The UHS Board of Directors is chaired by our founder, Alan B. Miller. Of the seven-member board, four are independent members and two are women.
- Each director has access to any member of management of the company. It is the policy of the Board to encourage its members to contact the CEO and other members of management of the company at any time to discuss any aspect of the company’s business.
- The Board has six committees: Audit Committee, Compensation Committee, Executive Committee, Finance Committee, Nominating and Governance Committee and Quality and Compliance Committee.
The Board of Directors and senior management of UHS are committed to healthcare operations that are ethical and in compliance with all applicable laws and regulations.
- UHS’ Chief Compliance Officer oversees the UHS Compliance Program and regularly reports on the company’s compliance program operations to the Quality and Compliance Committee of the Board of Directors and to the UHS Compliance Committee.
- UHS maintains a compliance program that includes appropriate policies and procedures consistent with legal and regulatory requirements, compliance education (including enterprise-wide compliance training of all new employees as part of the onboarding process), and its audit and monitoring and disclosure programs.
UHS operates a Compliance Hotline as part of its Code of Conduct. To report an ethical dilemma or potentially inappropriate or illegal conduct, individuals may call the Compliance Hotline (toll free at 1-800-852-3449) or use Internet-based reporting at www.uhs.alertline.com.
- We are committed to fostering a culture of accountability at all levels and encourage our employees to report anything they believe could be out of compliance with our values. We prohibit retaliation for the good faith reporting of compliance concerns and offer the ability for individuals to anonymously elevate any concerns.
- Our commitment to fairness and integrity extends to everyone with whom we interact and do business.
- Our Code of Conduct provides guidance on expectations for acceptable behavior for those who work on behalf of UHS. It is intended to promote honest and ethical conduct; deter wrongdoing; ensure compliance with all applicable governmental laws, rules and regulations; and promote prompt internal reporting of violations and compliance concerns.
- Our Compliance Manual serves as a resource of basic healthcare compliance standards and an overview of the UHS Compliance Program. Further, our Code of Business Conduct and Corporate Standards provides standards of ethical business practices and must be followed by all UHS personnel.
- In addition to in-house Executive Leadership teams, UHS’ Acute Care and Behavioral Health hospitals and our ambulatory surgery centers (ASCs) have organized Medical Staff and local governing bodies jointly overseeing patient care.
- Facilities’ Boards of Directors have both financial and non-clinical operational decision-making authority but delegate oversight of patient care and Medical Staff governance to local governing bodies.
- Local governing bodies for Acute Care Division facilities typically include representation from local community members, medical staff and hospital or regional leadership. Local governing bodies for Behavioral Health Division facilities typically include representation from the local facility and Division leadership, and may include current or retired medical staff.
- In the U.K., our Cygnet facilities are governed by a 13-member Executive Management Board. In 2020, Cygnet established a four-member Advisory Board to provide independent scrutiny and strategic insight to Cygnet’s experienced leadership team.
- The Acute Care and Behavioral Health Divisions each have their own Division Compliance Officer, while each hospital has a designated Facility Compliance Officer to oversee their local compliance program and obligations of their respective facilities.
- As with their peers, UHS facilities receive regular visits and inspections by state and federal regulatory agencies. Each Division has its own Chief Medical Officer and quality designees.
- Similar roles are in place at the regional level, and when appropriate, at the individual facility level. To improve quality management, leadership reviews and analyzes performance metrics each month. Best practices are then shared throughout the company.
- The Acute Care and Behavioral Health Quality and Clinical teams actively promote a culture of continuous quality improvement that incorporates evidence-based best practices and clinical variation reduction to optimize clinical services and help ensure the effective and efficient delivery of high-quality medical care.
- In the Acute Care facilities, programs such as the Zero Harm Patient Safety Campaign are in place to reduce the number of hospital-acquired conditions, healthcare associated infections and patient mortality.
- Our Behavioral Health Division continues its efforts to ensure that all its patients are treated in a safe environment focused on trauma-informed principles of care.
Risk Management Measures
Risk Management teams are in place for the Acute Care and Behavioral Health Divisions. Each has a Division Director, Senior and/or Regional Managers, and Facility Risk Managers. There are also dedicated Corporate Loss Control, Claims, and Environmental Risk and Emergency Management departments. UHS’ robust Risk Management process includes four key steps: Risk Identification, Risk Analysis, Risk Control and Risk Financing.
- Risk Identification’s primary purpose is the early detection of adverse or unexpected patient outcomes and hazards. To this end, UHS has processes, systems, methods and tools in place to promptly identify the organization’s risk exposure to issues that may impact its Mission and Vision of providing superior, quality healthcare services.
