Trinity Health Integrity & Compliance Program: The 7 Requirements Explained

Leadership and Oversight

Strong governance anchors your program. Oversight resides with the Board’s Integrity & Audit Committee, while day‑to‑day strategy, coordination, and accountability are led by the System Integrity Officer. Together they set expectations, approve plans, and receive regular reports on risks, investigations, and corrective actions.

The System Integrity Officer ensures independence of compliance activities; aligns Legal, Privacy, Internal Audit, HR, and Operations; and escalates significant matters without delay. Regional and ministry compliance leaders execute the program locally, monitor controls, and validate remediation, creating a systemwide network that keeps standards consistent and effective.

Clear charters, a defined reporting cadence, and performance dashboards (e.g., case cycle time, substantiation rate, audit completion) give leadership visibility to make timely decisions and allocate resources where risks are highest.

Code of Conduct

The Code of Conduct is your foundation. It translates Trinity Health values into practical do’s and don’ts, applies to colleagues, medical staff, students, contractors, and vendors, and outlines your duty to ask questions and report concerns without fear of retaliation.

• Put patients first: safety, dignity, equity, and quality care.
• Protect information: HIPAA privacy, cybersecurity, and appropriate access.
• Document and bill accurately; avoid false claims and upcoding.
• Manage conflicts of interest; follow gift and vendor relationship rules.
• Comply with Anti‑Kickback Statute and Stark Law in physician arrangements.
• Maintain financial integrity, record retention, and responsible use of assets.
• Uphold professional conduct, a respectful workplace, and zero retaliation.

Annual attestation and policy acknowledgments reinforce understanding and accountability across the workforce and supply chain.

Education and Training

Education turns expectations into everyday behavior. New hires receive orientation on the Code of Conduct, reporting options, and key policies; all workforce members complete annual refreshers tailored to role and risk.

• Core modules: Code of Conduct, how to report, non‑retaliation, and privacy/security basics.
• Role‑based topics: documentation, coding and billing; EMTALA; research compliance; device and pharmacy risks; vendor interactions; conflicts of interest.
• Scenario‑based learning, microlearning refreshers, and phishing simulations that build real‑world judgment.

Completion is tracked; leaders follow up on overdue assignments; and post‑training quizzes and spot checks confirm understanding and retention.

Risk Assessment

An enterprise Compliance Risk Assessment identifies where issues are most likely and most impactful. You synthesize internal data (hotline trends, audits, incident reports, operational changes) with external intelligence, including the DHHS‑OIG Work Plan, enforcement actions, and new regulations.

• Inventory inherent risks across clinical, revenue cycle, privacy, research, supply chain, and third‑party areas.
• Score likelihood, impact, and detection velocity; map existing controls to determine residual risk.
• Assign risk owners and develop a prioritized audit and monitoring plan with timelines and metrics.

The assessment is refreshed routinely and whenever significant changes occur (new services, technology, or laws), ensuring resources follow the highest‑value mitigation opportunities.

Response and Prevention

When concerns arise, a standardized process drives fair, timely, and well‑documented outcomes. Intake channels route to triage, case assignment, and an impartial investigation plan.

• Containment first for patient safety, privacy incidents, or billing holds when warranted.
• Evidence preservation, interviews, and objective fact‑finding with clear case notes.
• Root cause analysis leading to corrective action plans—policy updates, workflow redesign, targeted training, technology controls, or staffing adjustments.
• Effectiveness checks and sustained monitoring; self‑disclosure and repayments when appropriate.

Lessons learned flow back into training, policy improvements, and the next Compliance Risk Assessment, preventing recurrence and strengthening controls.

Enforcement and Discipline

Disciplinary Policies apply consistently to leaders and staff alike and are communicated in advance so expectations are clear. Consequences match the severity of conduct and consider intent, history, and cooperation.

Preventive controls support enforcement: Background Checks verify qualifications and history; ongoing Sanctions Screening against federal and state exclusion lists helps ensure no ineligible individual or entity provides services or is paid. Confirmed matches are escalated promptly, and access or payment is blocked until resolved.

Progressive discipline, leadership accountability for oversight failures, remediation commitments, and vendor contract remedies reinforce a culture where doing the right thing is non‑negotiable.

Effective Lines of Communication and Reporting Systems

Multiple, easy‑to‑use channels encourage speaking up: a 24/7 hotline, a secure web portal, direct contact with managers or compliance officers, email, and in‑person discussions. You may report anonymously where permitted, and confidentiality is protected to the fullest extent possible.

Non‑retaliation is unequivocal. Leaders model respectful responses, remove barriers to raising concerns, and follow documented procedures for intake, triage, and timely feedback to reporters.

Modern case management tools assign unique case IDs, track milestones, and generate metrics (time to first response, cycle time, substantiation rate) for the System Integrity Officer and the Integrity & Audit Committee, enabling transparency and continuous improvement.

In summary, these seven requirements—governance, a clear Code, targeted training, rigorous risk assessment, effective response, consistent enforcement, and strong reporting systems—work together to make the Trinity Health Integrity & Compliance Program resilient, data‑driven, and people‑centered.

FAQs.

What are the key roles in Trinity Health's Compliance Program?

Core roles include the System Integrity Officer, who leads the program enterprise‑wide; the Board’s Integrity & Audit Committee, which provides strategic oversight; regional and ministry compliance officers; Privacy and Information Security leaders; Internal Audit; and partners in Legal, HR, Supply Chain, and Revenue Cycle. Leaders at every level share responsibility for modeling the Code and promptly addressing concerns.

How does Trinity Health conduct compliance risk assessments?

The team performs a structured Compliance Risk Assessment at least annually and after significant changes. It combines internal data (audits, hotline trends, incidents) with external signals such as the DHHS‑OIG Work Plan and new regulations. Risks are scored for likelihood, impact, and detection speed; owners are assigned; and a prioritized plan of audits, monitoring, and mitigation actions is produced and reported to leadership.

What training is required under the Integrity & Compliance Program?

All workforce members complete new‑hire orientation and annual refresher training on the Code of Conduct, reporting options, and non‑retaliation. Role‑specific modules address privacy/security, documentation, coding and billing, EMTALA, Anti‑Kickback and Stark compliance, conflicts of interest, and other job‑relevant risks. Completion is tracked, and leaders follow up on overdue courses.

How can employees report compliance concerns?

You can report through a 24/7 hotline, a secure online portal, your manager, or directly to a local compliance officer. Anonymous reporting is available where permitted, and retaliation for good‑faith reports is prohibited. Urgent patient safety or privacy issues are escalated immediately while the investigation proceeds through documented intake, triage, and resolution steps.