Program efectiveness a resource guide
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A Resource Guide
ISSUE DATE: MARCH 27, 2017
HCCA-OIG Compliance Effectiveness Roundtable
Roundtable Meeting: January 17, 2017 | Washington, DC
Measuring Compliance Program Effectiveness ? A Resource Guide
HCCA-OIG Compliance Effectiveness Roundtable
Roundtable Meeting: January 17, 2017
On January 17, 2017, a group of compliance professionals and staff from the Department of Health and Human Services, Office of Inspector General (OIG) met to discuss ways to measure the effectiveness of compliance programs. The intent of this exercise was to provide a large number of ideas for measuring the various elements of a compliance program. Measuring compliance program effectiveness is recommended by several authorities, including the United States Sentencing Commission (see, Chapter 8 of the United States Sentencing Guidelines). This list will provide measurement options to a wide range of organizations with diverse size, operational complexity, industry sectors, resources, and compliance programs.
During the meeting on January 17, the participants broke into 4 groups of 10 attendees to discuss 2 elements of a compliance program at a time. During four sessions, every participant had a chance to suggest ideas about "what to measure" and "how to measure" with respect to all seven elements of a compliance program. We used the following categories, from the Health Care Compliance Association's CHC Candidate Handbook: Detailed Content Outline, as a guide to ensure that all elements of a compliance program were covered:
Compliance Program Elements:
1. Standards, Policies, and Procedures 2. Compliance Program Administration 3. Screening and Evaluation of Employees, Physicians, Vendors and other Agents 4. Communication, Education, and Training on Compliance Issues 5. Monitoring, Auditing, and Internal Reporting Systems 6. Discipline for Non-Compliance 7. Investigations and Remedial Measures
We have listed below many individual compliance program metrics. The purpose of this list is to give health care organizations as many ideas as possible, be broad enough to help any type of organization, and let the organization choose which ones best suit its needs. This is not a "checklist" to be applied wholesale to assess a compliance program. An organization may choose to use only a small number of these in any given year. Using them all or even a large number of these is impractical and not recommended. The utility of any suggested measure listed in
this report will be dependent on the organization's individual needs. Some of these suggestions might be used frequently and others only occasionally. The frequency of use of any measurement should be based on the organization's risk areas, size, resources, industry segment, etc. Each organization's compliance program and effectiveness measurement process will be different. Some may not apply to the organization's environment at all and may not be used.
Any attempt to use this as a standard or a certification is discouraged by those who worked on this project; one size truly does not fit all.
Element 1: Standards, Policies, and Procedures
A. Conduct periodic reviews of policies, procedures, and controls. B. Consult with legal resources. C. Verify that appropriate coding policies and procedures exist. D. Verify that appropriate overpayment policies and procedures exist. E. Integrate mission, vision, values, and ethical principles with code of conduct F. Maintain compliance plan and program. G. Assure that a nonretribution/nonretaliation policy exists. H. Maintain policies and procedures for internal and external compliance audits. I. Verify maintenance of a record retention policy. J. Maintain a code of conduct. K. Verify maintenance of:
1. A conflict of interest policy 2. Appropriate confidentiality policies 3. Appropriate privacy policies 4. Policies and procedures to address regulatory requirements (e.g., the Emergency Medical Treatment and Labor Act (EMTALA), Clinical Laboratory Improvement Amendments (CLIA), Anti-Kickback, research, labor laws, Stark law). L. Verify appropriate policies on interactions with other healthcare industry stakeholders (e.g., hospitals/physicians, pharma/device representatives, vendors). M. Assure policies and procedures address the compliance role in quality of care issues. N. Verify maintenance of a policy on gifts and gratuities. O. Verify maintenance of standards of accountability (e.g., incentives, sanctions, disciplinary policies) for employees at all levels. P. Maintain a Compliance Department operations manual. Q. Verify maintenance of policies on waivers of co-payments and deductibles. R. Assure governance policies related to compliance are appropriately maintained.
