everything ready for them.
CJ: That’s great, I bet they appreciate that as well.
Erick: Oh yes.
CJ: And they get to know you probably, so they start to trust the system.
Erick: That’s exactly right.
CJ: You mentioned you have hospital compliance officers over certain markets, and I wanted to Segway into my next question on that point because you’re hiring compliance professionals. You probably interview a lot. One thing I’m curious to ask my colleagues that are on the front lines, so to speak, from a professional standpoint, what are some of the key skills or characteristics, may two, three, or four, whatever number you think is good. Key skills or characteristics you’re looking for when you’re hiring compliance professional. Maybe one of these hospital compliance officers, or a different title, what are those key things in your mind?
Erick: Sure. Let me start off by saying CJ, that, in my department I have attorneys, I have nurses, and I have others that have Dr.’s degree’s in the policy. There’s really the gamut of different professions and training that they have as a background.
Erick: the areas that I look for, and that have benefitted us in this role in this organization, are really those that have open and timely communication. Building those relationships at all levels of the organization. Communication is one key skill that is very important because here’s a compliance professional that has direct reporting responsibilities to a corporate compliance officer, but they also have a dotted line to the CEO of that region of that market, and they work closely with the compliance program of the partner of a healthcare system that they have a very mature program, and they have been around for so long, and they have, they’re a stakeholder, and they have a huge investment in this joint venture. There is reporting to the governing board of that hospital on a quarterly basis. Again, open and timely communication, building those relationships, verbal and written communication skills are key. Because of our set up, I’m based here in Dallas, there are hospital compliance officers that are one thousand, fifteen hundred miles away from me, and we have all this technology nowadays, but I don’t see them every day. I don’t come into the office and walk by their office and walk by their office and say how you are doing Mike, or hey Bonnie. I rely on them to be self-starters, to be pro-active, and to be open to guidance and direction when appropriate, but they are running their own programs, and we’re meeting on a regular basis, but self-starter and pro-active is big as well.
CJ: Yeah, that’s interesting. So, the neighborhood hospitals are on the smaller side, are these compliance officer’s kind of compliance of one, dealing with the market, or are they big enough to have assistants, what’s the staffing like?
Erick: Sure. Really, the hospital compliance officer out in these neighborhood hospitals, because it’s again, it could be a forty to sixty-bed hospital in four, five, six, seven different facilities, they are the compliance leader in that market. So yes, they don’t have someone else that reports directly to them, at least not up to this point. Now, we do have corporate positions that report directly to me, and that is in the compliance department, that help them on a regular basis. For instance, we have a revenue cycle compliance director, we have a compliance specialist slash analyst, we have a compliance assistant, and the way we set it up was from a corporate level, those are resources for all the HCO’s in the company as we continue to build more, and partner with different health systems. They are the one, they don’t have someone that directly reports to them out in these markets.
CJ: I think that brings back to the point you made about skill is building relationships, because they can kind of direct the compliance program but you really need somebody that can kind of convince the nurses and doctors and the pharmacist, and whoever, that these compliance policies and procedures are really something they need to be doing, so you’re trying to build that relationship of trust so that they will actually do it.
Erick: Absolutely. Building that team chemistry in those markets, and of course in the department is key. Then, of course, holding themselves accountable. All those areas are very important, as you mentioned, they are the face of compliance in their markets for anybody and everyone in that area. The other thing that has benefitted us as we have this type of setup in our department, is because we do have different backgrounds, we have the clinician, the attorney, we have people that have worked in privacy, in billing and coding, revenue cycle, we as a team can come together and there’s no reason why someone in Las Vegas can’t reach out to someone in Pennsylvania or El Paso and say hey, what is the best practice, what have you seen in this area. We’re always trying to work together to make sure that we’re getting, we’re capitalizing on everybody’s expertise, to be able to meet our needs.
CJ: Yeah, that’s awesome. Erick, I wish we had a lot of time to talk, we’re coming close to our end here, but I wanted to see if you have any last-minute thoughts. Considering who’s listening to this, it’s our colleagues right, other compliance professionals, from different types of providers, but a lot of them are a hospital. Any last-minute thoughts that you have, or advice that you have to listeners, either on bettering their programs, or even these last questions where we’ve been talking about key skills that compliance professionals need.
Erick: Sure. What I would share, CJ, is I’ve found that a lot of times in the beginning when somebody thinks compliance they are thinking, here comes someone who is going to enforce a rule.
Eric: Which is true, but the reality is or should be true, but the reality is, I don’t see myself as a cop, or a police officer for the organization. I see myself as someone who can positively collaborate and influence others to do the right thing, to surface the right things that need to be addressed, and obviously to bring them up so that we can get them to the right people that can address them. On our side, to be ready with, to be prepared with the why.
Erick: Then to have the knowledge to differentiate between a requirement, a recommendation, based on best practice or experience, to mitigate, or eliminate the risk. A lot of times we think of it as these rigid compliance officers, or someone who doesn’t have a lot of personability, is not a people person, so I would just suggest one of the things that have helped me, although I’ve had to get out of my comfort zone in many ways in this area, is to really have that charisma to build a culture of compliance in the organization.
CJ: Yeah, that’s so important, I agree with you. I had someone introduce me once as, here’s our compliance officer, he’s part of the internal police. Right after that introduction, I said, I hope none of you think that I’m the police, because, I’m too busy. I’m too busy trying to understand the rules, and just trying to put them into place. Now, yes, in a way we’re doing auditing and monitoring because that’s an effective part as a compliance program, but I don’t think of it as a punitive, though it might come across that way. I always think of it, as you said, look I’m trying to make a collaboration here, and keep the organization safe and out of trouble so you can meet your mission. There’s nothing worse than having compliance issues that will distract your leadership, and your core operations from what you’re really trying to achieve, right?
CJ: That’s great advice, Erick, thank you so much for joining us on this episode of Compliance Conversations. I wish you a good day and wish all the listeners a good day as well, and hope you’ll come back for our next episode. Thank you.
Erick: Thank you CJ, thanks, everyone.