Our Board of Trustees is comprised of independent health care, business and community leaders who offer a range of professional competencies. They serve in volunteer roles to establish goals, make strategic policies and decisions, and facilitate systemwide decision making, accountability and efficiency.

Each year, board members:

Standing board committees include:

Our board members and executive leadership teams continued implementing and refining key organizational strategies during the year. Wes Turner, board chair, and Dennis Stripling, M.D., vice chair, served their second year of a two-year term.

Voting members:Sixteen
Term:• Texas Health CEO
• Chair, Physician Leadership Council
• Bishop, Central Texas Conference of the United Methodist Church (no vote)
• General presbyter, Grace Presbytery of the Presbyterian Church (no vote)
Ex-officio members:Three years (can serve for nine total)
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. Our primary leadership teams include the:

Goal Icon
We want to appoint passionate and competent leaders who can strengthen our health system, to operate ethically and to maintain compliance with applicable health care laws and regulations.

We designed our Business Ethics and Compliance Program 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.

Each year, we require employees, volunteers, employed physicians, physician leaders and board members to receive ethics and compliance training. Physicians also 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 are expected to observe our ethics and compliance policies as well.

Additionally, we have policies and procedures to detect fraudulent activities, such as internal audits, fraud risk assessments, financial audits and reviews, conflict of interest disclosure and evaluation of internal controls.

To protect the rights and welfare of human research participants, Texas Health has an Institutional Review Board that determines if studies are conducted ethically and are in compliance with federal regulations, state law and our policies and procedures.

If improprieties occur, employees can anonymously report allegations 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 issues 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.

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.

To protect consumer health information, federal and state privacy laws and regulations govern how we use, disclose and secure this data. Our privacy compliance program provides management, oversight and coordination of our privacy policies. Program leaders also oversee 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.

Some of the critical legal, regulatory and accreditation bodies include:

2018 Performance

Texas Health fully complied with HIPAA training, supplier agreements, conflict of interest disclosures, and certification and accreditation requirements. We also were not fined or penalized for noncompliance.

Law enforcement notified system leaders that we had been part of a nationwide security breach early in the year. We conducted an immediate investigation and found hackers had gained access to some of our emails that contained personally identifiable information. This impacted about 4,000 patients, but there has been no indication that any information has been misused to date. We have implemented additional security measures to prevent this from reoccurring.

Internal audit findings cleared100%100%100%100%100%100%
OMB Circular A-133* audit report material weaknessZeroZeroZeroZeroZeroZero
Operations/compliance risk assessment**AnnuallyFullFullFullFullAnnually
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%96%97%98%95%99%
Compliance hotline callsInvestigated100%100%100%100%Investigated
Compliance/privacy dashboards**QuarterlyIssuedIssuedIssuedIssuedQuarterly
The Joint Commission/Centers for Medicare & Medicaid Services accreditation reviewFullFullFullFullFullFull
Magnet/Pathways to Excellence**AchievedIssuedIssuedIssuedIssuedAchieved
Workplace safety/OSHA citations000000
Workplace security compliance100%93%97%83%76%100%
EPA compliance management100%100%100%100%100%100%
Sanction screening (federal and state)Monthly100%100%100%100%Monthly
Sanctions legal violations**000000