Members of the Texas Health Board of Trustees serve in volunteer roles to establish goals, make strategic policies and decisions, and facilitate organizational accountability and efficiency.

Voting Members: 18
Term: Three years (can serve for nine total)
Ex-officio members:
Chair emeritus: Three non-voting members; no term requirements

Our executive management team leads different facets of operational strategy and performance, conducts our transformation into a fully integrated health system, and directs our financial and organizational sustainability.

2017 Performance
To become “One Texas Health,” the board of trustees voted to change the organization’s governance structure starting in 2018 to provide consistency and efficiency. This entailed revising corporate and entity bylaws, reducing its voting members to 16, and reducing its 11 committees and subcommittees to six.

Additionally, board members approved a new initiative called Texas Health Community Impact that will allocate additional funding to address health challenges and social issues that affect the lives of North Texans.

Goal: We want to appoint passionate and competent leaders who can strengthen our health system.

Since our formation in 1997, Texas Health has embraced and integrated our Values of Respect, Integrity, Compassion and Excellence into our expectations for ethical conduct. By so doing, we earn and maintain the trust of those we employ and serve.

Our Business Ethics and Compliance Program is designed to meet and exceed regulatory, legal and accreditation requirements. It is overseen by our chief compliance officer, Executive Leadership Committee, the board’s Audit and Compliance Committee, our System Compliance Committee and the Business Ethics Council.

Annually, we provide mandatory ethics and compliance training for employees, volunteers, employed physicians, physician leaders and our board of trustees. Physicians agree to abide by medical staff bylaws and our Physician Code of Conduct, and we provide ethics and compliance materials at initial credentialing and at each re-credentialing. Our vendors and suppliers must also agree to observe our ethics and compliance policies.

Reporting
Employees can anonymously report allegations of improprieties to supervisors, patient advocates, our chief compliance officer or CEO, or through a toll-free hotline without fear of retaliation. Per our policy, we investigate all incident reports and respond to verified improprieties with the appropriate disciplinary action, including termination, if warranted.

Confirmed violations are reported to senior leaders and the board of trustees. Physician violations are handled through disciplinary action under medical staff rules and regulations.

Compliance
Texas Health operates in a complex legal and regulatory environment with numerous strict regulations and standards that are designed to ensure access to care, protect privacy, promote patient and workforce safety, and enforce public responsibility. Our Audit and Compliance Committee and senior leaders oversee compliance to avoid legal, financial, personal and reputational harm.

Goal: We aspire to maintain compliance with all applicable health care laws and regulations, and to operate in a fair and ethical manner.
Texas Health Hospitals Have:

Texas Health is committed to proactively safeguarding our patients’ health information from inappropriate use or disclosure.

Federal and state privacy laws and regulations also govern how we use, disclose and protect health information. We have a privacy compliance program that provides management, oversight and coordination of our privacy policies. This program also oversees training, auditing, monitoring, investigating and reporting of any unsecured information breaches. If potential privacy breaches occur, we notify applicable regulatory agencies and any impacted individuals.

Key Legal, Regulatory & Accrediting Requirements

Agency/RegulationFocus
Centers for Medicare & Medicaid Services (CMS)Participation in Medicare and Medicaid programs
The Joint Commission (TJC)Accreditation standards; safe practices; Centers of Excellence certification for specialty programs
Health Insurance Portability & Accountability Act (HIPPA)Privacy and security of patient information
Equal Opportunity Employment Commission (EOEC)Non-discrimination in employment
Occupational Safety & Health Administration (OSHA)Workplace safety
State/local health departmentsStandards for facilities, services, staffing
American Nursing Credentialing Center (Magnet)Nursing quality
Blue Cross, Aetna, United Healthcare and CignaCenters of Excellence certification for specialty programs

2017 Performance

Texas Health fully complied with HIPAA training, supplier agreements, conflict of interest disclosures and other related requirements. Additionally, no significant privacy breaches occurred.

ProcessTarget20132014201520162017
Internal audit findings cleared100%100%100%100%100%100%
OMB Circular A-133* audit report material weaknessZeroZeroZeroZeroZeroZero
Operations/compliance risk assessment**AnnuallyFullFullFullFullFull
Board of trustees, employees and volunteers’ compliance/HIPAA training100%100%100%100%100%100%
Supplier HIPAA agreements in place100%100%100%100%100%100%
Board of trustees, officer and other conflict disclosures100%100%100%100%100%100%
HIPAA non-compliance resolves**100%100%100%100%100%100%
Employees do not fear retaliation**100%n/a96%97%98%95%
Compliance hotline callsInvestigated100%100%100%100%100%
Compliance/privacy dashboards**QuarterlyIssuedIssuedIssuedIssuedIssued
The Joint Commission/Centers for Medicare & Medicaid Services accreditation reviewFullFullFullFullFullFull
Magnet/Pathways to Excellence**AchievedIssuedIssuedIssuedIssuedIssued
Workplace safety/OSHA citations000000
Workplace security compliance +100%92%93%97%83%76%
EPA compliance management100%100%100%100%100%100%
Sanction screening (federal and state)Monthly100%100%100%100%100%
Sanctions legal violations**000000