To begin designing or enhancing your organization’s compliance program, it is important to understand the maturity of the compliance program. As an initial step, compliance officers should obtain feedback from key stakeholders including management and the board of directors and/or its applicable committee. It also is important to obtain feedback from key departments such as Finance, Operations, Procurement, Legal, Information Technology, Audit, Risk, Quality, Human Resources, Marketing and physician leadership.
It is common to complete an assessment of the compliance program against a government issues checklist. For example, Health Care Compliance Association (HCCA) and the Office of Inspector General (OIG) issued a compliance effectiveness resource guide and sample checklist.[4] It is also important to check your state’s guidance with regards to compliance effectiveness. For example, New York’s Office of Inspector General issues guidance on what it expects to see in a compliance program. These checklists help organizations identify if there are gaps in their compliance program.
Interview Key Stakeholders
It is vitally important to interview key stakeholders within the organization as part of an overall compliance-program assessment. Key stakeholders to interview should include, but are not limited to, board leaders including the chairperson, corporate suite executives (chief executive officer, chief operating officer, chief financial officer, chief nursing officer, and chief medical officer), leaders within revenue cycle (including patient access, charge capture, health information management and patient financial services), nursing, pharmacy, laboratory, practitioners including physicians, information systems, reimbursement, legal, risk management, and accreditation.
A comprehensive assessment must include many different aspects of the organization to ensure a full appreciation can be gained on the organization’s compliance program. Gaining an interdisciplinary perspective should bring forward information that will assist in identifying gaps within the compliance program.
Arguably, nothing replaces an old-fashioned, in-person conversation about potential areas of concern or risk that a key stakeholder knows about or perceives. Face-to-face conversations represent the seriousness that a compliance assessment should be given. However, getting time on the weekday calendar of an executive or key department leader can be challenging. Therefore, electronic data gathering methods can be an efficient means to gather the greatest possible amount of information from the breadth of individuals needed to accurately assess a compliance program. Survey tools and questions can be customized and easily distributed to many people across the organization to be completed at their convenience. Likewise, feedback can be easily centralized and analyzed.