By Frank Ruelas
Facility Compliance Professional, St. Joseph’s Hospital
and Medical Center/Dignity Health
Help me out here. Understand that if this may apply to you and your organization, it is by no means a negative comment but a genuine request to help me understand how compliance professionals in the following situation can genuinely believe they have effective compliance programs.
We are all familiar with the seven elements as defined by the OIG, the eight elements as defined by the ACA, and the nine elements as described in the FSG. No problem there. The problem or challenge is that despite which of these three frameworks are used, there are a few of the elements that are consistent to each. One, in particular, is the element of auditing and monitoring.
For years it seems that people have stayed away from developing the auditing and monitoring element within their compliance program framework. Some of these reasons quite frankly are related to the fact that some compliance professionals simply don’t know “how to” set up auditing and monitoring.
Oh sure, many compliance professionals can talk the talk. They may even have a few “metrics” that they display to the Board as some type of dashboard in an attempt to show the general health or state of the compliance program, but in the end, are these Boards really getting a good picture or idea of the overall effectiveness of the organization’s compliance program? In my view, I can’t understand how that can be so I am genuinely asking for perspectives from those to help shed some light on this question.
I also want to pose the following for your consideration and feedback. We can have some of the best policies and procedures in place in terms of how the staff can clearly understand their content, very effective training and education to inform the staff on what it needs to know, and timely and effective responses to incidents that may also include enforcement that may result in sanctions or disciplinary actions. These are all very positive. But I ask you, what are we relying on to know if what we propose in policy and procedure is translating itself into action? For some, maybe most, we are in the reactive mode. We wait and see what comes our way by means of incident reports or the hotline, which I know for some, if they get one or two calls a week that is a noteworthy occurrence.
Auditing and monitoring is an essential function that can serve a vital role in a couple of ways. For one, and I hesitate to use the tried and true…and tired…idea that allows compliance professionals to be proactive. Rather, I think it allows compliance professionals to be active. Active in looking for those instances where noncompliance exists so the causes can be identified and mitigating efforts done to align what needs to be brought back into compliance. Auditing and monitoring also serves as a powerful “reinforcer” though it may be sometimes perceived primarily as a way to find when people are doing something wrong. Consider the following. How often do we as compliance professionals communicate a message of a “job well done” to others when we see that their behavior and conduct is promoting the objectives contained in our compliance programs?
There is more to share for thought for sure. However, my point remains the same. I fail to understand how compliance professionals with little or no auditing and monitoring function within their compliance programs can honestly say to themselves and others that they have an effective compliance program, but I am the first to admit I am willing to learn!