Feature Article: Meet Bret S. Bissey, Senior Vice President, Ethics and Compliance Officer at UMDNJ
In an exclusive interview with Compliance Today, Bret Bissey shares his story as the Senior Vice President, Ethics and Compliance Officer at the University of Medicine and Dentistry of New Jersey (UMDNJ).
Editor’s note: This interview with Bret Bissey was conducted in September 2011 by Margaret Hambleton, Senior Vice President, Ministry Integrity, Chief Compliance Officer for St. Joseph Health System.
MH: Mr. Bissey, thank you for agreeing to do this interview for Compliance Today. Please tell our readers a bit about the University of Medicine and Dentistry of New Jersey (UMDNJ) and the depth of your institution.
BB: The University of Medicine and Dentistry of New Jersey is the nation’s largest ($1.8 billion) free-standing public health sciences university. UMDNJ has more than 6,000 students and 15,000 employees, including nearly 3,000 faculty members. It is currently a statewide network of eight schools on five campuses in Camden, New Brunswick/Piscataway, Newark, Scotch Plains, and Stratford. The schools include New Jersey Medical School, Robert Wood Johnson Medical School, School of Osteopathic Medicine, New Jersey Dental School, Graduate School of Biomedical Sciences, School of Health Related Professions, School of Nursing, and School of Public Health, with more than 200 education and health care affiliates throughout New Jersey. University Hospital and University Behavioral Health are inpatient facilities that are a component of nine organizations that encompass UMDNJ’s health care facilities.
MH: You have been with the University now for about a year. Can you tell us what brought you to UMDNJ?
BB: Since 1997 (with the exception of one year in international clinical research), I have been actively engaged in compliance and ethics as both a compliance officer and a consultant. When I was contacted by UMDNJ, the Senior Vice President position was vacant and they were interested in meeting with me. I understood the extensive history at the University, and it sparked my competitive juices about being responsible for their compliance program. When I met the new leadership (i.e., President, Chairman of the Audit Committee, and Chief of Staff) they were able to validate for me very quickly that they were interested in doing compliance the “right way” and that I would be given the authority, autonomy, and resources to try and get the job done. In summary, I perceived this to be a huge challenge and felt that this was the right time in my career to take this on.
MH: As most of our readers know, UMDNJ is operating under an extensive 5-year Corporate Integrity Agreement with the Office of Inspector General for the Department of Health and Human Services. What additional challenges does your compliance program face with such intense scrutiny?
BB: This is the second CIA I have been involved with as Compliance Officer. The first was at Deborah Heart and Lung Center and was a result to the nation’s first voluntary disclosure settlement. Thus, I am very familiar with operating under a CIA and the unique challenges it presents, including that you cannot take a “pass” on any issues that are in front of you, because they all must be dealt with. One initial comment I have is that the OIG’s guidance and direction to me and my legal colleagues at UMDNJ has been very valuable.
The breadth and depth of UMDNJ is the obvious challenge. On my commutes back and forth to Newark and other parts of New Jersey, I constantly find myself asking “What am I missing?” To address that concern, I try (hopefully in a friendly way) to delegate responsibility to any employee that I interact with, including leadership, that if you “know, sense, or smell something that isn’t right,” I fully expect you to inform us… no excuses!
Another challenge is that UMDNJ (for some) has been branded as a corrupt system, university, etc. I know that this perception will not and has not changed overnight. In response to this, we continue to implement a number of creative educational venues (in addition to those mandated by the CIA) to get the message out that we are not that system anymore. One of the biggest challenges the senior leadership of UMDNJ faces is how to continue to reinforce this message to the external UMDNJ environment, including our New Jersey state leadership.
MH: How do you ensure you are maintaining an effective compliance program in light of these challenges?
BB: Obviously, the CIA helps tremendously with delineating the requirements of what needs to be done, no excuses. But, I think as important to the vast community of UMDNJ is a constant reminder that the Model Program Guidance, the US Sentencing Guidelines, and other external factors don’t give us a choice.
MH: Given the state’s budget crisis and the pressure to cut state and community health services, how do you balance your fiscal responsibilities with ever increasing regulatory scrutiny?
