Blog Post

In 2021, Consider Meeting DOJ And OIG Guidance About Evidencing Compliance Culture

Richard P. Kusserow | December 2020

Key Points:

  • OIG compliance guidance recommends evaluating all elements of a compliance program through employee surveys.
  • Results of surveys early in the year are useful for Compliance Program planning.

The Department of Justice (DOJ) 2020 Evaluation of Corporate Compliance Programs (“Guidance”) calls for prosecutors reviewing an organization’s culture of compliance to consider whether the company has surveyed employees to gauge the compliance culture.  Prosecutors are instructed to ask: How often and how does the company measure its culture of compliance? and [w]hat steps has the company taken in response to its measurement of the compliance culture?

The Department of Health and Human Services (HHS) Office of the Inspector General (OIG) compliance guidance recommends evaluating all elements of a compliance program through employee surveys. In “Measuring Compliance Program Effectiveness: A Resource Guide,” the OIG also suggests using surveys to learn about employee knowledge and understanding of compliance issues.

Survey instruments must be both reliable and valid for respondents and reviewers to view the results as credible. Reliability and validity must be examined and reported, or references cited, for each assessment instrument used to measure outcomes. The goal is to obtain a representative sample, such that the people who respond represent the thinking of the entire surveyed population.

There are two types of compliance surveys: those that measure employee knowledge and awareness of compliance, and others that focus on the compliance culture by measuring attitudes and perceptions. Compliance Knowledge Surveys use a dichotomous instrument with yes-or-no answers that measure employee knowledge, awareness, and understanding of the Compliance Program. The results include recommendations and suggestions for strengthening program effectiveness. Meanwhile, Compliance Culture Surveys feature a Likert scale instrument with degrees of agreement with questions to assess compliance culture; they gauge how well the Compliance Program has affected the workforce’s attitudes and perceptions relating to compliance in the organization. Although they measure different factors, both surveys are very useful in evidencing compliance program effectiveness. It is critical to use independently developed and deployed instruments to gain reliable, credible, and actionable results.

The optimal time to conduct compliance surveys is the first quarter of the calendar year. Results can be used to develop the annual Compliance Program Work Plan in order to improve results and, as called for by both the OIG and DOJ, evidence that the program is continuing to evolve and improve.

For more information on employing validated and reliable compliance surveys, contact Laurel Eakes (leakes@complianceresource.com).

About the Author

Richard P. Kusserow established Strategic Management Services, LLC to assist health care organizations develop, implement and assess compliance programs. Mr. Kusserow has worked with health care organizations to conduct compliance program effectiveness evaluations, deliver advisory services, develop policies and procedures and deliver compliance and internal investigations training.

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