Blog Post

Compliance Privacy and Code of Conduct: Reviewing and Updating

Richard P. Kusserow | June 2022

What is the Code of Conduct in Healthcare?

As a foundational document for an effective compliance program, the Code of Conduct (Code) evidences an organization’s commitment to compliance and helps inform employees of their organization’s expectations. It guides legal and ethical business practices for individuals at all levels of the organization.

The Importance of Code of Conduct Review

To remain consistent with ever-changing regulatory standards and guidance, the Code should undergo periodic review and updating. It is also critical to continually verify that the Code and compliance-related policies are not in conflict, as any inconsistencies among these documents could create potential confusion and possible liability. Equally important is involvement by compliance oversight committees at the executive and board levels in the development and revision of the Code as evidence of their commitment to a “culture of compliance.”

12 Tips for Compliance Officers Conducting Privacy and Code of Conduct Reviews

Compliance Officers should consider the following when revising the Code:

  1. How much time has elapsed since the previous review?
  2. Who has ownership of Code development/revision?
  3. Does the review process include a cross-section of employees to ensure it is user-friendly?
  4. Has there been a change in the CEO since the last revision?
  5. Is there a Cover Letter from the current CEO to introduce the Code?
  6. Have there been any structural changes in the organization?
  7. Have there been significant changes to compliance-related policies?
  8. Have there been changes in law or regulation that may impact a current Code topic such as privacy?
  9. Are any of the guidelines outdated?
  10. Have the Code and compliance-related policies been cross-referenced for consistency?
  11. Are there separate compliance policies detailing policy statements in the Code?
  12. Is there evidence of executive leadership and board involvement in Code review and approval?

For more information on this topic, contact Richard Kusserow at [email protected].

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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