BB: We’ve been very fortunate to have the complete support of the UMDNJ trustees and the president in understanding that the budgeted resources, which have been planned for the 5-year CIA, need to be held. During my recruitment, one of the things we discussed extensively was that to do this job, given the CIA and history, we need significant resources for education/training, performing external/internal audits, hotlines, new initiatives, etc. We are constantly challenging ourselves to work smarter and more efficiently to make sure we are getting “top value” for our efforts, including fiscal resources.
MH: Given the increased focus on governance and board involvement, how do you integrate your board’s compliance oversight with other oversight responsibilities, such as quality of care, strategic initiatives, and financial oversight?
BB: Again, I am very fortunate that the Audit Committee of the Board is very, very interested in compliance. Monthly compliance is a standing agenda item at the meeting, where I am totally free to discuss any matter. In addition, also monthly (and more frequently as needed) I have a call or meeting with the Chair of the Audit Committee to discuss open matters. I was informed from Day One that the president and trustees do not want any surprises, thus we “over-communicate” on compliance issues. Again, much of this is necessary, based upon the past history and the need to make sure we are compliant in all activities.
Regarding quality-of-care matters, we have recently instituted that Compliance is a standing member of the applicable committee, is performing the necessary audits, and has the authority
to raise matters as we deem to be appropriate. I serve on the president’s nine-member Cabinet, thus Compliance is very integrated with strategic discussions and financial issues at the senior management level.
MH: Can you describe the structure of your compliance program?
BB: We are independent from any other operational department within the University. I report directly to the Chairman of the Audit Committee of the Board of Trustees and the president. We have a department of 33 budgeted full-time employees with billing/coding/reimbursement auditors, information technology specialists, and educators/trainers assigned to all aspects of the University. They work for/with senior compliance officers and assistant compliance officers. We also have compliance officers/directors responsible for the hospital functions, privacy activities, operations/budget/special projects, and an ethics liaison officer (required for the state of New Jersey) who is the director of the ethics and manages the conflict of interest website/portal and CIA education activities. We have very dedicated administrative staff who help us get thru each day. It is also important to know that we have a separate Investigations department and a distinct Internal Audit department; we work very closely with both of these areas.
MH: How do you evaluate and prioritize the compliance risks facing UMDNJ?
BB: We use a combination of factors, including the OIG Work Plan, state initiatives, historical events, audit findings, and new challenges that we see in the industry to develop an annual work plan that is approved by the Audit Committee each year. Given this is my first year, through this process at UMDNJ, I have attempted to inform everyone that this plan will be dynamic and subject to multiple revisions, given all of the issues that we are faced with in today’s environment.
MH: We know that having an effective compliance program is critical, so how do you measure the effectiveness and success of your compliance program?
BB: The CIA (which I think is one of the most robust in the country) mandates that annually the Audit Committee must engage an external compliance expert to perform a complete compliance effectiveness review of our program. An important point is that I do not control this function; rather is the Board in charge. This is a very valuable activity for me personally and for my compliance colleagues, because it gives an impartial assessment to identify where we can do better. In addition to this activity, in our management meetings (my regular meetings with the compliance officers and directors) we constantly discuss the seven elements of compliance and how/if we are reaching our goals for each. As far as measurement, we have a lot of data from our hotline and audit systems that help develop matrixes to assess where opportunity might exist. In addition, we have a very sophisticated education/training system (implemented per the CIA requirements) that gives us much data on how our education programs are working. One of the other areas that I think all large systems find challenging is how to tackle the issues of assessing all of your contracts for fair market value and assuring there are no Stark or Anti-kickback issues. We spend significant time and resources to review these issues with our legal colleagues, in an effort to make sure that all due diligence is performed and the proper questions are being asked. Also, the CIA has very specific requirements of how frequently contracts need to be audited and other important contract-related tasks that need to be performed.
MH: How do you get employee and management buy-in and strong operational support for your compliance program?
BB: I think this is where unique education ideas help. In my first nine months here, I personally have held many compliance education sessions/updates with multiple different audiences. I plan for this to increase as we move to the close of calendar year 2011 and into 2012. I believe the leader of this compliance program has got to be very visible and interactive. UMDNJ has such an extensive history with very public compliance-related events that it isn’t very difficult to get the attention of individuals within the system. The opportunity I see for the next several years is getting everyone to understand that we are making significant improvements via all of our compliance and ethics activities.
