Make Your Compliance Hotline More Effective: Here Is How

A key component of an effective compliance program is having an effective hotline program. The operative word is “effective.”  Many healthcare organizations hire a compliance hotline provider to handle internal reporting, but the supporting program is not effective. If an organization institutes a hotline simply as a formality but really does not want the hotline to do much, the organization is making a grave error. The hotline should be a priority to bring complaints and allegations of wrongdoing in-house. The alternative is to drive such information externally to government agencies, litigating attorneys, media, etc., and that can only spell trouble. Receiving and resolving issues internally is the right approach, and is good for the organization on many levels. Failing to do so can result in potential liabilities, headaches, and a lot of remedial work.

First, effort must be made to ensure effectiveness of the compliance hotline system, as well as to prevent external involvement and claims of retaliation. Therefore, it is important to promote a culture that encourages employees to raise concerns and report perceived problems. Equally important is for managers to understand their responsibility and role when employees address concerns or complaints. Managers should be counseled that employees’ complaints are opportunities for improvement in the department and the overall organization. As with other activity protected by law, such as discrimination, health, safety, or environmental complaints, coworkers and supervisors must be trained that their initial and instinctive reaction to complaints must not be resentment or hostility. Instead, they should thank the person making the report, follow up in a non-threatening way, and be extra careful to refrain from doing anything that might be interpreted as retaliatory. By maintaining a culture open to communication, employees will be more comfortable to raise concerns informally and resolving matters within the company’s management structure, ultimately lessening the employees’ need to resort to “whistleblowing” to external parties.

Second, follow-up with individuals who report a concern should be made. In some cases, employees will disclose their name and/or contact information. In those cases, the Compliance Officer should check back with them 60 or 90 days later, to make sure that they do not feel retaliated against. It is important that the Compliance Officer also makes record of the follow-up.  If an employee reports retaliation, at the time of follow-up or before that time, it raises a potential liability that needs to be addressed immediately by an investigation.

Third, a confidential recordkeeping system should be maintained to enable a review of employment history for those employees who have raised concerns or reported problems.  This can be used as evidence that the individual was not treated improperly subsequent to reporting.  Such examples that would evidence no retaliation or negative repercussions from reporting could include their continued employment, timely pay raises, training opportunities made available, no promotions withheld, and other favorable treatment of employees after they made a formal report. Having such information will enable the organization to evidence its favorable treatment of whistleblowers. This is important if there were any adverse action brought, such as a claim of retaliation or discrimination due to reporting a potential problem, to show that the adverse action was an unrelated and legitimate job performance or misconduct factor issue. As in other areas of employment law, maintaining contemporaneous documentation of poor performance and misconduct is crucial to demonstrating that unlawful retaliation has not occurred.

Fourth, it is extremely important to have written guidelines relating to the use of the compliance hotline for both the Code of Conduct and policy documents. These should include policies on:

• Hotline Operations
• Duty to Report
• Non-Retaliation
• Anonymity
• Confidentiality
• Investigations of Complaints

Additional tips to consider in making the compliance hotline more effective include:

1. Have a poster on the employee bulletin boards about the availability and use of the hotline.
2. Ensure the hotline number and its availability is included in new employee orientation.
3. Have information about the use of the hotline made part of the Employee Handbook.
4. Consider having a flyer go out to all employees on the availability of the hotline.
5.  If there is an Intranet for employee use, include information about the hotline.
6. If there is an organization newsletter, use it to promote the hotline.

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 3,000 health care organizations and entities in developing, implementing and assessing compliance programs.