Compliance is about always doing the right thing. But how do you know whether your healthcare compliance program is helping the organization achieve compliance?
An effective healthcare compliance program consists of seven elements outlined by the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG). However, simply implementing the seven elements to check a box does not mean the compliance program is effective nor does it mean it helps employees to do the right thing. In order to maintain an effective healthcare compliance program the Compliance Office, including the Compliance Officer, HIPAA Privacy and Security Officers and the Compliance Office staff must actively carry out and maintain compliance activities, including routine monitoring and auditing, employee training, open communication channels, policies and procedures and compliance effectiveness surveys. These compliance activities are outlined in the HHS OIG’s compliance program guidance documents for healthcare organizations. All together these compliance activities and their results can evidence that a compliance program is effective.
A compliance effectiveness survey specifically can provide an overall view of how well the healthcare compliance program is operating. In the HHS OIG’s compliance program guidance documents, the OIG recommends the use of questionnaires to solicit impressions from a range of workforce members. The use of questionnaires or surveys should be incorporated into periodic compliance program reviews. The reason being is because surveys yield insightful data on the strengths and weakness of the program and can be used to determine the effectiveness of the program within the organization.
Healthcare compliance program surveys are underutilized in organizations. The stigma is that surveys are costly, lengthy and employees will be unreceptive. This cannot be further from the truth. In my experience working with dozens of healthcare organizations, employees welcome surveys because it shows that the executive management is interested in employees’ feedback. Also, when done right and outsourced, surveys are a low cost service that yields quick and practical results within a few weeks.
The real value in compliance effectiveness surveys is the ability to benchmark result data. Benchmarking is the next level of survey analysis. There are two methods to examine the healthcare compliance program survey results: (1) Against yourself and (2) Against your peers.
First, benchmarking against your own previous healthcare compliance survey results show progression in the compliance program, as well as areas that have declined. If you are benchmarking against your previous years’ results the same survey must be used. In most cases this can easily be done. However, you must ensure that the compliance survey template does not change. Even rewording a question can affect how employees’ understand and interrupt the question. Therefore, before implementing a compliance survey template, that template must be well tested to ensure valid and reliable results are produced.
Second, benchmarking your compliance effectiveness survey results against your peers reveals how well your healthcare compliance program stands up against other healthcare organizations. It is particularly helpful to identify compliance program areas that are below your peer’s average. Any below average areas would need immediate attention and are compliance risk identifiers. Conversely, above average compliance program areas are strong indicators to the Board of Directors, and to outside agencies, that the compliance program is effective. The only way to benchmark against peers is in cases when those healthcare organizations use the same compliance survey template. The easiest and perhaps the only way to benchmark against peers is to engage a consulting firm or compliance survey tools vendor that specializes in healthcare compliance. Such firms and vendors can ensure that the same compliance survey template is used and that the result data is accurately computed. Additionally, these firms and vendors can provide invaluable insight, resources and efficiencies that could not be gained by conducting a survey with in-house resources. They have experience working with numerous healthcare organizations that vary in size and complexity.
Compliance program effectiveness surveys should not be conducted every year since changes in the results will be minor year-to-year. Surveys can be conducted as frequently as every two years to every five years, depending on the survey objective. Compliance effectiveness surveys that assess employees’ knowledge, awareness and understanding of the compliance program can be conducted every two years. The reason being is that employees undergo annual compliance program training. During that time the workforce also gains new members. It typically takes at least two years to see measurable changes in the employees’ knowledge. Compliance effectiveness surveys that examine compliance dimensions that focus on personal job satisfaction, compliance with laws and regulations, quality of care/service, employee communication and management and HR practices should be done every five years. The organization’s culture will take time to change and it is not something that will change significantly with new hires or compliance training.
Ultimately the results yielded from surveys can be used to assess your healthcare compliance program. The strengths and weakness provide focus areas for the Compliance Office’s compliance plan or annual audit plan. Survey data provides a view of how the organization is in the moment. However, benchmarking the data against your own data from previous years or against peers can show how the effectiveness of a healthcare compliance program.