Corporate Compliance is an organizational-wide commitment to creating and maintaining a culture of compliance with applicable state and federal health care laws. Programs are designed to establish and maintain a system of internal mechanisms that are intended to prevent and detect unethical and/or illegal business practices and violations. Mechanisms include written policies and procedures, operational practices, designated personnel charged to monitor practices, and management staff charged with oversight and correction.
Corporate Compliance involves developing ethical and regulatory guidelines as a foundation for the organization as well as educating personnel on company policy, laws, and regulatory compliance issues that guide and apply to their day-to-day responsibilities as well as their overall responsibility to assist in creating an ethical and compliant work atmosphere.
It is of the utmost importance that a facility develops efficient methods to provide confidential reporting of suspected violations of the corporate compliance standards and that personnel understand that there is no reprisal for legitimate reporting of a suspected non-compliance issue.
It is of great benefit to the organization to ensure that all personnel is familiar with the compliance program in order to accomplish a workplace that is fully cognizant of a personal code of conduct that adheres to the organization’s corporate compliance program.
A compliance program assists in many ways, including but not limited to, creating harmony and respect within the work environment, educating staff so that they may avoid violation of regulatory and/or compliance policies and assist in the detection of violations in their work environment, and assist in reducing and/or eliminating risk management issues. Lack of an effective compliance program does not excuse an entity of responsibility if regulatory requirements are not adhered to.
Compliance issues are many-faceted and include workplace discrimination, harassment, conflict of interest, bribery, and other unethical practices.
An effective corporate compliance program provides many benefits to management, staff, and the community. It provides guidance in regard to legal and ethical issues and emphasizes common values that organizational staff shares. It provides oversight and assistance to help resolve questions about appropriate conduct in the workplace, establishes a structure to disseminate legal and policy changes, and provides an accurate view of the internal functioning of the organization to management.
More importantly, an effective compliance program greatly reduces risk management issues by providing policies and procedures that follow all regulatory requirements. With appropriate reporting mechanisms in place, a compliance program will provide a proactive stance as well as track and trend problems prior to discovery and/or reporting to external agencies. Compliance reporting shows intent on the part of the organization and assists in improving responses to lawsuits, investigations, or audits.
An effective corporate compliance program may include, but is not limited to, a statement of intent that encapsulates the facility’s intent and primary chains of authority and responsibility for the program, a means of providing each staff member (through orientation, handbook, or other mechanisms with a basic understanding of the program, and policies and procedures that demonstrate the compliance program’s underlying principles, to include ethics and expected code of conduct for the facility.
Facilities should provide ample educational and training programs to ensure understanding of laws, code of conduct, and procedures in monitoring, evaluation, investigating and correcting corporate compliance issues. They should have clear and concise procedures in place to investigate, clarify and resolve real and/or suspected violations.
The facility should have a practice in place that ensures a signed acknowledgment on file for personnel understanding of compliance, ethics and expected conduct and their responsibility to follow these as presented by the facility. Each facility should also have a clear chain of command in place for reporting violations of these standards, i.e., a Compliance Officer and a secondary officer. Although many facilities do not have a secondary officer, this position is desired so that there is accountability for the primary Compliance Officer. This allows personnel to know that not even the compliance officer is exempt from being reported. The facility should also have a Corporate Compliance Committee in place, chaired by the Compliance Officer, to make recommendations to the governing body (or authority) in regard to policy and procedure changes, better facilitation of the program, and development of a monthly report for the governing body’s review. The facility’s Risk Management or Safety Officer should also be a part of the corporate compliance committee.
Facilities should have an ongoing examination of the efficiency and effectiveness of its compliance reporting processes, and fully utilize the entire process of corporate compliance to minimize and prevent risk management issues.
Clear policies and procedures are necessary to eliminate inconsistencies in how compliance issues are handled. Because all facilities have unique issues, these policies should be tailored to fit the specifics of each organization. It is critical to develop corporate compliance in this way because establishing a program that your facility cannot possibly adhere to is worse than not having a compliance program at all. A written but unimplemented program has no corporate value. This development includes the establishment of SMART (Specific – Measurable – Attainable – Realistic – Timely) training and acknowledgment methods for policies and procedures, ethical practices and code(s) of conduct.
There are multiple means for reporting non-compliance issues from the simplest to the more complex. Some methods of reporting include voice mail, fax, email, or a facility hotline that is answered only by the Compliance Officer, with an additional contact number for the secondary compliance officer. Regardless of the method chosen, staff should have confidence that their report will remain anonymous, with no fear of reprisal for reporting. Personnel will respond to corporate compliance based on the confidence of the reporting mechanism utilized and the consistency with which the facility resolves compliance issues.
Key facets of a good corporate compliance program include designation of individuals who are responsible for administering the program, ensuring that all staff members receive and acknowledge that they understand the corporate compliance program, providing initial and ongoing training for personnel in regards to compliance, investigation of any reported suspected violations, and resolution based on the resulting investigative results. Other factors include ensuring that all reports and investigations remain confidential, that reprisal is not visited on any staff member who reports a suspected episode of non-compliance, conducting of regular reviews of the compliance processes, and well as periodic review of job descriptions and scope of practice for all personnel and/or departmental groups of the facility.
It is important to note that compliance starts at the top of any organization, and that staff takes their cue from those in management over them. A successful Corporate Compliance program must include a commitment from all staff members and must be a fully implemented program. A compliance program that is a paper tiger has no ‘teeth’ to it and is therefore useless (and even detrimental) to an organization, whereas a healthy, active compliance program establishes credibility and integrity within the workplace and within the community.