Effective Corporate Compliance Program Checklist

Effective Corporate Compliance Program Checklist

An effective Corporate Compliance Program in healthcare is a critical necessity!  Corporate compliance professionals spend a lot of their time assessing the performance of other people in their hospital or medical group.  But who evaluates the effectiveness of the corporate compliance program itself?  The Department of Justice and the Office of Inspector General (OIG) have both recently issued tools for assessing compliance plans and activities.  Both are comprehensive and long.

Effective corporate compliance program checklist

In healthcare, we already use a variety of tools to perform self-assessments of our processes and activities.  So why not use a tool to measure the effectiveness of the corporate compliance program?   Complete the tool honestly, and it should yield results that help improve the program for any healthcare organization.

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Measuring Corporate Compliance Program Effectiveness

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Seven dimensions for evaluating an effective corporate compliance program

The OIG Guidance for all corporate compliance programs for healthcare organizations contains seven elements of an effective program.

  1. Written Policies and Standards of Conduct:  this documentation is the foundation for all effective corporate compliance programs.  Your policies have to describe the scope of the corporate compliance program and who is covered.   Policies should also cover how compliance issues are investigated and the expectations for ethical conduct on the part of all staff members.
  2. Designation of compliance program staff and reporting relationships:  most organizations will have a Compliance Officer and a Compliance Committee.  Spell out the roles and responsibilities of these individuals/bodies.  Make sure there is a viable reporting path to the CEO and the Board of Directors of the organization.
  3. Effective Training and Education:  make sure your compliance training program addresses everyone in the organization, including hospital or clinic employees, volunteers, and members of the medical staff.  And don’t forget members of the Board of Directors.  Address reporting methods available to staff.
  4. Effective Lines of Communication:  capture communication to staff and from staff.  These days, it is relatively easy to establish internal hotlines that enable anonymous reports.  External hotline services are also available.  Also, after initial training, don’t forget about reminding staff about the program and how to report issues.  In addition, consider elements of communication during a crisis and the use or abuse of social media.
  5. Effective Systems for Routine Monitoring and Auditing:  establish an annual work plan that includes audits of some of the risk areas. For most healthcare organizations, that means billing government programs.  Each department in the risk areas should participate in annual auditing of its activities.
  6. Enforcing standards through well-publicized disciplinary guidelines:  when individuals fail, there must be consequences.  Make sure policies address individuals at all levels of the organization.  Avoid recruiting individuals who have previously been convicted of a violation of healthcare laws.
  7. Investigation and remediation of identified systemic problems:  document investigations and complete them promptly!  Make sure corrective action plans are developed and implemented.  Be prepared to get legal assistance if you uncover an issue of serious non-compliance.

Effective corporate compliance programs can lead to real changes

Healthcare is a complex industry and it is easy in busy environments to keep the focus on completing audits and investigations.  Compliance professionals should periodically turn the spotlight on assessing the effectiveness of their corporate compliance program.  It can help you uncover blind spots. And you can find areas where there has not been enough emphasis in the past.

Need to speak with a HIPAA expert?

Jim Hook, MPH

Mr. James D. Hook has over 30 years of healthcare executive management and consulting experience in medical groups, hospitals, IPA’s, MSO’s, and other healthcare organizations.

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