Blog Post

Gaining Board Empowerment for the Compliance Program (Part III – Auditing and Monitoring)

One of the greatest challenges for Compliance Officers lies in gaining interest and support at the executive and board levels. As explained in Part II of this blog series, the key to gaining Board support and empowerment is in the type of information provided. Board level compliance committees want to focus on whether the overall operation of the program is achieving the desired goals of reducing the likelihood of wrongful acts which create financial liabilities, litigation, bad press, and loss of community confidence in the provider. Reports related to the hotline, compliance training, and sanction-screening do not fulfill that need unless tied to a “big picture” framework.

The question becomes: What kind of reports to the Board oversight committee provides the right framework to engage continued interest, involvement, support, and empowerment of the compliance program (CP)? The Department of Health and Human Services (HHS) Office of Inspector General (OIG) compliance guidance provides the answer to this question. It cites an assessment of the CP by experts independent of the Compliance Officer as one method for creating credible evidence of CP effectiveness.

According to the OIG, all programs, including the Compliance Program, should be subject to “ongoing monitoring” for compliance. As a program manager, the Compliance Officer is responsible for:

  • Keeping abreast of changing laws, regulations, and rules relating to the CP;
  • Implementing written guidance in the form of a Code of Conduct, policies and procedures for the operation of the CP and adherence to applicable laws and regulations;
  • Training employees on the CP, compliance standards, and their obligations; and
  • Monitoring to verify appropriate staff adherence to policies and procedures.

In addition to monitoring efforts, there exists an obligation to conduct “ongoing auditing” of the program as well. Independent parties, unaffiliated with the Compliance Office, should conduct audits to assess how well the program is meeting objectives. Additionally, auditing can validate whether written guidance is effective in achieving the desired outcome. The focus of any such review should be on metrics supporting the effectiveness of the Compliance Program.
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Periodically engaging properly qualified independent experts to assess the compliance program and present certified findings to the compliance committees at both the executive and board levels provides extremely valuable information, insights, and understanding of the CP. The fact that the assessment has been performed by outside and independent experts adds great credibility to the results.  It is advisable for experts to present results directly to the committees since this increases their impact. The results of expert reports can give the compliance committee a framework to better understanding the relevance of other more specific reports provided by the Compliance Officer. Additionally, it is far easier for an outside party to advocate compliance program needs that could potentially be viewed as self-serving coming only from the Compliance Officer.


  1. Experts should certify that they will conduct the reviews in accordance with Generally Accepted Government Audit Standards (GAGAS).
  2. Compliance Officers should review the prospective audit methodology; If the methodology consists of a simple checklist related to the Seven Standard Elements of a Compliance Program, it would be wise to consider other services.
  3. Ensure the focus of the review will be on identifying supporting metrics for the CP.
  4. Use only a firm that has had many years of experience and extensive experience in the field, preferably having conducted dozens of compliance program evaluations in the health care arena.
  5. Ensure that prospective firm reviewers are named in the proposal to avoid a “bait and switch” problem where experienced consultants are replaced by lesser qualified ones.
  6. Ask for the references of 5 to 6 parties with whom the firm has conducted CP reviews and assessments.
  7. Those conducting the review should ideally have had personal experience in managing and operating compliance programs or be certified in healthcare compliance.
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