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Leadership and Oversight

Effective compliance programs must designate leaders to oversee the implementation and operation of the compliance program. DHHS-OIG notes that designating a compliance officer with sufficient authority is critical to the success of the program. The compliance officer must have direct access to the governing body and the chief executive officer. Compliance responsibilities may be the individual’s sole duty or added to other management responsibilities, depending upon the size and resources of the organization.

How Trinity Health addresses this standard

  • A System Integrity Officer (SVP – Integrity & Audit Services) has been appointed with overall responsibility for the Integrity & Compliance Program.The System Integrity Officer reports to the President and CEO and to the Integrity & Audit Committee of the Trinity Health Board of Directors.
  • Each Ministry has appointed an Integrity & Compliance Officer (ICO), a senior member of management, to lead the Integrity & Compliance Program in the local organization.
  • Governance oversight of the Integrity & Compliance Program is provided at both the System and Ministry levels: