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[Excerpted from “Organizational Steps: Gain Support and Commitment” which is published in HCCA’s Compliance 101 – 2016]
When you roll out your compliance program to staff will depend on many factors. Certainly the sooner you can enlist staff participation the better. And you need not have everything absolutely final before you officially launch the compliance program companywide. However, you do need to have the code of conduct ready.
How the code of conduct is written can vary. The code of conduct is usually drafted by the Compliance Officer and then shared with the Board, compliance committee and management for input. By obtaining their input it helps to garner commitment. You may also want to have your compliance committee help to develop the code of conduct. In drafting the code the Compliance Officer can review sample Codes from other organizations. However, it is not advisable to “lift” a code of conduct from another source, make minor tweaks, and try to make it fit your organization. Your code of conduct should reflect your organization’s spirit, tone, and culture. If it doesn’t ring true to staff, securing their participation and cooperation in the compliance program will be much more difficult.
There may not be a “one size fits all” code of conduct but there are certain elements that every code should include. Most codes of conduct begin with the official Board resolution approving the compliance program or the memo announcing the launch of the program. The code should begin with this strong endorsement from the highest levels of management. An endorsement signed by the board chairman or the CEO makes the message personal and says “you have my word on it.” This executive message is the place to state unequivocally that everyone in the organization and all affiliates are expected to act in an ethical manner and abide by all applicable laws and regulations affecting the organization. A strong message in support of staff is also in order. The code of conduct provides guidelines and tools developed to help employees in situations created by today’s confusing and complex health care environment. Staff honesty is not the issue. When a situation poses uncertainty, the code of conduct provides guidance for appropriate conduct or, in more challenging situations, offers the way to get answers within the organization.
The code of conduct might be seen as an elaboration on the organization’s mission or vision, both of which deserve a highly visible place in the code of conduct. Many organizations have identified specific values that help accomplish the mission. If your organization has values in addition to the mission, these too should be prominently featured in the code of conduct.
As a resource for all staff and affiliates, the code of conduct should also include a detailed outline of procedures for handling questions about compliance or ethical issues, beginning with a description of chain of command. The best reporting mechanism is an open door. When a question arises, it is hoped the employee will feel comfortable in approaching his or her supervisor, the first link in the chain of command. In the event that the employee and the supervisor cannot resolve the issue, usually the department manager is the next step. If discussions with the supervisor and department manager are not satisfactory, the Compliance Officer should be consulted unless it is an HR issue, then it would go to HR. These steps should be delineated in the code of conduct along with a clearly stated promise of non-retaliation.
However, every employee will not be comfortable talking to management so there are alternate methods of reporting potential problems or posing questions. The code of conduct should provide a clear, concise explanation of how those alternate reporting methods work. For instance, list the hotline (or helpline) telephone number along with hours of operation. In this context, emphasize that all calls will be anonymous or held in complete confidence. To the extent possible, it will help to outline the procedures for how the organization will respond to reports or questions. Can you promise that the compliance department will investigate all reports or will handle every complaint equally and consistently, i.e., all get triaged, managed to resolution, etc.? Can you promise that all compliance-related questions or allegations, whether received through chain of command, the hotline, or other reporting mechanism, will be investigated within 48 hours? Such specifics are important to include but will be reassuring to staff only if there is evidence that this is occurring and is sustainable.
As a key element of an effective compliance program, every code of conduct will want to include a description of the compliance program along with names of all compliance office personnel and members of the compliance committee. Add pictures, phone numbers and e-mail addresses for all key contact personnel.
The narrative section of the code of conduct can deal with a wide variety of issues. For instance, high risk areas can be addressed in scenario based examples. You may cover general areas such as: conflicts of interest, Stark Law, gifts and gratuities, etc. Areas of specific weakness or risk should be addressed in the code, depending on the organizational setting. Most importantly, the code must emphasize zero tolerance for fraud or abuse, a commitment to submitting accurate and timely billing, and compliance with all laws and regulations. Consequences of malicious or uncorrected wrongdoing should be noted, with a description of the progressive discipline procedures, if appropriate. Also, clearly state that everyone has a personal obligation to report any possible wrongdoing. Not reporting makes an employee subject to discipline as well.
The code of conduct holds the potential to be an abstract document, one that might not seem relevant to the day-to-day work of the individual. Therefore, many organizations add a “sample question” or “examples of compliance violations” section. A mixture of the general and specific is suggested. The examples should be inherent to your organization. Sample general questions might be:
- I think I saw someone accept a gift card from a vendor. Who should I contact?
- Should I report a possible problem even if I’m not sure? Will I get in trouble?
- What if my supervisor asks me to do something I think is wrong?
- How can I be sure my report will be kept confidential?
- If a physician asks me to code something I know is wrong should I just do it?
Finally, most codes of conduct come with an acknowledgement or attestation form. The attestation form, requiring the employee signature, emphasizes the importance of the document and could provide certain legal advantages should there ever be a government inquiry. Attestations should be completed on an annual basis as a standard of practice. Annual attestations are required in most Corporate Integrity Agreements. To encourage the employee to return the attestation form promptly, some organizations will require a signed attestation form before new employees can be assigned perquisites such as parking space. Attestation forms should be filed in the employee’s official human resources file. The compliance department may want to maintain copies. It is also acceptable to have electronic attestations.
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