Measuring Compliance Program Effectiveness Objectively With Surveys

Measuring compliance program effectiveness can be achieved through the use of surveys. The U.S. Department of Health and Human Service Office of Inspector General calls for the use of a compliance survey in their numerous compliance program guidance documents for healthcare organizations. Healthcare compliance programs, compromised of seven elements, must undergo annual review to ensure the program is operating effectively. Therefore, the OIG recommends “as 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 … employees and staff.”[1]

A professionally developed and independently administered compliance survey can provide powerful empirical evidence for measuring compliance program effectiveness. The results of the compliance program effectiveness survey are invaluable evidence to your oversight committee and to outside authorities to show the strengths of the compliance program.

One key compliance effectiveness survey is the Compliance Knowledge Survey, which tests employees’ understanding of the operation of the compliance program, including (a) structure and operations of the compliance program; (b) role of the Compliance Officer; (c) how the hotline functions; and (d) other key factors called for by the OIG for an effective program.

A properly designed employee compliance survey will achieve the following:

1. Identify areas of strength upon which the Compliance Program can be anchored.
2. Identify areas that warrant attention in improving the overall compliance environment.
3. Establish a benchmark against which progress of the Compliance Program can be measured.
4. Measure employee perceptions and morale related to management and leadership.
5. Gather employee perspective on the effectiveness of meeting Compliance Program goals.
6. Identify issues affecting attitudes and morale.
7. Permit comparison to the universe with all those that have employed the same survey.

Optimal compliance survey questions can yield results that signal strengths and weaknesses in the compliance program.  Compliance survey question examples include:

1. Do you find it difficult to get access to current policies and other written guidance to do your job?
2. Do you know how to contact the compliance hotline to report a concern?
3. Did the annual compliance training explain the purpose and operation of the compliance program?

A properly developed and independently administered employee compliance survey should provide detailed analysis for the results of each individual question, as well as the overall results of the compliance survey that includes a comparison of the organization against other similar organizations that completed the same compliance survey questions. If done properly, it is reasonable to expect more than just numbers, e.g., how many employees answered Yes, how many employees answered No. The compliance survey results should include textual analysis for each questions, an indication of whether the results are positive or negative and recommendations on how to improve compliance program effective.

When all is said and done, a compliance program survey will yield the most valuable insight on compliance program effectiveness for the least expense. In order to keep the integrity of the results, it is recommended to not conduct compliance surveys more often than annually.

[1] U.S. Deparyment of Health and Human Services Office of Inspector General. OIG Supplemental Compliance Program Guidance for Hospitals. Federal Register Vol. 70, No. 19. (Jan. 31, 2005). <http://oig.hhs.gov/fraud/docs/complianceguidance/012705HospSupplementalGuidance.pdf>

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.