Benchmark to measure compliance effectiveness
As many compliance programs enter their second and third year, compliance officers are increasingly faced with justifying their program budget, improving staff buy-in, and measuring program effectiveness. According to Catherine Colyer, senior manager, health care advisory services with Ernst & Young in Atlanta, those three objectives are inextricably linked and are best accomplished together.
One tool Colyer says hospitals can use to accomplish those tasks is a benchmark survey her firm conducted that drew responses from more than 300 hospital compliance officers. Notably, of the compliance officers who said their programs had fully developed policies and procedures, nearly half also reported they were only in the early stages of developing methods to demonstrate program effectiveness.
In fact, while roughly 60% reported they have fully implemented a hotline and standards of conduct, only about 10% had fully implemented a program to measure effectiveness, and only about 5% had fully implemented a benchmarking program.
The Ernst & Young survey also shows several easy ways to implement reporting mechanisms are largely underutilized. For example, only 38% had implemented an e-mail system, only 44% had established a suggestion box, and only 47% had appointed an ombudsman. "All of these are mechanisms that can help gauge effectiveness and demonstrate program value while at the same time increasing staff participation or buy-in," asserts Colyer.
According to Colyer, smaller organizations were often able to implement better reporting mechanisms than larger organizations. "This indirectly gets at program effectiveness because they are often able to use things like the exit interview process, which many organizations completely ignore."
The exit interview serves another important purpose, she adds. "You take the soapbox out from underneath a potential whistleblower if you have an effective exit interview," argues Colyer. Typically, whistleblowers are long-term employees who are heavily vested in the organization. "If you have an effective compliance program and are giving the person multiple opportunities to report problems, it is difficult for them to say they tried to communicate a problem but could not," she explains.
Nevertheless, the Ernst &Young survey shows that only 17% of hospitals have fully implemented a post-termination interview.
Compliance officers also were split about their plans for the second and third years of their compliance program, according to Colyer. Half reported a focus on high-risk targets and training, while the other half reported a focus on general compliance training. "If you are part of an organization that has not resolved that issue, one thing that might be helpful is to go back to the OIG guidance and key in on the phrase behavior modification program.’"
Roughly 55% of the hospitals established at least one hour of training including application of standards to factual examples and 60% have new employee compliance orientation. But less than 20% give legal counsel the opportunity to lecture employees, while 15% use videotapes and only about 5% use interactive computer technology.
A third of the compliance officers surveyed said that management does not conduct risk assessments within their organization. "This is particularly important because we looked at other questions indicating that those compliance officers who did use managers to help them conduct risk assessments were also the ones that said their auditing and monitoring processes were effective," says Colyer. "There was a very strong correlation to the perceived effectiveness of their program."
"The primary challenge for compliance officers today is that they are busy putting out fires and can not define their agenda," asserts Colyer. She argues compliance officers must increasingly begin delegating authority, identifying their own issues, and setting their own agenda. "That is what compliance officers are struggling to do and that is directly related to demonstrating program effectiveness," she says. "You are not demonstrating program effectiveness if you are just responding to fires as they pop up."
It’s not unusual for a compliance officer to be responsible for 17 different program areas, she adds. "It’s worth it to find out what is out there and where you can best spend your money."
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