EDITOR’S NOTE: Donna Thiel, former chief compliance officer and now director of the ProviderTrust compliance integrity division, participated in a roundtable conducted by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). The following is her report.
In late 2016, the Health Care Compliance Association (HCCA) and the OIG invited 30 providers to participate in a roundtable format to discuss various ways to measure the effectiveness of a compliance program.
Prior to the event, providers were given a set of guidelines to help prepare their thoughts and ideas. Participants were told that they would be creating a resource for healthcare providers across a wide spectrum of care. The intent was not to create a checklist or best practice standard but to give providers as many ideas as possible so they could select measures based on their organization’s specific needs.
In early January 2017, the group gathered in Washington, D.C. for a fantastic day of idea-sharing. They broke up into four groups and rotated throughout the day, sharing ideas on two compliance elements per rotation. Groups were facilitated by members of the OIG, and a scribe was assigned to each group.
- Create a detailed list of what to measure and how to measure the elements of a compliance program.
- Assist organizations and compliance professionals from all types of organizations.
- Create a toolkit to help identify what to measure in determining a compliance program’s effectiveness.
For each compliance program element, the group’s tasks were to identify what to measure and recommend how to measure. The following compliance program elements were discussed:
- Standards, policies, and procedures
- Compliance program administration
- Screening and evaluation of employees, physicians, vendors and other agents
- Communication, education, and training on compliance issues
- Monitoring, auditing, and internal reporting systems
- Discipline for non‐compliance
- Investigations and remedial measures.
At the end of the day, providers had the opportunity to offer feedback on, and additional ideas about, their experiences and any other ideas they may have had after a particular rotation. All participants agreed that it was a great day of collaboration and hoped for many more roundtable events in the future.
On Monday, March 27, 2017 Inspector General Daniel Levinson proudly pre-launched the compiled results of the roundtable recommendations to the 3,000 attendees of the annual HCCA Compliance Institute in Washington, D.C. entitled, “Measuring Compliance Program Effectiveness – A Resource Guide." The compendium is a welcomed resource to compliance officers and legal advisors, especially since it represents “the voice” of those on the front lines of the healthcare compliance industry.
As you look at the "HCCA-OIG Measuring Compliance Program Effectiveness: A Resource Guide," read through and highlight the items you are already doing and also some new ideas to use for future monitoring. Note, however, that there are 402 metrics listed in the 55-page guidance. This is not a checklist. The OIG emphasized that none of the metrics listed are required and not all are applicable to all provider types. Instead, they are a compendium of best practice ideas for measuring effectiveness.
The report also noted, in its introduction, that “any attempt to use this as a standard or a certification is discouraged by those who worked on this project; one size truly does not fit all.”
Here are just a few highlights from each section in the guide.
- Standards, Policies, and Procedures
- Interviewing or Surveying Staff
- Ask staff to articulate a policy or procedure to evaluate communication.
- Ask staff if they know how to access policies and procedures (P&Ps) or who to talk to if they have a concern with their ability to meet the requirements of a P&P.
- Availability of P&Ps
- Code of conduct is properly and timely implemented.
- Compliance Program Administration
- Review Board’s process for compliance oversight, budget, resources and reporting.
- Review the Compliance Committee’s:
- Attendance and participation
- Review role of the Compliance Officer and reporting structure.
- Screening and Evaluation of Employees, Physicians, Vendors and other Agents
- Audit and document the employee disclosure process both pre-hire and throughout employment.
- Setup and audit the exclusion monitoring process.
- Interview staff to confirm understanding of importance of not letting licenses expire and the effect of exclusions.
- Communication, Education, Training on Compliance Issues
- Assess how training is being assigned. Audit to confirm that training is being conducted based on role.
- Include one compliance topic or slide into each training conducted within the organization.
- Audit to ensure proper post-testing is being conducted and evaluate employee understanding.
- Monitoring, Auditing, and Internal Reporting Systems
- Document review and audit the hotline call process.
- Are all calls logged and investigated?
- Are the calls properly closed and responses provided?
- Conduct compliance culture survey to evaluate the effectiveness of the compliance training, comfort in contacting compliance, and understanding of compliance expectations.
- By comfort, we mean evaluating whether or not the employees feel comfortable contacting the compliance department with any type of concern.
- Some employees may fear retaliation for raising concerns so it is important to survey staff to determine their current “comfort” level in communicating concerns
- Review the risk assessment process.
- Is there an enterprise-wide risk assessment?
- Is there a work plan to support the audit process?
- How are audit outcomes reported and addressed?
- Discipline for Non-Compliance
- Assess the understanding of the difference between discipline and non-retaliation.
- Evaluate whether or not disciplinary actions are tracked and trended.
- Review process for senior executive performance reviews to determine if compliance efforts are a factor in their reviews.
- Investigation and Remedial Measures
- Review and confirm that the investigation process is in place and documented.
- Audit investigation files to validate content and quality of investigation.
- Review how outcomes are communicated and whether or not corrective actions were put in place to prevent future occurrences.
It was a true honor and pleasure to join my compliance colleagues at this roundtable and to share our opinions of best practices in healthcare compliance.
One of the things I love most about this industry is that everyone shares the same goal, which is to provide quality and safe care for all. In today’s environment, we can all learn from each other and share best- practice ideas related to the many facets of compliance.
Given how many regulations affect the healthcare industry, it is exciting to see how the compendium will be used to help healthcare providers find new ways to measure compliance program effectiveness, which is a very difficult task.