There’s no single measure for compliance effectiveness
There’s no single measure for compliance effectiveness
Now that hospitals have scrambled to set up compliance programs, compliance officers are increasingly facing questions about whether problems continue, whether the education has worked and whether employees trust and understand the purpose of hotlines, says Roy Snell, assurance and business advisory services manager at PriceWaterhouseCoopers in Minneapolis. But he says there is no easy way out of that conundrum.
Snell says when the General Accounting Office was asked by Congress to determine if compliance programs were effective, it was unable to complete its study because no one could tell them what an effective compliance program was. He adds that the Department of Health and Human Services’ (HHS) Office of Inspector General’s (OIG) basic elements of an effective compliance program don’t really get at the question of how to measure a compliance program.
There is no simple method to gauge effectiveness, agrees James Young, chief compliance officer at Johns Hopkins Health System in Baltimore. He says his organization relies heavily on an oversight committee, which serves as an advisory group for the compliance office.
"What we try to do is to take information to the committee to make sure they are aware of what we are doing and ask for their assistance," says Young.
He says that means identifying areas that require attention, as well as generating political support within the organization to deliver the necessary message to various departments.
Compliance committees should be seen as a "change agent," adds Steve Miller, chief financial officer and corporate compliance officer for Noyes Memorial Hospital, a 72-bed rural hospital in upstate New York. "There are a lot of internal processes that just don’t match the external legislation, so we look at our compliance committee to be that change agent for our hospital."
One method Young developed was a checklist designed to identify items that must be documented such as training logs and minutes from compliance oversight meetings. "It isn’t a numbers base system, but a statistical base that focuses on documentation," he argues. "It is similar to what we tell everyone on the medical records side, and that is, If it isn’t documented in the medical records, you didn’t do it.’"
Another dilemma hospitals face is whether to use outside consultants. If organizations do opt to use a consultant to perform risk assessment, they should narrow the assessment’s scope so that consultants don’t simply come in, turn up a bunch of problems and, leave, warns Dion Shiedy, national partner of PricewaterhouseCoopers’ Healthcare Regulatory Group.
"You start by determining what the scope is that you want the consultant to cover and making sure that the consultant’s engagement letter has a clear understanding of the expectations," he says. "You do not want, all of a sudden, lots of paperwork showing up on your desk telling you that the sky is falling."
"It comes down to you having to manage the consultant and not the consultant managing the organization," argues Shiedy. "When you are doing that effectively, you shouldn’t have those problems." He says that means people within an institution must prioritize their own risk and then have the consultant come examine the departments that are most at risk, rather than having someone come in and question everyone.
"Management has to be part of that risk assessment — at least at the 50,000-foot level — to determine what the scope of the deeper risk assessment is going to be," he adds. "Someone coming in from the outside is not going to know the extent of process, policy, and procedure that exists inside the organization and where you believe where you are vulnerable."
Everyone agrees that organizations must have a clear baseline against which to measure. But how to draw that baseline is another matter. One method of accomplishing that is a benchmark survey. (See Compliance Hotline, "Benchmark to measure compliance effectiveness," December 13, 1999, p. 1.) But while benchmarking may help organizations determine where they stand relative to other organizations, they are not the only method.
"We have taken a different approach," says Miller. "Of course, we are doing the benchmarking and statistics, but we are changing our philosophy a bit and not doing percentages and ratios." Instead, he says his organization is actually going to staff members and asking them about the standards and whether they understand them and how they impact their jobs. "We are taking a different kind of approach to effectiveness and using it as an interviewing tool," he explains.
From an operational perspective, Tim Timmons, vice president of corporate compliance services for Healthfuture in Medford, Oregon, says his organization looks at the compliance program as basically a risk management program that is attempting to define processes.
"Rather than trying to get at specific statistical measures that might serve to document the effectiveness of our program, we are looking internally," he explains. "Our bottom line indicator of effectiveness is whether we get into trouble or not." Timmons says that is not much different than a safety program, a clinical risk program or risk management program.
"I have problems with hotlines that say if you have less than X’ percent of your employees calling in that you don’t have a successful program," he argues.
"Just because your number of calls goes down, doesn’t mean that people are paying less attention," agrees Anthony Boswell, chief compliance officer for the Dallas-based Laidlaw Inc., a health care transportation and physician practice management company. Rather, he says the educational aspects of compliance, including hotlines, are part of a story providers should be telling the government. "They want to draw the conclusions that they want to draw," he says. "What is going to keep you out of trouble is the story you can attach to those numbers."
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