Blog Post

Involve Others in Code Development, Revision, and Approval

Richard P. Kusserow | May 2022

The Code of Conduct (Code) is one of the foundational documents for any effective compliance program. Guidance from the United States Sentencing Committee, the Department of Health and Human Services Office of Inspector General, the Department of Justice, and other regulatory and enforcement agencies all state that an effective compliance program needs to have such a document and that it be kept up to date. 

The Code needs to be user-friendly. As such, it is advisable to create a workgroup drawn from no more than 8-10 representatives from human resources, finance, clinical operations, risk management, and other operational areas to help develop and revise it.  Following this approach is a way to test market the document to gauge employee reaction and understanding, as well as assist in gaining buy-in from the workforce. Added benefits of this type of process are demonstrating to employees the organization’s commitment to and promotion of its values and compliance.

Deciding on the Code’s form and format will facilitate moving directly to the substantive content in the body of the Code. Once the Code is drafted, it can be taken to the Executive (or Management) Compliance Committee for their approval. It is also advisable to present the draft document to the governing Board for its approval. Executive leadership and board involvement in this process are important in evidencing the organization’s commitment to a “culture of compliance.” 

For more information on this topic, contact Richard Kusserow at rkusserow@strategicm.com.

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.

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