With the New Year Comes the Time for a New Compliance Annual Work Plan: Suggested Tips in Meeting the Challenge
The beginning of a new year brings with it a challenge for compliance officers. Now is the time that compliance officers are faced with the task of developing a work plan that will evidence ongoing effectiveness of the Compliance Program (“CP”). According to The Department of Health and Human Services Office of Inspector General (HHS-OIG), one of the best methods of identifying what to include in the work plan is to hear from the organization’s employees.
The OIG states that one test of Compliance Program effectiveness is whether employees and other covered persons know and understand what is expected of them under the CP. Further, the OIG’s Compliance Program Guidance for Hospitals and Supplemental Guidance for Hospitals specifically identify the use of surveys as a method to benchmark CP effectiveness, stating that “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 the hospital’s employees and staff.”
The OIG reinforced this suggestion by recommending that organizations should evaluate all elements of a CP through employee surveys. Surveys are very inexpensive and cost only a small fraction of consultant-led CP evaluations. They can test knowledge of CP structure and operations, including the understanding of the compliance officer’s role, the hotline function, etc. These metrics are useful in providing empirical evidence of the advancement of CP knowledge, understanding, and effectiveness. Compliance officers can identify areas warranting special attention and include them in the work planning process. To be fully effective, a survey should be kept to a reasonable length and generally take no more than 20 to 30 minutes to complete. If it takes longer, employees may become apathetic and begin responding in a careless fashion.
Jillian Bower, whose firm has been conducting health care compliance surveys since 1993, offered the following advice: “a professionally and independently administered compliance knowledge survey can identify relative strengths in the Compliance Program, as well as those areas where there are opportunities for improvement. Furthermore, a truly professionally administered survey can provide direction and specific suggestions for making improvements to the program that can be used to provide the basis for a major part of any annual compliance work plan. It also can be a very powerful report to the compliance oversight committees, as well as credible independent evidence for any outside authority questioning the program. The Compliance Knowledge Survey© that we use also is able to benchmark an organization, overall and by question, against a very large universe of those who have used the same instrument.”
Tips on Surveying
- Anyone can draft a questionnaire, but it may not necessarily produce reliable, valid, and credible results.
- Internally developed/administered surveys may be questioned for potential bias or unreliability, both in their preparation and administration.
- It is best to use a valid and independently administered survey tested over many organizations.
- Professionally developed/tested surveys cost less than surveys developed/tested internally.
- Surveys must ensure participants that their responses will be confidential.
- Using a firm specializing in health care compliance is surprisingly inexpensive.
- Surveys offer added value if they can provide comparative data to others who have taken an identical survey.
- For optimum credibility, all survey reports should certify that a valid and reliable survey tool tested over many clients was used, and that the administration and report development met independent and objective standards.