MH: You have such a strong and extensive background in health care compliance, what value does your participation with HCCA bring you in your position?
BB: Thank you for that acknowledgement of my background. HCCA to me is the resource that all compliance officers and compliance professionals need for education, training, sanity, and collegiality. I have attended almost all of the annual conferences since 1998 or ‘99, spoken at many, and I have also been involved in the Regional conferences. The key thing to me is that as compliance officers, we need HCCA. No doubt in my mind. I arrived at UMDNJ in December, 2010, and because of my previous involvement with HCCA, one thing I was concerned about was that rarely in the past was there anyone from the University represented at the annual Compliance Institute. My approach is, if you are working in health care compliance, it is your area of expertise and you need to be present and absorb all the necessary information, both in a classroom and collegial setting. Continued education in this field is invaluable, necessary, and required. This year at the annual Compliance Institute, my plan is to have a very good representative of the UMDNJ compliance/ethics staff in attendance. In addition, we just had great representation at the HCCA Regional meeting in New York City several months ago (May, 2011). I hope this is another indication that we are very serious about compliance at UMDNJ. One other quick story. I have colleague compliance officer who was at his institution following the conclusion of their CIA requirements; the leadership lost some of its focus on compliance activities. Going to the HCCA conferences at that point in his career was extremely valuable, because it validated for him personally that, even though the support for his efforts had diminished within the hospital, he still knew that he was doing the right thing as their compliance officer.
MH: What advice would you give to organizations struggling with creating or maintaining a strong culture of compliance in these difficult times?
BB: Now that is a very interesting question; I will speak to some of my past experiences where, as just mentioned, leadership lost their focus on compliance. Sometimes you have to make a very tough decision to look for other opportunities if your efforts are not being valued. Some would say that is a drastic reaction to a non-compliant environment. I would argue it is the right decision. I really don’t think a compliance officer (no matter how good they are) can change or alter the culture of an organization and its leaders thoughts and motivations. I think they can be influenced, but change is a stretch. Hopefully, if an organization has created a compliance program, it isn’t just “window dressing”; rather it is a full commitment to do the right thing all the time and that the program has teeth in it. In other words, if someone does something wrong, it needs to be dealt with! This culture starts at the top and usually then extends throughout the organization.
A quick story: It is October, 2003 and Chris Anderson (former Chief Compliance Officer at Gentiva) and I are invited to speak at a non-health care, Wall Street, banking/mortgage industry conference on compliance, “Self Disclosure and ‘Doing the Right Thing’” in New York City. We go through all the steps of the model compliance plans, OIG interactions, CIAs, value to the organization’s compliance, self-disclosure, corporate culture, etc. We thought it was an excellent presentation. The Wall Street executives basically laughed us off the stage, with comments like “Oh, sure we will do that” and “What about profits?” (basically insinuating that we were foolish and that this approach wouldn’t fly in corporate America). Well, years later I look back at all the corruption and corporate malfeasance that has occurred in corporate America and, given that day in New York, I wonder what might have been if there had been active, robust compliance programs in those industries?
I mention that story because I think it is the compliance officers’ responsibility to remind leadership constantly about what can happen if you are not diligent all the time. I think this is another reason that the compliance function should be independent from legal counsel and report directly to the Board.
MH: What is your hope for the future of UMDNJ and how will your culture of ethics and compliance help you get there?
BB: As this interview is being conducted in late September 2011, UMDNJ faces many unique challenges, including a very real possibility that three of the educational schools could, in the near future, become a component of Rutgers University instead of UMDNJ. This is part of an initiative to improve the delivery of higher education in New Jersey.
My immediate goals include having a highly educated Compliance and Ethics department that is able to serve the Board and the University in a valuable and proactive manner, while fulfilling all of the requirements of the Corporate Integrity Agreement and the New Jersey State Ethics Commission. My hope is that we continue to increase our compliance efforts and continue to find and fix problems, and make sure that they don’t repeat. If we continue to accomplish this, hopefully people will begin to realize that things can change and that the UMDNJ has changed!