Office of The Chief Medical Director

Introduction

The decision to institute a Compliance Unit in the Hospital is one of the Professor Adekunle Ebenezer Ajayi audacious demonstrations of his preparedness for the herculean demand of his office when he assumed office as Chief Medical Director of the Hospital on 1^st January, 2018 which would largely depend on reverence to established rules, regulations, protocols and ethics.  To achieve the hospital vision, mission and Chief Medical Director’s core values, the Compliance Unit played two levels of responsibilities.  Firstly, the compliance with the external rules that are imposed upon our organization as a whole and secondly, compliance with internal system of control that are imposed to achieved compliance with the externally imposed rules.

Vision of the Unit

In accordance with the Hospital vision, the Compliance Unit is focuses on ensuring adherence to applicable regulations and policies while maximizing available resources to support the good of providing excellent care opportunities to our patients.

Mission of the Unit

Our mission is to ensure that operational compliance standards and procedures are established and followed, to assist with the implementation and enhancement of internal controls, and to support an ethical work environment to effectively contribute to the pursuit of the Hospital mission.

Values of the Unit

In keeping with the core values of the Hospital, this Unit is directed by the following values:

Respect – we treat others equitable and support thoughtfulness and inclusion.

Integrity – we exhibit honestly and ethics in our work and interactions with others.

Consistency – we work diligently to serve the hospital and process request in a similar manner.

Efficiency – we strive to ensure that processes and workflows are streamlined to the extent possible.

Knowledge – we seek to stay informed of relevant issues to better serve our hospital.

OVERVIEW OF COMPLIANCE UNIT

Compliance Unit identifies risks that an organization faces and advises on how to avoid or address them.  We implements controls to protect the Hospital from those risks.  Compliance Unit monitors and reports on the effectiveness of controls in the management of the organizations risk exposure.  We are responsible for ensuring that member of staff of the Hospital adheres to government regulations – domestically as well as globally, if applicable – and avoids missteps that could result in hefty fines, legal ramifications and reputation damage.

STAFF DEMOGRAPHY CHART

ASSISTANT DIRECTOR OF ADMIN	1
PRINCIPAL ADMINISTRATIVE OFFICER	1
HIGHER EXECUTIVE OFFICER	1
CHIEF CLERICAL OFFICER	1

FUNCTIONS AND STANDARD OPERATIONS PROCEDURE OF COMPLIANCE UNIT

Compliance Unit typically has five areas of responsibility:

Identification
Prevention
Monitoring and Detection
Resolution
Advisory.

1.  WE REVISE EACH DEPARTMENT WORKING PROCEDURES PERIODICALLY TO IDENTIFY HIDDEN RISKS AND NON-CONFORMITY ISSUES

• Get understanding and acquainted with the hospital standard operation procedure.
• Identify the hidden risks
• Give advice on how to get the hidden risks resolved
• Develop and refines the guidelines as appropriate
• Ensure that the desired result is achieved
• Follow up on implementation of policies and directives of management
• Reviewal, assessment and evaluation of other Units procedure and performance in accordance with vision and mission of the hospital

2.        MAINTENANCE COMPLIANCE

• Receive notification of Chief Medical Director’s approval on maintenance and repairs.
• Monitor that the appropriate of materials are used.
• Certify that the task is performed according to the hospital standard.
• Issuance of compliance work completion certificate for the officer that implemented the repair(s)
• Ensure that the Accountable Advance for the funds is retired in the Account Department in line with the financial regulation.
• Evaluation of pace and progress of the maintenance as directed.

3.  WORKING ON PERSONAL FILE(S) AND POLICY FILE(S)

• Get acquitted of the minutes on the file.
• If it is related to issuance of memo or letter it would be treated as appropriate.
• Any matter requiring comments, suggestion and submission relating  to compliance would be dealt with as appropriate
• Act on Chief Medical Director’s approval.

4.  LIAISE AND WORK WITH COLLEAGUES WHEN NECESSARY TO IDENTIFY COMPLIANCE ISSUES AND PROVIDE ADVICE

• Work with other colleagues in various department as the needs arise
• Give advice on compliance as appropriate
• Ensure that desirable result is produced.

5.  PROCUREMENT COMPLIANCE

• Receive notification of Chief Medical Director’s approval on procurement
• Monitor the release of the funds
• Ensure that the appropriate specification are procured
• Issuance and signing of Procurement Compliance Certificate for the retirement of the Accountable Advance obtained by the Procurement Officer.
• Ensure that the Accountable Advance for the funds are retired in the Account Department in line with financial regulations

6.  ALLIED FUNCTION

• Collate all Chief Medical Director’s directive during round
• Forward the directives to the concerned officers
• Ensure and monitor that the concerned officers worked on the directive
• Ensure that the desired result is achieved.