Many healthcare providers are accustomed to assessing their compliance programs on a regular basis. The OIG recommends this practice annually - and, as of November 28, 2019, nursing homes are required to conduct an annual review. It is common for providers to evaluate compliance policies, training, auditing programs, and other aspects of the seven elements of an effective compliance program. It is less common - and yet crucial - for organizations to evaluate their compliance culture.
Why culture matters
Your culture determines whether compliance is a dormant binder of policies gathering dust (poor culture), or an active part of daily operations (a strong culture). Your culture marks the difference between policies being followed or ignored; misconduct being reported (or ignored); and whether compliance issues are properly recognized (or ignored). When it comes to compliance, ignorance is NOT bliss - and the only way to tell if your organization is in the dark is to assess your compliance culture.
We also know culture is key because regulators and industry thought leaders tell us so. The Supplemental OIG Compliance Program Guidance for Hospitals states: "In short, the hospital should endeavor to develop a culture that values compliance from the top down and fosters compliance from the bottom up. Such an organizational culture is the foundation of an effective compliance program."
Likewise, the OIG Supplemental Compliance Program Guidance for Nursing Facilities states: “It is important for a nursing facility to have an organizational culture that promotes compliance.”
How do you measure compliance culture?
Employee surveys are a great place to start.
In 2017, the OIG and the Health Care Compliance Association (HCCA) jointly published a Resource Guide for Measuring Compliance Program Effectiveness. This document mentions surveys 59 times.
Conduct an anonymous employee survey designed to gather feedback about compliance program and compliance officer awareness; comfort levels with reporting options; confidence in supervisors’ ability to lead ethically; and comprehension of basic compliance concepts. For example, you might ask:
- Who is our compliance officer?
- Would fear of retaliation prevent you from reporting non-compliance internally?
If possible without compromising anonymity, evaluate data by department in order to identify areas to target education. And remember to include open-ended questions in addition to multiple choice. While open-ended questions require more time to analyze, they are more likely to yield valuable insights regarding compliance strengths and risks.
Finally, share survey results with your Compliance Committee, leaders, and governing body. Then, enjoy the results: diligent response to survey results can show improvement in future years.
Need a compliance survey? MPA can conduct your annual review. Email me today to learn more.