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Part 2 of 2: Measuring the Effectiveness of Your Healthcare Compliance Plan

June 10, 2020

In the second part of our two-part series, we covered three ways to measure your healthcare compliance program’s effectiveness. In this, the second part of the document, we will discuss four more categories to measure healthcare compliance effectiveness.

8 Things to Review in Your Monitoring, Auditing, and Internal Reporting Systems

  1. Reporting System: Review and audit reporting-system documents for the following: benchmarking reports, adherence to policy, compliance department involvement, report tracking, accessibility, thoroughness of investigation files, response time, key compliance indicator prioritization, use and monitoring of the system, and completion notes. Survey employees for perception and understanding of the reporting system, including internal awareness, non-retaliation, subordinate vs. management actions, discipline, and the escalation process.
  2. Risk Assessment: Review documentation for organization-wide risk assessment, internal audits, and fraud risk assessment. Create or review your risk assessment map. Evaluate the map for the following: clarity, topic prioritization, participation, mitigation steps, education/training, and reporting of results. Review the risk assessment work plan and monitor its effectiveness. Follow up with leadership participation in risk reporting and resolution.
  3. Auditing Work Process: The review of the audit process and audit tools should include attorney referrals, minutes, documentation, benchmarking, methods, reporting, monitoring, corrective action, and compliance committee involvement.
  4. Monitoring and Auditing Work Plan: Review and audit the work plan to understand audits and audit reviews, the hiring of outside experts, involvement of the compliance department, the completion of items in the plan, and gift policy and procedure.
  5. Corrective Action Plan: Review the corrective action plan to ensure it includes root cause analysis, documentation, minutes, reports, refund tracking, trend tracking, corrective action, and follow-up audits.
  6. Auditors: Hire a third party to validate audit results and check for auditor background, independence, and skill set. Review audit guidelines and files for resource selection and consistency.
  7. Vendor oversight: Review vendor contracts and certifications to ensure adherence to the compliance program.
  8. Non-retaliation: Conduct surveys, focus groups, and exit interviews to verify non-retaliation for reporting compliance issues.

4 Ways to Measure the Effectiveness and Consistency of Disciplinary Action

  1. Awareness: Review documentation and survey employees to ensure effectiveness and understanding of compliance expectations. Clarify the difference between discipline for non-compliance and retaliation. Review policies and standards of conduct for clarity concerning disciplinary action. Verify that training and documentation requirements for vendors and employees are completed.
  2. Consistency: Verify that the disciplinary policy for non-compliance is always followed and compare those of similar cases. Involve the compliance committee to ensure fairness. Include a review of policies and procedures for consistency as part of the disciplinary process and audit personnel files. Involve appropriate parties in disciplinary action, and complete actions in a timely manner.
  3. Documentation: Review documentation of disciplinary policy, policy exceptions, and recording tracking systems for transparency. Review minutes, disciplinary files, and business plans for inclusion of discipline for non-compliance. Review documents to verify that disciplinary policies are also in place for non-reporting of non-compliance.
  4. Promotion Criteria: Review documents for the inclusion of compliance criteria in consideration of candidates for promotion.

12 Investigations and Remedial Measures

  1. Guidelines for Conducting Investigations: Review policies and procedures for conducting investigations. Check the investigative process for efficacy by verifying consistency, transparency, timeliness, flexibility, and clarity. Ensure the process follows policy. Create a communication plan for interviews that focuses on individual accountability and protects individuals from negative repercussions for reporting. Maintain a consistent process for keeping records.
  2. Training of Investigators: Review the list of investigators and ensure proper certification and training.
  3. Professionalism and Competency of Investigators: Conduct mock investigations to evaluate timeliness, efficacy, professionalism, and discretion of investigators.
  4. Independence of Investigators: Interview investigators using an external source. Review policies and procedures with the investigators. Check the reporting structure to avoid conflicts of interest.
  5. Content of Investigation Files: Create or maintain a process for the documentation of investigation files that complies with the required retention period.
  6. Quality and Consistency of Investigations: Audit investigations for the following: quality of question asked, appropriate department of involvement, thoroughness of investigation files, and appropriateness of process to allegations. Consider conducting mock investigations to test the process.
  7. Tracking and Trending Investigations: Audit tracking system to determine if investigations are categorized appropriately. Review documentation, reports, and processes. Maintain a compliance log.
  8. Escalation of Investigations: Audit investigation files and review board minutes for timeliness of escalation to senior leadership and the board.
  9. Communication of Investigation Outcomes: Create opportunities for organizational learning from investigational outcomes. Review communication with senior leadership and relevant departments. Survey individuals involved to learn employee perception of the organization’s handling of the investigation.
  10. Involvement of Legal Counsel: Ensure policies and procedures protect privilege. Interview legal counsel to determine their level of collaboration with compliance officers.
  11. Timeliness of Response: Audit investigation outcomes for timeliness. Review documentation to ensure that disciplinary actions are carried out quickly.
  12. Corrective Action Plans and Remedial Measures: Verify that investigational outcomes are shared with those whose responsibility it is to take corrective action. Provide closure reports to the compliance committee. Create corrective action plans and review and track to make sure all issues are addressed.

9 Ways to Measure the Effectiveness of Compliance Training

  1. Training: Ensure the organization has appropriately designated high-risk positions and has established a training plan, including assigning individuals to administer the training. Verify training program attendance. Ensure that compliance-related training completion (and re-training as necessary) is documented. Survey employees with disabilities to ensure accessibility. Survey all employees for compliance training relevance. Take advantage of OIG’s compliance training resources.
  2. Accountability: Review performance evaluations and job descriptions for inclusion of compliance criteria. Survey employees for their understanding of compliance requirements and responsibilities. Determine consequences for failure to adhere to requirements.
  3. Awareness: Survey employees to probe their awareness of the compliance plan and review the organization’s compliance activities.
  4. Board: Review documents for compliance competency from Board members and compliance training for incoming Board members. Track questions from Board members to ensure understanding and compliance program effectiveness.
  5. Vendors and Volunteers: Review documents to ensure that vendor and volunteer compliance training is performed and completed adequately.
  6. Competency: Review personnel files and job descriptions to determine if compliance competencies and certification requirements are followed. Make sure requirements for staff compliance training, including investigation, risk assessments, and audits, are established and followed. Commit appropriate resources to your compliance program.
  7. Communication: Review documents to ensure that the compliance plan, including responsibility and accountability, is communicated to all staff. Conduct document reviews to verify regular updates and the discussion of healthcare compliance issues at decision-making meetings. Survey employees for understanding of compliance and reporting issues.
  8. Incentives: Review the recognition and rewards process to determine if compliance is considered as part of incentive programs.
  9. Culture: Review the organization’s training materials and survey employees to determine if the organization promotes a culture of compliance.

Healthcare entities, especially those who receive Medicare and Medicaid funding, are expected to follow OIG regulations in order to prevent fraud and ensure patients receive the highest quality of care. Measuring compliance programs can seem complex, but compliance program effectiveness matters. Having a plan to follow makes the process of measuring healthcare compliance effectiveness much easier.

Stay compliant by screening against FACIS® by Verisys. FACIS is the gold standard in healthcare data used to screen providers for exclusions, sanctions, debarments, and disciplinary actions. Verisys keeps your organization safe, secure, and compliant while meeting government standards and regulations. Enhance your compliance program with real-time access to the most comprehensive dataset for screening and monitoring providers, allowing your organization to operate with full transparency.

Juliette WillardWritten by Juliette Willard
Healthcare Communications Specialist
Being creative is my passion! Writer. Painter. Problem Solver. Optimist.
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