One finding from an external effectiveness review of Novant Health’s compliance program was that some employees couldn’t name the compliance officer and didn’t know how to report a compliance concern. It’s never welcome news, and Novant Health, which has 13 hospitals and hundreds of outpatient centers and physician offices in North and South Carolina and Virginia, wanted to know more about its employees’ knowledge of compliance and privacy. Although the standard operating procedure is to survey employees about the compliance and HIPAA program, that didn’t go according to plan.
The next idea had a bigger payoff, says Loree Simmons, assistant director of compliance.
First the survey: Novant Health emailed it to a sample of its 26,000 employees. The number of responses was disappointing, partly explained by the fact that some of them don’t have access to email or don’t check it (e.g., float nurses), she says. So the compliance department developed a different approach to outreach, which is interactive and promotes problem solving. Since January 2018, three compliance program managers and two compliance educators have been slowly making their way through the hospitals, outpatient departments and physician offices, asking employees about compliance and HIPAA basics, and spot-checking a few things while they’re there. For example, do employees know that Novant Health has a compliance officer and what her name is? Do they know where to access compliance policies and social media and photography policies on the intranet? Can they show the compliance program managers and educators how they would access the hotline if they wanted to report a concern? Do they feel comfortable reporting wrongdoing? Do they know how to access the code of ethics and disclose conflicts of interest? Do they know where to go if they have compliance questions (e.g., call the general compliance phone number, use multiple compliance email addresses, ask supervisors and managers)? Are they aware they should reject offers of cash or cash equivalents from patients, family members, vendors and suppliers? Do they know how to access the disciplinary standards?
