Best Effort Security

This timely webinar for health care leaders is a discussion on current security threats and typical organizational solutions for countering those threats. Through a review of current cyber incidents, participants will gain an understanding of why, despite well-designed countermeasures, security incidents and breaches continue to occur. During the session the phrase “best-effort security” will be defined, how “best-effort” leads to security failures, and four areas of focus that will help any organization move from “best-effort” to “effective security”.

Using recent cyber incidents as examples, attendees will be able to:

  • Contrast between security measures that work as intended and those that fail and associated consequences;
  • Accurately describe what “best-effort security” means in practical terms and explain the difference between “best-effort” security and “effective security”; and
  • Explain four areas of IT security to focus on in order to strengthen organizational security posture.   

Hospital board members, CEOs, CIOs, IT

Dr. Fernando Martinez is a career healthcare executive and technologist who has worked with some of the largest healthcare systems in the country. Dr. Martinez is a recognized technology and operations expert with a history of developing innovative and transformational strategies for organizations of all sizes.

Dr. Martinez has dual roles at the Texas Hospital Association serving as a corporate Sr. Vice President/Chief Strategy Officer, and President and Chief Executive of the Texas Hospital Association Foundation. Prior to coming to the Texas Hospital Association Dr. Martinez held CIO roles for multiple healthcare systems and hospitals for over two decades.

Dr. Martinez has earned industry recognition for his work including CIO Innovator of the Year (2017), Technology Executive of the Year (2012) and Information Security Executive of the Year (2009). He has published articles focused on management, technology strategy, IT security and governance, is a frequent public speaker, and is an Adjunct Faculty member of Graduate Healthcare Management Programs for the Chapman School of Business at Florida International University. He holds undergraduate and graduate degrees in Information Technology with concentrations in information security and has an earned PhD in Educational Leadership and Organization.

Dr. Martinez advanced to Fellow status for the Healthcare Information and Management Systems Society (FHIMSS) and the College of Healthcare Information Management Executives (FCHIME). He is a credentialed security professional and instructor since 2002 and holds CISSP (ISC2), CISM, CISA and CGEIT certifications from ISACA, along with credentials from APGM as a certified instructor for the ISACA CISM and CISA certifications.

April 12; 5:00 p.m. MTN

Access instructions and materials will be emailed to the person completing the registration prior to the program date. If you do not receive the instructions at least 24-hours in advance, please contact IHA.

Governing Board and C-Suite Responsibilities: CMS, TJC and DNV Requirements

The Centers for Medicare and Medicaid Services (CMS) has issued many citations related to the Governing Board and the C-Suite. This program will discuss the standards and responsibilities of the Governing Board and C-Suite members for hospitals under CMS Conditions of participation and hospitals accredited by The Joint Commission and DNV, which are closely cross-walked to the CMS CoPs.

The governing board of a hospital is responsible for operation and management of the hospital. Members of the C-suite are also involved with the operation of the hospital, as they are tasked with ensuring implementation and safe provision of care within the hospital.  All these sections have various responsibilities which are evaluated by CMS and the various accrediting organizations. 

This presentation will cover the requirements for the Governing Board and C-Suite of hospitals under the CMS Conditions of Participation and those accredited by the Joint Commission and DNV Healthcare.

  • Describe CMS, Joint Commission and DNV standards for Governing Board and management.
  • Explain that the Governing Board is responsible for operation of, and provision of care by the hospital.
  • Explain that C-Suite management is responsible to the Governing Board for implementation of policies and procedures and provision of safe care.
  • Recall that CMS requires that Board ensure all services, including contracted services, are reviewed as part of the QAPI process.
  • Governing Board members
  • C-Suite (CEO, CFO, CNO, CMO)
  • Director of Accreditation and Regulation
  • Hospital Attorneys
  • Risk Managers
  • Individuals responsible for contracted services
  • Quality improvement director
  • Department directors
  • Patient safety officer
  • Compliance officer
  • Joint Commission coordinator
  • Regulatory department directors

Laura A. Dixon, BS, JD, RN, CPHRM

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020.  In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states.  Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.  Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California.  In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States.

Ms. Dixon’s legal experience includes medical malpractice defense and representation of nurses before the Colorado Board of Nursing. 

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa.  She is licensed to practice law in Colorado and California.

March 8; 5:00 p.m. MTN

Access instructions and materials will be emailed to the person completing the registration prior to the program date. If you do not receive the instructions at least 24-hours in advance, please contact IHA.

The Intersection of DEA, Opioids & Hospital Risk

During 2021, hospitals in Texas, Michigan, and Missouri were fined almost $14 million by the Drug Enforcement Administration (DEA) for the improper handling and prescribing of controlled substances. As a result of the ongoing opioid epidemic, it appears that hospitals have been added to the government’s continued focus on prescription opioids. This webinar will link the DEA’s specific authorities in the practice of medicine and controlled substances, in light of the opioid epidemic, and how it specifically relates to hospitals and medical clinics. Through a review of federal law and actual case studies involving several hospital investigations, attendees will learn what triggers a DEA investigation, how to respond, and more importantly, how to prevent one from ever happening at their hospitals.

This webinar is not a “theories class” or a discussion of recent case rulings, but will be an engaging, data driven, common sense review of recurring problem areas and red flags from a former DEA agent with real life prescription opioid experience. The course will also
cover updates regarding new federal law pharmacy requirements for “suspicious order monitoring,” DEA registration, controlled substance security requirements, and emerging best practices tips.

  • Describe the DEA’s specific authorities and role in relation to controlled substances, hospitals, and the practice of medicine;
  • Articulate characteristics and red flags that are often seen in hospitals that result in monetary fines; and
  • Discuss practical strategies and tips to reduce opioid risk a at medical organizations while complying with federal law.

COOs, CMOs, CNOs, nurse staff, pharmacy staff, compliance officers, medical staff coordinators, risk managers, patient safety officers, documentation specialists, hospital legal counsel, joint commission coordinators, regulatory officers, education department
staff, audit staff, and others responsible for compliance with hospital regulations, including documentation compliance

Dennis A. Wichern is a partner with Prescription Drug Consulting (PDC) where he focuses his efforts on risk mitigation and compliance initiatives to protect healthcare organizations and providers nationwide. Prior to joining PDC, Wichern completed 30 years of
public service as a DEA agent, last serving as the agent in charge of the Chicago Field Division. Before his transfer to Chicago in 2014, he oversaw DEA operations in Indiana where he observed first-hand the deadly effects resulting from the prescription drug and opioid
epidemic. Wichern has been a guest lecturer on medical prescriber safeguards to medical students, residents, and prescribers at Harvard Medical School, Northwestern University Feinberg School of Medicine, Illinois State Medical Society, and several additional
schools and hospital groups. He has also lectured with the American Bar Association Health Law Section, the American Health Lawyers Association, and the Indiana University McKinney Law School, as well as at the DEA Training Center in Quantico, VA.

February 15; 5:00 p.m. MTN

Access instructions and materials will be emailed to the person completing the registration prior to the program date. If you do not receive the instructions at least 24-hours in advance, please contact IHA.