Developing or Revising the Code of Conduct

Key elements of any effective Compliance Program include written Compliance guidance for employees that clearly states the organization’s expectations for workplace conduct. A Code of Conduct (“Code”) is a central part of this guidance and should underscore the organization’s commitment to compliance with all laws, regulations, and professional conduct standards. Reviewing, updating, and revising the Code should be part of ongoing monitoring of the Compliance Program. Generally one of four models for Codes is followed: (1) management philosophy statements describing the manner in which business is to be conducted; (2) corporate statements of values and objectives that are directed toward internal and external constituents; (3) ethical precepts that focus on cultural values being applied to the work place; and (4) a Compliance Code that provides guidance on expected conduct.

Carrie Kusserow, a senior Compliance consultant with 15 years experience providing Compliance advisory services to organizations and serving as a Compliance Officer advises, “One of the biggest mistakes in creating or revising the Code and Compliance policies is not involving the individuals to whom it will apply. Doing so will help gain buy-in by the staff. It also provides a reality check on whether these documents will be readily understood and user-friendly. Imposing finished documents without this input frequently brings in poor results. It is also important to include senior management and the Board in the process by involving them in reviewing and approving these documents.”

Jillian Bower, an experienced Compliance consultant and Vice President for the Policy Resource Center notes, “The trend has moved away from simple philosophical statements to assertive Compliance guidance, as this is the practice the OIG has encouraged in all its guidance documents. The days in which an organization would have little more than restatements of the ‘golden rule,’ ‘doing the right thing,’ or simple statements of corporate values have long since passed.” She offers the following suggestions and tips for developing or revising the Code.

1. Involve employees in the process, including gaining feedback on existing written guidance and its clarity in outlining what is expected of them; and seek input and suggestions from them regarding how it can be improved.

2. Include with the Code a cover letter from the CEO endorsing it, calling for everyone at all levels to abide by its provisions, and inviting anyone who is aware of potential violations to report them without fear of retribution.

3. Write the Code as a statement of principles limited to 12-15 pages, leaving the details for other written guidance, such as the policies and procedures.

4. Codes are normally divided into sections by subject matter. The OIG Compliance guidance offers ideas that should be included in both the Code and Compliance training, especially matters related with applicable laws and regulations.

5. Include a description of the Compliance Program and Compliance Office with contact information.

6. Balance out each of the topical sections so that they have the appearance of parity to avoid inferences that one section is less important to the organization than another.

7. Use either short paragraphs or a bullet points to provide a simple, crisp, and easy format for the general employee population to understand.

8. For clarity and understanding, all statements should be declarative and consistent with other statements, and in the active voice, person, and mood.

9. Avoid compound sentences – each statement should stand alone.

10. Language and sentence construction should be written so that the lowest common denominator in the covered population can understand it; no language should rise above a 10^th grade reading level.

11. Decide whether the Code should be presented in positive or negative terms. The latter expresses conduct that is not permitted, whereas the former expresses expectations of employees that will be far more acceptable to the work force.

12. Codes should focus on all stakeholders, including patients served and privacy of their records; workforce issues; protecting organization interests; health/safety standards; conflicts of interest; and compliance with applicable laws, regulations, rules, standards, etc.

13. It is imperative that the Code have a restatement of the policy against retaliation or retribution for reporting violations of the Code or organization policies, laws, and regulations.

14. There should be clear guidance on how to report potential wrongdoing to management, the Compliance Office, and/or the hotline, which includes the hotline number.

15. It is useful to have an acknowledgement signed by those who receive the Code, along with a statement that they understand the Code and agree to abide by it.