Evidencing Management’s Healthcare Compliance Commitment

Compliance is a top-down program, beginning with members of the executive leadership.  At all levels, they must clearly articulate commitment to, and priority in, establishing and maintaining effective compliance measures. When there is little appreciation for, or interest in, effective controls expressed by leadership, subordinate staff may question the importance of controls. This increases the likelihood of waste, fraud, abuse, mismanagement, noncompliance, and exposure to liability in the workplace.

The Obligation of Evidencing Management’s Compliance Commitment

The Compliance Officer needs to strongly communicate to management at meetings and during presentations and training programs that compliance is a priority and must be an integral part of everyone’s operations.  Management must understand that their failure to meet this obligation could result in serious exposure to regulatory and enforcement actions. All program managers and department heads should provide status reports on their compliance control systems as part of their ongoing monitoring of compliance risk areas.

These status reports are very important because they identify compliance risk issues and outline the steps being taken to correct the identified weaknesses. Ongoing auditing of compliance risk areas is equally as important. Such audits should be conducted by parties independent of the function being assessed to verify that program and department managers are actively engaged in ongoing monitoring of their risk areas.

Examining Compliance-Related Policies and Procedures to Evidence Healthcare Compliance Commitment

Another way to measure management commitment to compliance is by examining the document-management process to determine how well compliance-related policies and procedures are controlled, updated, and disseminated to staff. These policies and procedures include operating manuals based on rules, regulations, and laws required by federal, state, or other jurisdictional and accreditation institutions.

They should also be designed to help control risks. The likelihood of noncompliance is reduced when policies and procedures are written, up-to-date, distributed to employees on a timely basis, and enforced. In making these determinations, reviewers should address the following:

1. Are there policies/procedures for the area activity, including compliance controls?
2. Is that documentation easily available for all affected personnel?
3. Is that documentation formally reviewed at least annually?
4. Are updates implemented in a timely manner and disseminated to all affected personnel?
5. Is training provided on new or updated policies and procedures?

Executive leadership and other management’s commitment to compliance is important for reducing fraud, waste, and abuse in the work environment. By making the compliance program a priority, organizations can show staff members that they are dedicated to effective operations. 

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.