HCAD 650 UMDC Health Law Litigation and Managerial Legal Compliance Discussion
Evaluation and Analysis PowerPoint
(1)Stop and Repeat as you watch the video
(2) Rereview the video before each discussion or assignment
(3) Download the PowerPoint to review specific areas you need to work on before each discussion and assignment.
complete the discussion question assigned. Answer ALL guided questions under Part 1 and Part 2 in ONE post.
Review the document The Law, Compliance Tools, and Managerial Actions posted in the Compliance Library.
Use only classroom materials to complete the discussion. This would include the textbooks, weblinks, and the Classroom law library, and Compliance library.
Part 1: Critical Analysis of the Law
Identify, cite the code, and give a short description of one health law found in the common health care statutes document. For the health law selected, evaluate the following.
Evaluate whether the law is a federal or state law, civil or criminal, public or private. How do you know?
Why is it important to know when a statute has been modified by administrative regulation, court decision, or new statute? How can you find out about these changes?
What are the penalties associated with non-compliance with your law? Why would it be important to you and your organization to avoid these penalties? How could you comply with the law you described?
Evaluate the role of the health care administrator or health information technology administrator in legal compliance.
Why is your role important in preventing litigation and supporting legal compliance?
What tools are available for legal compliance? Name one compliance tool from the Week 12 Managerial Compliance Tools list and describe the tool. Evaluate how the tool would control this risk.
How can you take action to reduce legal risk? (Describe at least one managerial action you could take and how you would use the tool you just described to limit legal liability.)
Part 2: Strategic Compliance with the Law
You are an administrator for Big City Hospital Inc., a large medical center. Your medical center has just received a Summons indicating that a Complaint has been filed in the state district court in your city claiming that Dr. Quick, Nurse Sleep, and your medical center were negligent during a recent surgery.
The claim is that the doctor left before the surgical count, the nurse didn’t notice a missing sponge during the count, and the patient now has an x-ray showing that there is a sponge in the abdomen. The medical records do not reflect that a sponge count was even completed. Your state of Maryland has an arbitration process that has been completed and the lawsuit has started.
As part of the lawsuit, you receive a litigation hold letter requesting that all documents related to the lawsuit be preserved including electronically stored information (ESI).
How would you do this? Describe three actions you would take to preserve documents (prevent destruction) for this lawsuit.
What key documents would need to preserve because they relate to what happened?
Laws, Compliance Tools and Managerial Actions
Success Tip: Talk about the law, compliance tools and managerial actions in all
Evaluate what the law requires the organization to do.
Evaluate how compliance tools can be used to ensure legal compliance or
correct legal problems.
Evaluate how specific management actions can be taken to use compliance tools
and ensure legal compliance.
What is a law?
A law arises from a Constitution, statute, regulation or court decision at the federal or
state level. It sets the standard of conduct of what is required. Laws often include
penalties that state what will happen if the requirements of the law are not met. This
can include financial penalties or jail time. For example, HIPAA ;aw has both civil and
Tip: Always start by knowing what the law requires and what the penalties are for noncompliance.
Federal/State Type of Law
Citation Example and Web Link
U.S. Const. Art I
42 U.S.C. 325 (2021)
U.S. Court of
29 C.F.R. 151 (2021)
Advocate Health Care Network v. Stapleton, No. 1675 (2017)
Jones v. Smith, No. 3:2021cv12349 (2nd Cir. 2021)
Markson v. Knox, No. 1:2021cv01334 (Md. Ct. 2021)
Maryland Const. Art. IV
Maryland Mental Health Facilities §10-404 (2018)
COMAR 09.11.02.01C(2)(a)(i) (2020)
North Hospital v. Zenick, No. 34ag/21 (MD. Ct. App.
What is a Compliance or Risk Management Tool?
A compliance or risk management tool is something that is used to help an organization
comply with the law. Any tool that is used to solve a problem should be evaluated to
determine how it will apply to correct the specific problem. For example, a general tool
such as a corporate checklist would need to be adapted to include items on the
checklist to ensure that the company met a specific compliance goal such as avoiding
discrimination in hiring.
Tip: Any managerial tool should be adjusted to meet the specific problem. Evaluate
how to use the general principles of the tool to correct specific problems. Give reasons
to support how your tools resolve the legal problem.
