Blog Post

Evidence Your Compliance Program Is Effective With Reliable Benchmarks

Richard P. Kusserow | March 2015

It is becoming a common practice for executive leadership and Board of Directors (Board) to request evidence of compliance program (CP) effectiveness in the form of metrics. It is easier to produce such metrics than you may think. Reliable metrics can be obtained through the use of surveys. The U.S. Department of Health and Human Services Office of Inspector General (OIG) suggests the use of surveys in its Compliance Program Guidance for Hospitals and Supplemental Compliance Program Guidance for Hospitals. The OIG states, “[A]s part of the review process, the compliance officer or reviewers should consider techniques such as…using questionnaires developed to solicit impressions of a broad cross-section of the hospital’s employees and staff.” The OIG continues by stating it “recommends that organizations should evaluate all elements of a compliance program through “employee surveys.”

Survey tools are among the best means for evaluating, evidencing and benchmarking the effectiveness of a CP. Unfortunately surveys are also the least utilized tool, which is surprising because the cost of using a survey is relatively inexpensive. Results yielded from a professionally and independently administered survey can serve as powerful evidence to your Board and committees, as well as to outside authority.

Survey results identify strengths in the program, as well as areas that require necessary attention. In order to obtain these types of results, two types of surveys can be used, Compliance Culture Survey and Compliance Knowledge Survey.

The Compliance Culture Survey assesses the current state of the compliance climate or culture of an organization. This survey focuses on the beliefs, attitudes and values that guide the thinking and behavior of employees within an organization. The results can be used to measure the outcome of the CP and examine the extent to which employees and management demonstrate a commitment to compliance. The answer format is a Likert Scale, requiring the respondent to answer “Strongly Disagree,” “Disagree,” “Neutral,” “Agree,” or “Strongly Agree” to each question. Utilization of the Compliance Culture Survey every three to five years could reveal a measurable change in the compliance environment over a period of time.

The Compliance Knowledge Survey tests employees’ knowledge of the CP structure and operations, including the understanding of the CO role, hotline functions and policies and procedures. Results are useful in providing empirical evidence of the advancement of program knowledge, understanding and effectiveness. The answer format is dichotomous, requiring the respondent to answer   “Yes,” “No,” or “I Don’t Know” to each question. This answer format creates the simplest of all the closed-ended questions and, as such, is extremely easy for respondents to answer. All the questions on the survey are referred to as nominal, and no binomial statistics are applied. The Compliance Knowledge Survey are used most often with maturing CPs to learn about the progress of the program in reaching the employee population.

Using these surveys yield reliable results based on the current state of the compliance program. But, even more so, results can be benchmarked against previous years and even against peers. An organization may decide to use the same survey every three to five years. Then, results from past years can be benchmarked against the current year to reveal trends, improvements and declines. Using different survey tools has the advantage of providing different dimensions and perspectives on a CP.

Avoid using the same survey every year because it will diminish its value. Furthermore, changes in the employee population do not occur overnight and, therefore, results may not materially differ from one year to another. The better approach to annual surveys is alternating between the two different types, or conducting surveys every other year.

Lastly, using surveys has an added benefit, it signals to employees that their opinions are valued, the organization is committed to them as individuals and their input is being used to make positive changes. These messages can have a powerful influence on increased compliance, reduced violations, and heightened integrity.

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.

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