Optional_2023 Board Resources

BANNER HEALTH CORPORATE RESPONSIBILITY AND CORPORATE COMPLIANCE BOARD OF DIRECTORS QUESTIONS

Structural Questions 1.

How is the compliance program structured and who are the key employees responsible for its implementation and operation? How is the Board structured to oversee compliance issues? • Banner’s Compliance Program is overseen by the Vice President of Ethics & Compliance, who also serves as the Chief Compliance Officer for Banner. o The Chief Compliance Officer chairs the System Compliance Committee, which consists of several senior management representatives from such areas as Ethics & Compliance, Legal, Internal Assurance, Revenue Cycle, Human Resources, Business Health, and hospital and provider groups. The Committee is kept informed of Banner’s various compliance activities, and its members offer advice and guidance to the Chief Compliance Officer. o The Chief Compliance Officer also manages the Ethics & Compliance Department that implements and oversees the day-to-day operation of Banner’s Compliance Program. As part of that Department, there are Compliance Officers who address local compliance issues at the hospitals, provider groups, ancillary service areas, and insurance divisions (collectively, “Compliance Officers”). The Ethics & Compliance Department also includes a compliance audit group, which is further subdivided into areas that focus on hospitals, providers, pharmacy, and ancillary service areas. o Compliance committees at the hospitals, provider groups, ancillary service areas, research, and insurance divisions assist the Compliance Officers in addressing local compliance issues and concerns. • The Board is organized to oversee compliance issues through its Audit Committee. Banner’s Bylaws specify that the Audit Committee shall: “Review and recommend to the Board the approval of the corporate compliance program and plan, monitor the implementation of the program, and receive reports and recommendations from the senior compliance officer of the corporation.” The Chief Compliance Officer regularly attends the quarterly meetings of the Audit Committee to report on compliance activities. 2. How does the organization’s compliance reporting system work? How frequently does the Board receive reports about compliance issues? • Within Banner, employees are required to promptly report potential compliance issues. They have several avenues of reporting, including their supervisors, department managers and directors, Compliance Officers, the Ethics & Compliance Department, and the ComplyLine. The ComplyLine is Banner’s confidential hotline, which can be accessed by phone or online and allows anonymous reporting. This is addressed in Banner’s policy entitled Reporting and Investigating Potential Compliance Issues . • The Chief Compliance Officer informs the Audit Committee about Banner’s compliance issues at its quarterly meetings. The Chair of the Audit Committee then