When the compliance team at Fairfield Medical Center in Lancaster, Ohio, reviewed the effectiveness of the compliance program in December, it mostly sought feedback from the compliance committee. The assumption was the compliance committee, with its representation of operational leaders and others, is a proxy for the entire organization.

“Whatever they think is happening or isn’t happening is a pretty good litmus test for what the organization thinks,” said Corporate Compliance Officer Melony Rarick.

Compliance committee members were surveyed on the seven elements of a compliance program, plus nonretaliation. For example, they were asked whether the hospital participates in ongoing compliance training programs and tracks participation. Does it have appropriate overpayment policies and procedures? Does the hospital verify that compliance risk assessments are conducted periodically? Does it ensure the inclusion of compliance obligations in all job descriptions? And, of course, many other fundamental indicators of an effective compliance program.

The most significant survey finding: “We didn’t have an auditing and monitoring plan,” Rarick said. Audits are performed only in response to external auditors or in the Joint Commission arena by the quality improvement department. To increase auditing and monitoring, Rarick has requested the addition of an internal auditor as well as auditing software. There was some good news in the effectiveness review as well. For example, policies and procedures and disciplinary actions for noncompliance are strengths.