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Background Information:

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. This list will provide measurement options to a wide range of organizations with diverse size, operational complexity, industry sectors, resources, and compliance programs.

Screening and Evaluation of Employees, Physicians, Vendors, and Other Agents Element #3


We are going to divide this Element up into two blogs. Today, we are going to look at what the OIG recommends for the evaluation process.

It is necessary for the facility to have a consistent evaluation process in place. The employees should understand and be able to perform their job description so that they can be evaluated accordingly.  The OIG report goes on to discuss the necessity of having compliance be a part of the evaluation process for staff.  Conduct focused interviews with employees.  Periodically audit the performance review process.  Ensure compliance expectations are well understood.  It is necessary for employees to understand  the facilities expectations so that they can be held accountable. A training of facility expectations may be necessary in an all staff in-service.

Upon termination from the organization, an exit interview should be conducted. It is recommended that the exit interview take place in an interview format, or through a survey, or a questionnaire. It’s important to have a system in place for all employees to attain an exit interview.  An audit process should be conducted to verify termed employees have conducted an exit interview.  Compliance questions should be associated with the exit interview process.

Element 3 Compliance Program Standards:

Below, is the list that was outlined on January 17, 2017 of what the OIG and team believed is important in the evaluation process of individuals under Element #3.

  1. Assure organization has processes in place to identify and disclose conflicts of interest.
  2. Confirm there is an inclusion of compliance obligations in all job descriptions.
  3. Assure inclusion of compliance accountabilities as an element of performance evaluation.
  4. Confirm compliance‐sensitive exit interviews occur.
Element 3 How to Measure:

The report has many suggestions on how to measure these four points, and I have listed a few ideas for you below:

  1. Assess the job descriptions, training materials, orientation materials, and annual performance evaluations to ensure employee responsibility is clearly stated.
  2. Verify employee performance can be measured from their job description.
  3. Review the conflict of interest for completeness and understanding.
  4. Interview employees to verify employees understand compliance expectations and that they are aware of their accountability for the expectations.
  5. Audit employee education files to verify the organization training program is being attended at 100% completion.
  6. Check post-tests of education sessions for understanding.
  7. Review organizations employee termination process and make corrections where needed
  8. Examine all exit interviews to ensure compliance questions are included and that the exit interview was conducted according to the policies of the organization.
  9. Audit all licenses and credentials on a continuous basis.

(For more ideas on how to measure, see concluding paragraph for details.)


The link to the OIG site as to what to measure and how to measure is below. They created a table of categories related to evaluations on Conflict of Interest, Employee Accountability, Employee Disclosure, Licensure, and Exit Interviews  If you have ever done an audit with me on where you are currently in the building of you compliance program, a lot of these measures are in the audit.  There is a lot of valuable information in these tables and I highly recommend you review them.  If you want more information, the link is https://oig.hhs.gov/compliance/101/files/HCCA-OIG-Resource-Guide.pdf .

Should you have any questions or want a consultation of your program, please contact me at karen@bcgdata.net.