WHEREAS, the Health Commission is the governing body for the Community Health Network which includes the San Francisco General Hospital, Laguna Honda Hospital, and the community health centers; and,

WHEREAS, the Health Commission is committed to the provision of the highest quality health care in the most appropriate, effective, and efficient manner; and,

WHEREAS, the Health Commission is determined that the Community Health Network shall comply with all applicable federal and state standards, and all program requirements of federal, state, and private health care programs; and,

WHEREAS, the most effective way to ensure that the Community Health Network complies with all applicable requirements is to develop and implement an effective compliance program; now, therefore, be it

RESOLVED, that the Community Health Network is hereby directed to develop and implement an effective compliance program that includes, at a minimum, the following elements:

1. The hiring of a Compliance Officer who shall report directly to the Executive Administrator of the Community Health Network;
2. The development and distribution of written compliance policies and procedures;
3. The development and distribution of written standards of conduct that promote a commitment to compliance and address specific areas of potential concern;
4. The development and implementation of education and training programs for all appropriate employees on compliance issues;
5. The creation and maintenance of a hotline or other communication mechanism designed to receive anonymous complaints;
6. The development and maintenance of a system for the prompt and effective investigation and resolution of identified problems;
7. The performance of regular audits/evaluations to monitor compliance and determine the effectiveness of the resolution of identified problems;
8. The development and distribution of policies addressing disciplinary action against employees who have violated internal compliance policies/procedures and/or applicable laws or program standards;
9. The evaluation of supervisors and managers on the issue of compliance;
10. The updating of the Department of Public Health's Records Retention Policy to ensure that it appropriately addresses the creation and retention of appropriate records; and
11. Utilization of qualified legal counsel; and, be it

FURTHER RESOLVED, that the Executive Administrator of the Community Health Network shall report to the Commission within six months on the progress in developing a program that meets the requirements set forth above; and, be it

FURTHER RESOLVED, that the Executive Administrator shall report periodically thereafter to the Commission on the implementation of the compliance program and its effectiveness.

I hereby certify that the foregoing resolution was adopted by the Health Commission at its meeting of Tuesday, August 4, 1998.

Sandy Ouye Mori, Executive Secretary to the Health Commission