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Compliance office reports risk heat map, hotline results and seven active legal matters
Summary
Christy Lewis, chief compliance officer, presented an annual risk assessment heat map, a compliance work plan (45% complete), incident‑management results (three hotline incidents, two substantiated and closed) and litigation reporting including seven active cases with one recent dismissal.
Christy Lewis, the hospital’s chief compliance officer, briefed the Compliance Committee on the office’s risk assessment, compliance work plan, incident reporting and litigation status.
"Any health care entity should conduct a risk assessment on at least an annual basis," Lewis said as she walked the committee through a heat map and a scoring approach that combines probability and impact to prioritize risks. Examples scored at the top included a nonworking PA system for a floor (vendor bids in progress) and control steps tied to a new key system under capital expenditure.
Lewis said the compliance work plan is dynamic and currently about 45% complete, with 16% described as ongoing items. She listed accomplishments including revision and dissemination of the conflict‑of‑interest policy, completion of corrective actions from a 2025 audit, implementation of monthly phishing exercises with the information‑security team and rollout of an intelligent contract‑management system.
On incident management, Lewis said the hotline had three reports in the period: two substantiated and closed (one resolved with an action plan, another resolved to the reporter’s satisfaction) and one open with an extended review timetable; investigators aim to close matters within a 30‑day benchmark.
Lewis provided a litigation update: seven active matters including breaches of contract (one dismissed without prejudice this morning), one medical malpractice matter, a slip‑and‑fall now under further investigation, one personal injury, one EEOC matter and one other investigation; Metro Legal is handling the EEOC mediation scheduling.
Board members thanked Lewis and supporting teams and were invited to contact her for details on any specific case. The committee asked for ongoing updates on priority risks, hotline trends and any material legal developments.