Tip 2: Use the week 12 managerial tools for compliance links throughout the course
to assist with compliance tools for assignments.
How it could be used to limit risk or comply with the law
Litigation Hold Letter
A litigation hold letter is issued to ensure that electronic and
other evidence is preserved for litigation by putting a hold
on destruction of relevant evidence while litigation is
A contract should comply with the law and include contract
clauses to limit the risk of the organization should a dispute
arise. A contract should be adapted to meet the needs of
the specific situation and risks.
Contracts and Contract
Cloud Based Contract
including policies and
HHS OIG Compliance
COSO Internal Control
Code of Ethics from a
Organization or from
the Hospital, Clinic or
Technology or other
A cloud based contract management system helps ensure
that the organization complies with the requirements of the
contract and tracks the life cycle of the contract to limit risk
from non-renewal or renegotiation.
Corporate documents set the standards, vision, rules for
the organization to meet. They ensure consistency of
managerial actions and should be complied with. Any
management actions should comply with both law as well
as organizational documents and policies.
An Enterprise Document Management System (EDM)
creates is a way to keep all organizational documents in
digital forma for prompt review and retrieval. This gives the
organization a system wide process to manage, use, and
The HHS OIG Compliance protocol provides elements an
organization can use to comply with the law and limit the
risk of fraud and abuse.
The COSO Internal Control Framework provides a number
of controls that can be used in order to reduce risk within an
organization. General principles of control can be adapted
to manage specific organizational risks..
Health Information Technology can be used as a
compliance and risk management tool when the tool is set
up to comply with specific legal requirements and to limit
risk of non-compliance.
A Code of Ethics sets an ethical standard for those who
belong to the organization. Many organizations require a
person to sign the Code of Ethics as indication that they
agree and will comply with the ethical standards. This
ensures high ethical behavior which improves the likelihood
of legal compliance as well and limits the risk of
This is an assessment of the security risk to health
information within an organization. It is required by law and
helps ensure compliance with the law.
Internal audits give an organization a chance to catch
problems before an outside auditor, government regulator,
or accreditation agency comes in and finds a problem. This
allows the organization to correct the problem in order to
comply with legal requirements.
Checklists can be for a variety of activities and include a
surgical checklist, hiring, termination, or evaluation checklist
to ensure that all steps for safety are taken before a
procedure or activity. Checks can ensure consistency in
legal compliance no matter who is conducting the activity.
AHRQ, NCQA, Joint
Guidelines. and HHS
Sample Forms and
Guidelines provide a tool to meet high standard of practice.
They are not enforced like the law, but set high standards
that improve compliance and prevent problems.
Sample forms can help an organization set up a form for
patient intact, informed consent, consent refusal, prevent
violence, or encourage patient safety, ensure advanced
directives comply with state law, or take other actions in a
way that minimizes risk and complies with the law.
Formal training tools can be used to provide employee
training on HIPAA, OSHA Safety, or other issues to
encourage patient safety, legal compliance, etc.
What are Managerial Actions?
Managerial actions are things that you can DO as a manager to comply with the law.
These actions may include ways to use compliance and risk management tools to
comply with the law. Something that the government does is not a managerial action.
For example, issuing a litigation hold letter would be a managerial action to preserve
evidence when a lawsuit is anticipated.
Tip: Any recommended managerial actions should be specific to the problem and
correct the problem, reduce the risk, and prevent future problems. Always explain how
the recommended action will do this. Include reasons to support your recommended
Legal Problem it could correct
Issue a Litigation
Hold Letter as soon
as you know a
lawsuit will be filed.
Add an arbitration
clause to a contract
to keep a contract
dispute out of court
and the public
Create a new policy
on bullying to
prevent bullying in
Litigation Hold Letter
This would ensure evidence is
preserved for the lawsuit that is
anticipated before issuing the
litigation hold letter.
This could keep an contract issue
form going to court and limit
public exposure to the issue.
