Factors To Consider When Initiating An Internal Compliance Investigation

If there is a reported alleged violation of the Code of Conduct (Code), policies/procedures, laws or regulations, someone authorized to decide on an appropriate course of action should immediately act upon the possible violation. The threshold issue to be considered upon learning of potential wrongdoing is whether to initiate an internal investigation. Upon receipt of any complaint or allegation, it is important to make an immediate determination of the proper course of action. This process is often referred to as “triaging,” not unlike the process followed by caregivers in the emergency room that engage in a process for sorting injured people into groups based on their need for, or likely benefit from, immediate medical treatment. This involves a review of the allegations and information received to determine if there is an adequate “predication,” a factual basis and reasonable grounds to initiate an investigation. The Compliance Officer (CO), Human Resources (HR), Privacy and Security Officers, Legal Counsel and others each may bear responsibility to resolve issues and problems arising from concerns, complaints and allegations. Determining what needs to be done includes making decisions on the following:

1. Whether the allegation provides logical leads to follow;
2. Whether it would require action decisions (which it would if the allegations are borne out);
3. Overall purpose and objective(s) for the investigation;
4. Who would be responsible for the investigation (CO, HR, Legal, etc.);
5. What policies, procedures, Code, laws, and regulations might be implicated;
6. What facts and evidence would be needed to resolve the matter;
7. Who would be available and qualified to conduct the investigation;
8. Potential implications once the investigation becomes known;
9. List of interviewees and the order in which they will be interviewed;
10. Number, type and volume of documents to review;
11. Time frame for completion;
12. Level of evidence needed to decide whether to resolve the issue(s); and
13. Who the deciding authority will be to act upon results of the investigation.

For more information on this topic or Compliance Investigation Training programs, contact Richard Kusserow ([email protected]).

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 2,000 health care organizations and entities in developing, implementing and assessing compliance programs.