Shannon Hartsfield Salimone is a Partner in Holland
On March 27, 2017, the OIG released a 54-page guidance document regarding how to measure the
effectiveness of a compliance program. The guidance is the result
of a roundtable meeting on Jan. 17, 2017, where a group of
compliance professionals and OIG staff met to discuss how to asses
a compliance program's effectiveness. The guidance includes
hundreds of measurement options that could be used by a wide
variety of entities. Organizations are not required to use the
guidance as a checklist and do not have to make sure each one is
utilized in evaluating a compliance program. The OIG recognizes
that "[u]sing them all or even a large number of these is
impractical and not recommended." Instead, "[a]n
organization may choose to use only a small number of these in any
given year," and "[a]ny attempt to use this as a standard
or a certification is discouraged by those who worked on this
project; one size truly does not fit all."
Some of the interesting suggestions in the resource guide
include the following:
Measure the effectiveness of the
organization's standards, policies and procedures by conducting
a survey of employees to determine whether the policies and
procedures assist the employees in doing their jobs
Determine whether the compliance
program's administration is effective by conducting an audit to
determine how involved the compliance officer is in training,
policy development, and other business operations;
Evaluate whether employee, physician
and vendor screening is effective by auditing performance
evaluations to make sure compliance obligations are clear and the
employee's compliance performance is measured;
Measure effectiveness of compliance
training and education by verifying that at least one compliance
related topic is included in each of the organization's
educational presentations and programs;
Monitor the effectiveness of the
organization's internal auditing and reporting systems by
verifying whether hotline calls and matters are brought to the
attention of the compliance department and whether trends are
reported to the compliance committee and board;
Verify the effectiveness of the
organization's disciplinary measures by interviewing employees
to determine whether they understand that there are disciplinary
consequences for noncompliance; and
Assess the effectiveness of the
organization's investigations and remedial measures by
determining whether the process is "transparent," which,
according to the resource guide, means that "not everything
[is] placed under attorney client privilege."
The content of this article is intended to provide a general
guide to the subject matter. Specialist advice should be sought
about your specific circumstances.
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