The FIRPAC is a tool for leaders to submit significant decision requests to their supervisor. The intent is to capture key points as well as summarize the thinking of the leader making the request such that their supervisor can make the final decision.
The format is an abstracted application of the “IRAC” process used in law to analyze fact patterns or issues at law in order to determine the likely conclusions of an adjudicating body.
The elements include:
(F) Facts: Drill into all of the underlying facts that relate in any way to the issue at hand. Often, more facts will clarify or even change the real issue or lead to sub issues that require prioritization.
(I) Issue: Unbundle the fundamental content of the problems at hand to distill the essential issue(s).
(R) Rules, Regulations: External governmental/agency/accreditation/payer guidance for analysis and conclusion.
(P) Policies, Procedures, Precedent: Internal policies and procedures that affect the decision as well as previous similar decisions that inform this decision.
(A) Analysis: Apply “R,” “P” and principled, reasonable business and human judgment to the fact pattern and analyze the issue.
(C) Conclusion/Recommendation: If well done, fairly clear conclusions and recommendations should emerge. In most cases, the conclusions will be made self-evident in this analytic process.
EXAMPLE 1
Project: Capital Request for Intelligent Video Solutions – Recording Residency Training
Facts:
The recording system in the simulation lab and patient rooms at the Westside Residency Clinic is broken. The license for the software has expired.
Issues:
There are potential differences in how a trainee performs in the natural setting compared with a testing situation or when a faculty member is in the room with the resident. They are currently using a camcorder to observe resident interaction and cannot record interactions in the simulation lab.
Rules & Regulations:
The Accreditation Council for Graduate Medical Education requires direct observation of residents during patient care. The relevant citation: V.A.2.b) The program must: V.A.2.b).(1) provide objective assessments of competence in patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice based on the specialty-specific Milestones; (Core) V.A.2.b).(1).(a) This assessment must involve direct observation of resident-patient encounters.
Policies, Procedures & Precedent:
It is industry standard to have some form of recording system for the direct observation of residents. Programs differ in how they accomplish this, but most have a structured recording platform that allows for ongoing playback and teaching.
Analysis:
The cost of the preferred system is $59,006. The system is manufactured and installed by Intelligent Video Solutions. This company is not an approved vendor but is willing to complete the necessary steps to become an approved vendor. The balance of the facility budget earmarked for use with the family medicine residency program is $374,500.
Conclusion & Recommendation:
I recommend your approval for the required capital as soon as the vendor completes the vendor vetting process.
EXAMPLE 2
Project: Southeast Property Lease
Facts:
During the acquisition process the acquisition team leader agreed to reimburse Dr. Smith for the following expenses: utilities/water for the rentable space and his portion of janitorial/trash/utilities for the common area of the building. Due to a communication breakdown this deal point was not included in the lease. Real Estate was involved in this decision through weekly onboarding calls and matrix meetings leading up to acquisition date. The monthly expenses for these services average between $575 and $700. Dr. Smith owns 29 percent of the building. Dr. Smith was six months delinquent in submitting invoices to me for reimbursement. Upon receipt of the invoices it was discovered these expenses were unintentionally omitted from the lease agreement.
Issues:
Real Estate’s position is we cannot reimburse Dr. Smith for the additional expense items because doing so would raise the rent rate per square foot (psf) to a point that exceeds fair market value (FMV) compared with the other medical buildings across the street.
Rules & Regulations:
The lease agreement between Dr. Smith and us does not address utilities and common area pro-rata expenses listed above. In the lease drafted in April, Sub lessor (Smith), at its sole cost and expense, shall cause all utility services required by Sub lessee (us) to be provided to the Premises in the capacities required by Sub lessee. In addition, Sub lessor, at its sole cost and expense, shall cause janitorial services to be performed within the common areas of the Building in a manner consistent with similar properties in the market. Per Real Estate we pay $20.00 psf. Our attorney has provided a legal opinion that supports $20 gross, not $20 net due to the FMV rates of the medical building across the street.
Policy, Procedure & Precedent:
Our company policy prohibits paying lease rates that exceed FMV in the opinion of the Legal Department to mitigate any arrangements between our business units and physicians that could run afoul of The Federal Anti-kickback Statute.
Analysis:
During the acquisition process Dr. Smith and the acquisition lead director agreed to reimburse Dr. Smith for his portion of common area and his utilities/water expense. It was assumed the rent rate passed FMV review by the Legal Department during the lease draft process and FMV review processes.
Conclusion & Recommendation:
I recommend that we inform Dr. Smith that we will not be able to pay for the expense components that were not originally included in the lease and apologize for the oversight and communication breakdowns that led to this situation. I recommend we initiate a work group to ensure that the lease draft and FMV processes are reviewed to ensure similar situations do not occur in the future.