Challenges with Code of Conduct Development and Revision

A Code of Conduct (Code) is a foundational part of any effective compliance program. Compliance guidance from the Department of Health and Human Services Office of Inspector General, U.S. Sentencing Commission, Department of Justice, and other regulatory and enforcement agencies all emphasize that any effective compliance program must have an up-to-date Code. A well-crafted Code should represent the vision, mission, and values of an organization and provide guidance for employee behavior that reinforces these values. To that end, an effective Code can demonstrate the organization’s commitment to promoting compliance with relevant laws and policies. Furthermore, a Code, together with written policies and procedures, provides guidance as to what is expected of individuals in the workplace. Well written Codes help indoctrinate the importance of proper behavior within the workplace and enforce why compliance is important in health care. A properly developed Code can thus serve as a deterrent to employees engaging in unwanted conduct, by outlining acceptable behavior and exemplifying actions that will not be tolerated. As such, a Code can provide a roadmap for compliance, demonstrate commitment to a compliance program, and set the standards of behavior for individuals at all levels of the organization.

Tips on Developing a Code of Conduct

Carrie Kusserow, CHC, CHPC, CCEP, notes that many organizations have Codes that are outdated and fail to provide employees with guidance regarding their compliance obligations. However, many compliance professionals have witnessed organizations devote an unprecedented level of effort and attention to revising and updating their Codes. These efforts are likely the result of new compliance-related laws and regulations that are causing health care organizations to rapidly respond to these changes. To maintain compliance, compliance officers should establish regular internal reviews of their company’s Code to ensure that employees receive timely updates. The Code review process is an assessment of the written policies and procedures to help guide legal and ethical business practices. In that regard, it is critical that an organization’s Code and compliance policies do not conflict. Any inconsistencies among these documents could create potential confusion and possible liability for the company. As such, compliance oversight committees at the executive and board level should participate in the development and any revision of the Code. Ms. Kusserow advises compliance officers to consider the following questions when developing and reviewing their organization’s Code:

• How much time has elapsed since the last revision of the Code?
• Has there been a change in the CEO since the last revision?
• Have there been significant changes to compliance-related policies?
• Have there been changes in laws/regulations relating to a Code topic (e.g., Health Insurance Portability and Accountability Act, Emergency Medical Treatment & Labor Act, etc.)?
• Are any of the compliance guidelines outdated?
• Have the Code and compliance-related policies been cross-referenced for consistency?

Jillian Concepcion, MPA, CHC, CHPC, has worked with dozens of compliance officers to advance their compliance programs, through the development of Codes and written policies. Many of her clients have used the Policy Resource Center’s health care compliance services to review various Code models and policy templates as a checklist for ensuring that all the key elements are included. However, Ms. Concepcion stresses that drafting and posting these documents is not enough; an effective Code must be reinforced in many ways, including:

• Training all covered persons on the content and application of Code documents;
• Establishing methods for employees to seek any clarification of rules;
• Implementing a reporting process (i.e., a compliance hotline) to report suspected Code and compliance violations;
• Establishing a mechanism for investigating and resolving issues raised by employees;
• Assuring that employees understand the penalties for engaging in wrongful behavior; and
• Consistently applying penalties for Code or policy violations.

Keep Your Company in Compliance

Developing a Code of Conduct and ensuring it is up-to-date is a foundational part of maintaining an effective compliance program. If you’d like to speak to one of our compliance experts about Code development and revision, you can contact us online or give us a call at (703) 683-9600.