- These tools include The Joint Commission’s Sentinel Event Alerts and Failure Mode Effect Analysis, and internal safety processes (i.e., Incident reports, Adverse drug reactions reporting, Discrepancy reports, Executive and Unit Safety Huddles, rounding, patient safety surveys, grievances and complaints). Data is continually collected, analyzed and benchmarked against previous time periods, other UHS facilities and nationally available benchmarks/data.
- Risk Analysis provides the organization with a clear understanding of its risks and an opportunity to provide company-wide corrective action to minimize risk across the organization, when needed and/or in the future. It involves continually conducting thorough reviews of practices, processes, projects and services to recognize and/or detect problems or potential problems to minimize the potential loss.
- Risk Control’s purpose is to have loss prevention and control methods in place before an event occurs. This requires teams to conduct assessments of high-risk areas, new service lines, etc., and proactively adapt processes and procedures, if needed.
- Risk Financing is the methodology to ensure that financial resources are available to pay for the cost associated with loss should risk control techniques fail. UHS utilizes a risk management program evaluation process to ensure its highly effective program exists across all facilities.
- UHS’ Acute Care and Behavioral Health Divisions each have their own Patient Safety Organization (PSO), which is registered with the federal government under the Agency for Healthcare Research and Quality. These PSOs govern the risk management process and voluntarily report, aggregate and analyze data in an effort to improve the safety and quality of patient care.
- UHS’ evaluation process includes interactions of Corporate and Facility Administration, Patient Safety Council and Environmental Risk Management, as well as procedures and processes such as Root Cause Analysis (RCA), to identify and investigate issues, analyze results, implement corrective action (if needed) and educate key stakeholders to reduce safety risk among patients and staff.
- Within the Acute Care Division, a Corporate Patient Safety Council (CPSC), composed of its facilities’ executive leadership team and their respective regional vice presidents, establishes specific patient safety priorities each year to further identify ways to mitigate risk and reduce patient harm. Data from these initiatives are shared with the Board of Directors’ Quality and Compliance Committee each quarter. UHS’ Behavioral Health Division Senior Vice President and Chief Clinical Officer also review patient safety data with this committee on a quarterly basis.
In 2021, one patient safety priority was to utilize quantification of blood loss to drive early intervention and ultimately decrease severe maternal morbidity related to obstetrical hemorrhage. Across our 19 acute care facilities offering obstetrics services, our utilization of quantification of blood loss jumped nearly 5 percentage points to 92.3% by year end. In turn, our overall hemorrhage rate improved from 7.23% to 6.39% during the same period. Annualizing the data, this translates to 263 fewer moms impacted by hemorrhages.
- The Environmental Risk and Emergency Management programs work to analyze and contain risk and implement risk avoidance measures to help ensure a safe and secure working environment. The foundation of the programs focuses on the continuity model to mitigate, prepare, respond and recover through events.
- In 2021, a new SharePoint site was shared with all facilities to allow for continual engagement with program resources and real-time updates to industry standards and best practices. Facilities are also provided with Emergency Management playbooks on the topics of wildfire and winter storm to augment the preparedness, response and recovery capabilities of their programs.
In the event of an emergency, our Incident Command team is activated. This includes Environmental Risk and Emergency Management, crisis experts and subject matter experts essential for that particular event, including Clinical Operations, Human Resources, Supply Chain, Information Security and Communications.
For example, at the start of COVID-19 in 2020, like many other organizations we activated our Incident Command to direct the clinical guidance, protocols, operational adjustments, supply chain, human resources and communications necessary to equip our facilities to pivot care delivery and meet evolving needs as the pandemic expanded (and continues to ebb and surge). Through this unified orchestration, we quickly and effectively established and deployed best practices, communicated directives, reduced unwanted variation and escalated urgent issues.
To continuously improve, we learn from each event and seek to drive more efficient procedures, enhanced staff communication and greater consistency.
Training programs and systems to encourage workplace safety are a major focus in our organization. To this end, UHS has an Employee Safety Council chaired by the Corporate Director of Environmental Risk and Emergency Management.
- During 2021, our increased attention to workplace safety enabled us to continue our commitment to keeping our employees and facilities safe during the COVID-19 pandemic. UHS has a Staff Safety subcommittee composed of members of Clinical, Loss Control, Risk, Human Resources and Legal teams.
As part of our Staff Safety Initiative, Behavioral Health facility staff have access to new Workplace Violence Prevention training and a new Employee Assistance Program (EAP), as well as monthly “Spotlight on Safety” posters, clinical newsletters and virtual forums. The new toolkit, “We Care: Supporting Injured Employees,” was also deployed across the division, providing support and resources for employees injured at work.
UHS uses VendorProof, a service that helps ensure vendors of healthcare organizations meet federal compliance requirements.
- Vendors provide key information which ProviderTrust then uses to perform required compliance screenings, supporting a safe and efficient supply chain. All vendors that deliver goods or services are required to participate in the program.