When an issue arises a policy
can be created to prevent the
issue in the future and ensure
that if it arises it is consistently
Train employees on
how to use the
technology system to
keep PHI private and
secure with a quiz at
the end of training as
a knowledge check..
plan for an employee
who is chronically
late to work with a 30
day follow up
Create a checklist for Checklists
patient discharge to
that needs to be
completed prior to
Conduct an internal
medical record audit
to see if initial visit
coding is supported
by the medical
Create a hospital
Forms and Guidelines
protocol for opioid
use disorder (OUD)
screening based on
national guidelines to
screening of all
handled in conjunction with the
Any training should be specific to
the legal problem and provide
specific information to employees
so that the problem is less likely
This allows the manager to
correct a problem a specific
employee is having. It should be
followed up with review to see if
the corrective actions were
properly implemented by the
employee after a preset period
such as 30, 60 and/or 90 days.
This ensures that patient meets
medical criteria for discharge, has
received any training or
medication for discharge, and
that the discharge is in
compliance with the law.
An internal audit allows the
organization to review its own
records related to legal standards
and make needed changes to
comply with the law before an
outside auditor, regulator or
accreditor comes in to audit and
finds a problem.
Protocols ensure consistent
actions for all who do the same
Forms ensure that the
information that needs to be
captured to comply with the law is
on the form.
Week 1: Sources of Law, Litigation, and Managerial
Sources of Law
• The U.S. Legal System https://corporate.findlaw.com/litigation-disputes/the-u-s-legalsystem.html
• (Federal)Court Role and Structure: http://www.uscourts.gov/about-federal-courts/court-roleand-structure
• Comparing Federal and State Courts https://www.uscourts.gov/about-federal-courts/court-roleand-structure/comparing-federal-state-courts
• Office 365: How to Setup a Litigation Hold on a Mailbox
• Alison, J.R. Five Ways to Keep Disputes out of Court, Harvard Business Review (January –
February 1990) https://hbr.org/1990/01/five-ways-to-keep-disputes-out-of-court
• Determining Litigation and Statutes of Limitation Requirements for Records Retention
• Litigation Holds: Ten Tips in Ten Minutes
• Implementing a Litigation Hold with file hold Implementing a litigation hold with FileHold |
• Sample Litigation Hold letter https://iaals.du.edu/sites/default/files/documents/resources/05__sample_letters_-_litigation_hold_and_electronic_data_preservation.pdf
Legal Compliance and Risk Management
• Tips for Implementing an Effective Compliance Program
• What is Risk Management in Health care? NEJM Catalyst (April 25, 2018)
• Park, H., et,. al, Controlling Legal Risk for Effective Hospital Management. World J. Men’s
Health (April, 2018) 34(1)
• HHS OIG: Measuring Compliance Program Effectiveness: A Resource Guide (2017) Microsoft
Word – HCCA OIG Resource Guide (002) (hhs.gov)
Medical Record Documentation
• NCQA Guidelines for Medical Record Documentation https://www.ncqa.org/wpcontent/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf
• Make sure your documentation meets guidelines https://www.karenzupko.com/make-sureyour-documentation-meets-guidelines/
• AHIMA: Integrity of the Healthcare Record: Best practices for HER Documentation (2013
• Cahill, R. The Defensible Medical Record. The Doctors Company.
• Surgical Documentation Primer.- American College of Surgeons. (A.C.S.)
• WHO Surgical Safety Checklist https://www.who.int/teams/integrated-healthservices/patient-safety/research/safe-surgery/tool-and-resources
Find the Law Resources
• Online Legal Dictionary https://dictionary.law.com/
• Findlaw Cases and Codes https://caselaw.findlaw.com/
• U.S.Constitution – https://constitutionus.com/
• U.S. Laws, Codes & Statutes – U.S.Constitution, U.S.Code, State Codes
• Federal Statutes – The United States Code (U.S.C.) https://www.law.cornell.edu/uscode/text
• Federal Regulations – electronic Code of Federal Regulations (C.F.R.) https://ecfr.io/
• State Regulations – https://www.law.cornell.edu/regulations
• U.S.Supreme Court https://www.supremecourt.gov/
• Supreme Court of the United States (SCOTUS) Blog https://www.scotusblog.com/
• Federal Circuit Courts of Appeals https://law.justia.com/cases/federal/appellate-courts/
• Federal district court cases https://law.justia.com/cases/federal/district-courts/
• State court web sites https://www.ncsc.org/information-and-resources/state-court-websites