Many Compliance Officers (COs) raise questions and concerns relating to what kinds of reports can be made to the Board oversight committee. This is often preceded by laments about their Committee getting tired of hearing about how many hotline complaints were handled or employees trained. Yet, the HHS Office of Inspector General (OIG) has stressed the critical role that the Board oversight committee needs to play in order to meet its fiduciary obligations and for a compliance program to be effective. Failure of the oversight committee to meet its obligations may result in personal liability. This blog offers a few topics that might be considered when making reports. The CO could report on:
- The needs of properly implementing and managing the compliance program (CP)
- Resources necessary for proper operation of the CP
- The proposed annual compliance work plan and seeking approval for it
- How and why all covered persons must adhere to their compliance obligations
- The Committee’s role in Code/policy development, approval, and implementation
- Evidencing the Code and policies are understood by all covered persons
- Steps taken to publicize the importance of the Code to all employees
- Compliance-related policies and procedures that have been developed and implemented
- Other policies needed to address compliance risk areas and vulnerabilities
- The scope and results of compliance-related education and training
- Evidence of compliance training effectiveness in education on compliance and high risks
- Explaining the measures taken to enforce training requirements
- Results of ongoing high risk monitoring by program managers
- Results of ongoing auditing verifying and validating ongoing monitoring
- Explaining the manner by which the CO identifies and manages new compliance risks
- Updating them on significant regulatory and industry developments affecting risk
- Results of periodic independent reviews of the CP
- Compliance communication (g., hotline) results
- Explaining the process for evaluation and responding to suspected compliance violations
- Explaining how the CO protects and preserves compliance documents
- Metrics that evidence, track, and measure CP effectiveness
It is not possible to cover all these and other issue areas at every meeting of the Board Committee. That would tend to be redundant and uninteresting would sap the Committee’s interest and motivation to do what they need to do. COs may want to consider grouping issue areas into theme reports for each meeting. For example, the first meeting of the year could discuss the proposed CO work plan that includes addressing high-risk areas, including those recently identified, as well as ongoing auditing of the selected program manager monitoring of their respective compliance risks. A second meeting could address written guidance and the compliance education and training provided, and provide the necessary training for Board members. Another report could focus on compliance communication and hotline operations that includes how identified potential regulatory and legal problems were addressed, corrective action measures taken, any disclosures to outside parties, etc. The last meeting of the year could address overall results and metrics of the CP for the year, as well as justifying budgetary needs. Other issue areas can be added to any one of the four theme reports, as well as any ad hoc issues that may arise. By combining the issues into theme reports for each scheduled meeting, the Committee will learn as to what to expect from the meetings and not just get a rehash of prior meetings. The pattern of reporting could be repeated annually and become a settled process.
Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.
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Copyright © 2014 Strategic Management Services, LLC. Published with permission.