Source: CHC Candidate Handbook: Detailed Content Outline
Element 1: Standards, Policies, and Procedures
What to Measure Access:
How to Measure
1.2 Actual Access
Review link to employee accessible website/intranet that includes the Code of Conduct Survey - Can you readily access or reference policies and procedures? (Yes/No/Don't know) Survey - How and where do employees actually access policies and procedures? Test key word search (searchable) Audit and interview staff to show policies
Audit how many actual "hits" on policies and procedures
1.3 Accessible language for code, standards and policies Flesch Kincaid measuring standard ? no more than 10th grade reading level
Survey employees to determine the extent to which the code of conduct and other
Compliance program awareness and communication
compliance communications are available to employees Review to ensure the standards, policies, and awareness material is updated and distributed
within organization's guidelines
1.5 Impaired or disabled accessibility
Review accessibility options. Look at methods and speak to individuals.
1.6 Policy communication
Communication strategy of policies
1.7 Availability of policy content
Conduct surveys and observation
Accountability: 1.8 Accountability 1.9 Ownership and accountability of policies 1.10 Routine policies and procedures
Policy Coordinator designated
Audit process of how policies get enforced by chain of command when compliance is not the final approver. Is management taking responsibility for implementing and following policies?
Confirm that listed owner of each policy and procedure is the actual owner.
1.11 Annual review and Board approval of Compliance Plan
Audit: Review of Board minutes
1.12 Compliance documentation operations manual
Compliance or other oversight committee to review annually to ensure it is up to date.
1.13 Maintenance of policies
Check last review or revision
Number of policies reviewed and is the review timely
Process review/audit. Use checklist to ensure all basic policy elements are in place, updated consistently and reviewed/approved by appropriate parties.
1.15 Policy approvals
Checklist audit. Create list of policies, review committee and board minutes to ensure all approvals have been obtained.
1.16 Policy review process
Audit process by which policies and procedures are prepared, approved, disseminated, etc.
1.17 Process for ensuring full organizational participation Review documentation/minutes to verify input considered and solicited for policy and procedure
in policy and procedure development
development and review
1.18 Process for review and approving
Check for written process
1.19 Are policies (and procedures) as good as industry practice
Integrity of Process for developing and implementing policies and procedures
Audit policy and procedure on policy and procedures
1.21 Language and reading level of policies
Are policies written in plain language, appropriate grade reading level and written in applicable languages for organization? Policy review, Word grade level review and interviews of staff to make sure they understand.
1.22 Language translation
Audit or process review. Are policies and the code of conduct translated into appropriate languages for organization?
SURVEY - Do department policies and procedures assist you in doing your job effectively? (Yes/No/Don't know)
1.24 Need for policies that don't exist
Interview staff to determine if they need the certain policies to strengthen internal controls.
1.25 Policies and procedures
Request review from external experts
1.26 Assessment of all company policies
Check list of policies; which are compliance and which are business
1.27 Essential compliance policies and procedures exist Can staff actually articulate policies and procedures; test staff
1.28 Existence of procedure to support policy
Audit for procedure to support policy
1.29 Fundamental policies and procedures in place 1.30
Have focus groups of work units/departments to determine whether they understand the policies and procedures necessary to do their jobs.
Index of policies available and current Numbered policies, not just titles
1.31 List of policies are applicable to employees
Supervisors to assess direct staff
Are those affected by policy given the opportunity to weigh in on policy when developed?
Focus groups and interviews of those affected by policy.
1.33 List of required policies
Create checklist to make sure minimum policies are in place and then audit against the list.
1.34 Effectiveness of policies
Effectiveness of policies based on the submission hotline calls
Policies and procedures that have been identified as part of corrective action
Process review. Conduct annual meeting with compliance and legal to look at databases and control and prioritize review to ensure implementation and ongoing compliance with policies and procedures.
1.36 Policies for high risk and operational areas
1.37 Policies, standards and procedures are based on assessed risks
Risk assessment, policy exists for each risk identified in the risk assessment (coverage of a specific risk topic)
1.38 Policy inventory to ensure no overlap and contradiction of policies
Create inventory and analyze inventory. Analyze and review past efforts. Look at various departments that might have overlapping policies.
1.39 Policy review following investigation/issue
Top policies implicated in an investigation are reviewed to determine if policy ambiguous, complex, fails to adequately safeguard issues. Validate through audit.
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