Use a Survey to Improve Your Healthcare Compliance Policies and Procedures

Healthcare compliance policies and procedures are key elements of an effective compliance program. However, development and maintenance of these policies and procedures are often labor and time intensive. In my experience working with various healthcare organizations, compliance officers are looking for resources and assistance with healthcare compliance policies and procedures.

The U.S. Department of Health and Human Services Office of Inspector General calls for every compliance program to develop and implement written policies and procedures that cover high risk areas, claims development and submission, medical necessity, anti-kickback and self-referral concerns, retention of records and credit balances. Compliance related policies and procedures should be developed under the direction of the chief compliance officer and the compliance committee. Chief compliance officers and compliance committees should use the OIG’s compliance program guidance as a checklist against what policies and procedures are currently in place and what policies and procedures need to be implemented. Compliance Resource Center, LLC, along with our parent company Strategic Management Services, LLC, have worked with numerous organizations to develop new healthcare compliance policies and procedures, as well as work to improve their existing policies and procedures. For guidance on developing healthcare compliance policies and procedures, check out earlier articles posted on the Compliance Resource Center’s publication page.

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The OIG also states in its numerous compliance program guidance documents that healthcare compliance programs should include techniques to monitor and audit compliance areas and establish forms of communication between employees and the compliance office. These two compliance program elements should be examined when updates and revisions are made to healthcare compliance policies and procedures. Many would not think to consider these two elements; however, these two elements provide insight and feedback on how employees operate.

First, consider results of an audit or monitoring activities that examine how employees adhere to and carry out procedures. Results may reveal that procedures are unclear or that employees do not actually conduct work in the manner outlined in the policy. Or, it may reveal that employees are following the policies and procedures precisely. Either way, results of an audit or monitoring activity should be consider when improving policies and procedures.

Second, consider conducting a compliance program survey to examine employees’ knowledge of the compliance program. The OIG calls for the use of a compliance survey in their numerous compliance program guidance documents for healthcare organizations. The OIG recommends that the compliance officer use “questionnaires developed to solicit impressions of a broad cross-section of … employees and staff.”[1] Compliance officers can use a compliance survey to garner insight and feedback from employees at all levels of the organization. It is suggested that surveys are administer two to five years apart; more frequent then the suggested period does not reveal a measurable change in the data.  Because of the wait time between administering surveys, often time compliance survey questions highlight several (or all) of the compliance program elements. Compliance knowledge surveys are ideal compliance survey templates to include questions about written healthcare compliance policies and procedures.

Compliance survey questions are a powerful means to measure employees’ knowledge of policies and procedures. Therefore, crafting the right compliance survey questions can lead to answers useful to improve your healthcare compliance policies and procedures. Below are several compliance survey question examples.

  1. Have you received a copy of the Code of Conduct?
  2. Are policies and procedures specific to your job responsibilities easy to understand?
  3. Do you find it difficult to get access to current policies and other written guidance to do your job?
  4. Did the annual compliance training explain policies and procedures relevant to your job?
  5. Do you receive notice when policies and procedures are updated?

Similar to results of audit and monitoring activities, survey results should be considered when updating healthcare compliance policies and procedures. The results could reveal that employees have difficulty accessing policies or they find that the policies are difficult to understand. This valuable feedback must be considered when improving healthcare compliance policies and procedures. Improvements made based on feedback from employees can lead to greater compliance from employees and overall strengthens the compliance program.

[1] U.S. Department 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). <>