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How can we measure the effectiveness of our compliance program? It’s not an easy task and leave many of us baffled as to where to even begin.  Every facility is different including diversity in size, risk areas, resources etc.  To measure the effectiveness of your compliance program, you need to use the tools you have already and add the OIG recommendations.  We will walk through each of them in seven different blogs.

Background Information on a Compliance Program

The OIG met with HHS compliance professionals on January 17, 2017 to discuss this issue and to create a list of ideas for measuring the “various elements of a compliance program.” The list can be used and adjusted by any health care facility and it outlines the list of ideas OIG came up with to help us understand what an “Effective Program” means to the OIG.

At this gathering of minds, the OIG outlines a Compliance Program using the Seven Elements of a Compliance Program as:

  • Standards, Policies, and Procedures
  • Compliance Program-Officer and Committee
  • Exclusion List Checks and Evaluations
  • Communication and Education of Compliance Issues
  • Monitoring, Auditing and Internal Reporting
  • Disciplinary Actions for Non-compliance
  • Investigations

The OIG and team were very thorough in their thoughts and recommendations.  They emphasized time and again throughout the report, that these are only suggestions and should be used by the facility according to their needs and ability.  All of the suggestions cannot truly be used by every organization all the time, but should be applied as necessary.  Some of the suggestions will be used frequently by one organization and occasionally by another.  It is best to look at these as tools in the tool box and find what tools you need to make your compliance program the best it can be.

Standards, Policies, and Procedures OIG Recommendations

I am going to break this down into seven blogs, one for each of the elements. So tools in the tool box to use for Standards, Policies, Procedures include, but are not limited to:

  1. Conduct periodic reviews of policies, procedures, and controls.
  2. Consult with legal resources.
  3. Verify that appropriate coding policies and procedures exist.
  4. Verify that appropriate overpayment policies and procedures exist.
  5. Integrate mission, vision, values, and ethical principles with code of conduct
  6. Maintain compliance plan and program.
  7. Assure that a nonretribution/nonretaliation policy exists.
  8. Maintain policies and procedures for internal and external compliance audits.
  9. Verify maintenance of a record retention policy.
  10. Maintain a code of conduct.
  11. Verify maintenance of:
  12. A conflict of interest policy
  13. Appropriate confidentiality policies
  14. Appropriate privacy policies
  15. Policies and procedures to address regulatory requirements (e.g., the Emergency Medical Treatment and Labor Act (EMTALA), Clinical LaboratoryImprovement Amendments (CLIA), Anti‐Kickback, research, labor laws, Stark law).
  16. Assure policies and procedures address the compliance role in quality of care issues.
  17. Verify maintenance of a policy on gifts and gratuities.
  18. Verify maintenance of standards of accountability (e.g., incentives, sanctions, disciplinary policies) for employees at all levels.
  19. Maintain a Compliance Department operations manual.
  20. Verify maintenance of policies on waivers of co‐payments and deductibles.
  21. Assure governance policies related to compliance are appropriately maintained.

The OIG and team then go into what to measure and how to measure each of the seven elements. For Standards, Policies, and Procedures, they created a table of categories of Access, Accountability, Review Process, Quality, Assessment, Code of Conduct, Updates, Understanding, Compliance Plan, Confidentiality Statements, and Enforcement.  There is a lot of valuable information in these five pages of tables.  If you want to review the what and how’s to measure element #1, the link is https://oig.hhs.gov/compliance/101/files/HCCA-OIG-Resource-Guide.pdf .

Should you have any questions please contact me at karen@bcgdata.net.

Article written by Karen Steggerda