Compliance Program Elements Your Survey Is Missing

The use of compliance survey tools is an effective means to measure the performance of your compliance program. To be most effective, the survey must cover all compliance program elements considered essential to an effective program.

The U.S. Department of Health and Human Service Office of Inspector General adopted the U.S. Sentencing Commission’s elements of an effective compliance program. The OIG tailor these compliance program elements to the health care provider industry through a series of compliance program guidance documents issued from 1998 until present. These compliance program guidance documents, geared toward various types of health care providers, outline the seven compliance program elements and specific measures and mean to address each element.

These compliance program guidance documents can be used as a checklist in identifying which elements your compliance program has, and likewise, what elements it lacks.  This same approach can be used to construct a compliance survey template. The seven elements should serve as the backbone of the compliance survey tool and each element should be addressed with at least several questions to measure strengths and weaknesses in the healthcare compliance program.

There are two common types of compliance survey templates, compliance culture and compliance knowledge. You first must consider what you are measuring. Do you want to measure employees’ perceptions, beliefs and attitudes towards compliance in the organization? If so, then the compliance culture survey template should be used. Do you want to measure employees’ knowledge, awareness and understanding of the compliance program? If so, then the compliance knowledge survey template should be used.

Once you have identified what you are measuring (perception or knowledge) the next step is to identify questions that correlate to the respective compliance program elements. As an example, the following outlines the seven elements of an effective compliance program along with related sample questions ideal for the compliance knowledge survey.

1. Written Policies and Procedures: Have you received a copy of the Code of Conduct?
2. Designate a Compliance Officer and Committee: Do you know how to contact the Compliance Officer?
3. Conduct Effective Training and Education: Do you receive annual compliance program training?
4. Develop Effective Lines of Communication: Do you know how to access the compliance hotline?
5. Enforcing Standards Through Publicized Disciplinary Guidelines: Are disciplinary standards readily available to everyone?
6. Auditing and Monitoring: Is it clear to you that the organization monitors and audits your offices operations?
7. Responding to Detected Offenses and Developing Corrective Action Initiatives: Are you aware of the Compliance Officer ever visiting your department to conduct a review or look into a compliance matter?

The compliance knowledge survey must focus on gaining insight on how well employees understand the organization’s compliance program. As such, the employees answer the questions with Yes, No or I Don’t Know responses. The dichotomous answering and scoring provides a clear indication as to whether the employee knows or does not know answer. For example, if 50 percent of the employees do not know how to contact the compliance officer it is clear that the compliance officer needs more visual presence and/or needs more regular communication with the staff (either through annual training, monthly compliance newsletters).

Dichotomous scoring provides the compliance officer with the intel on what areas of the compliance program needs more awareness, coverage and importance in compliance program training and internal employee communication.

On the flip side, the results will also show the areas of strength in your compliance program. Areas of strength should not be overlooked. It is important to still address these compliance program elements to ensure they remain strong areas.