Using Culture Surveys to Measure Compliance Program Effectiveness

Richard P. Kusserow | July 2017

By Richard Kusserow, former HHS Inspector General and CEO of Compliance Resource Center.  Reprinted from Wolters Kluwer‘s Kusserow on Compliance Blog

Organizations are increasingly making use of employee perception and attitudes in measuring the compliance culture through using surveys. Increasingly, board directors, given their oversight duties and personal exposure, see the value of an independently administered survey to better understand the status of the compliance program. Using surveys to measure compliance culture has long been advocated by regulatory bodies.  The U.S. Sentencing Commission explicitly recognizes the significance of culture in its 2004 Amendments to the Federal Sentencing Guidelines, stating that businesses must “promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law.” The HHS Office of Inspector General (OIG) from its earliest compliance guidance documents has recommended the use of “[q]uestionnaires developed to solicit impressions of a broad cross section” of the workforce to evaluate program effectiveness that can measure the compliance culture of the organization. In the Compliance Program Guidance for Hospitals and Supplemental Compliance Program Guidance for Hospitals, it states that “fundamentally, compliance efforts are designed to establish a culture within a hospital that promotes prevention, detection and resolution of instances of conduct that do not conform to Federal and State law, and Federal, State and private payor health care program requirements, as well as the hospital’s ethical and business policies . . . 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 . . .Organizations should evaluate all elements of a compliance program through employee surveys.” In its Compliance Guidance for Nursing Facilities, it recommended evaluations of the compliance program through “employee surveys, management assessments, and periodic review of benchmarks established for audits, investigations, disciplinary action, overpayments, and employee feedback.”

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Jillian Bower Concepcion, a health care compliance consultant, has been overseeing, on behalf of the Compliance Resource Center, the administration of the Compliance Benchmark Survey© for six years to assess the compliance culture.  It has been administered to hundreds of health care organizations and more than a half million surveyed population since 1993. It measures perceptions and attitudes of employees on a number of issues, as they relate to them personally, their immediate work group, their supervisor, and the management of the organization. The results provide important insights as to organization’s strengths on which to advance the compliance culture and areas warranting special attention.  Results from the survey can measure the outcome of the compliance program and examine the extent to which individuals, coworkers, supervisors, and leaders demonstrate commitment to compliance. These can be extremely useful tools for assessing the current state of the compliance climate or culture of an organization.  Reports from the survey run 30-50 pages and include tips for addressing weaknesses. They also benchmark results against the huge universe of those who have used the same survey in three ways: (1) overall results, (2) by category, and (3) individual questions. Use of the same survey has an advantage to benchmark or measure survey results from the current year against past years. Most importantly for those using the survey, results can be benchmarked against peer organizations that utilized the same survey. This provides invaluable metrics of program effectiveness.

Steve Forman, CPA, has 35 years’ experience as a full-time compliance officer at major health care organizations, as well as in assisting organizations in developing and evaluating their compliance programs.   In all his evaluations of compliance programs, he urges clients to consider including an employee survey because the combination of the consultant’s findings and recommendations are reinforced in the survey report. He also cautions that to have a valid and tested survey instrument that produces reliable results is a serious business.  The survey needs to be developed by experts who validate and test the instruments over many organizations.  Any survey developed in-house is not likely to meet these standards.  They also can be viewed by employees as suspect and designed to bias the results in favor of management and will lack credibility to any outside authorities. As such, they will have little value in providing credible evidence of an effective compliance program.  Furthermore, the administration of the survey process is critical to useful results.  It must be independently administered that ensures the confidentiality and anonymity of participants.

Al Bassett, J.D., is another nationally recognized compliance expert with over 30 years’ experience in the OIG and as a consultant. He has found the use of surveys to evidence compliance program effectiveness is quite inexpensive, costing a small fraction of a full consultant-led compliance program effectiveness evaluation. As such, many of his clients opt for conducting the survey as a standalone engagement.  Another feature of using standardized surveys is that they can be supplemented with organization-specific questions and/or open-ended questions designed to provide more dimension to the information gathered.  He frequently links survey results in conducting focus group meetings and interviews when evaluating program effectiveness to shed additional light on the reason why there may be a problem, as might be suggested in survey response to certain questions. This can assist if certain issues require deeper probing and more nuanced evaluation.

Carrie Kusserow is another expert with 15 years’ experience as a compliance officer and consultant who has used compliance culture surveys extensively. She believes surveys can provide great insight into the compliance program’s effectiveness and very importantly can benchmark the progress of the program.  Reports can identify both strengths in the compliance program and potential gaps needing attention. Results can also be used as a benchmark for measuring progress and track improvements in the operation of the compliance program over time.  This is very important. She cites the OIG Compliance Program Guidance for Hospitals that states that “[t]he existence of benchmarks that demonstrate implementation and achievements are essential to any effective compliance program.” Another benefit of using an employee survey is that it can communicate a strong message to employees that their opinions are valued, the organization is committed to them as individuals, and their input is being used to make positive changes.  These messages can have a powerful influence on increased compliance, reduced violations, and heightened integrity.

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.