Essential Policies And Procedures For Effective Hotline Programs

Richard P. Kusserow | February 2014

Hotlines are an essential communication channel for healthcare organizations and serve as a key component in their compliance programs. Hotlines support the compliance program’s core mission, which is providing an avenue for reporting suspected or actual legal and regulatory violations. Such communication ensures healthcare organization can avoid and/or correct suspected or actual violations.

However, hotlines are only effective if employees are aware of and willing to use them. Therefore, steps must be taken to ensure that the hotline is operated in a professional manner and each call is handled in a consistent manner. One way to ensure this is by establishing policies and procedures that set clear objectives and standards. It is also important to recall that the Department of Health and Human Services, Office of Inspector General (OIG), stresses the importance of implementing written policies and procedures, in their compliance program guidance documents. The following includes several hotline related policies and procedures that establish and strengthen your hotline program.   

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  1. Hotline Operation Policy. The policy establishes the organization’s commitment to providing alternative channels for reporting suspected wrongdoing occurring within the organization. The policy should underscore that the hotline was established as an avenue for employees to report in the event that other communication channels are ineffective or so the employee can remain anonymous.
  2. Duty to Report Policy. The policy is to affirm that employees and managers have a duty to report suspected wrongdoing. Furthermore, the failure to report such wrongdoing could result in adverse action being taken against them.
  3. Non-Retaliation Policy. This policy states that any form of retaliation against any employee who reports suspected wrongdoing or a concern in good faith is strictly prohibited. Furthermore, any employee who commits or condones any form of retaliation will be subject to discipline up to, and including, termination.
  4. Anonymity Policy. The policy must ensure that employees can report suspected wrong doing anonymously. The OIG’s compliance program guidance documents specifically calls for organizations to have a policy to permit individuals to report problems and suspected violations anonymously. This policy will foster a sense of security for employees who report and, ultimately, facilitate a more willingness among employees to report.
  5. Confidentiality Policy. The policy ensures that all information reported via the hotline remains confidential. This policy can be combined with the Anonymity Policy. The OIG also states that a policy should exist to protect the confidentiality of those who report problems and request that their identity be protected.
  6. Answering Protocol. A specific answering policy protocol should be developed and implemented to assure consistency, accuracy and professionalism when operating the hotline. The policy should detail hours of operation, whether calls are handled by a live operator or voice mail service (live operators are strongly recommended) and ground rules for callers. The answering protocol should specifically address protection of callers’ anonymity and confidentiality.
  7. Coordination of Effort Policy. The policy establishes a formal working relationship between the Compliance Office and the Human Resources Department. It is expected that the majority of calls will be in the human resources arena, and, thus, a policy should address how the Compliance Office will transfer the reports. Furthermore, the policy should establish a formal working relationship with the Compliance Office and Legal Counsel. Reports that raise serious concerns are often resolved in cooperation with Legal Counsel or with the internal audit function.
  8. Misuse of the Hotline Policy. The policy prohibits and discourages misuse of the hotline. It is important to realize that employees may be improperly motivated to use the hotline; however, the policy should protect employees who report information in “good faith.” Reporting in good faith means employees believe the problem or information they are reporting is accurate.
  9. Hotline Records Management Policy. The policy establishes how hotline reports and associated materials are received, created, generated and documented, in both electronic and hardcopy format. Certain records must be maintained for a given period of time, as specified by applicable laws and regulations or as required by contractual obligations. Other records should either be retained or destroyed pursuant to a standard document management policy.

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 3,000 health care organizations and entities in developing, implementing and assessing compliance programs.