It is a critical element of an effective compliance program to establish and maintain lines of communication between employees and others in the work place and the compliance officer. Any interruption in this communication channel may result in unwanted events that could give rise to liabilities, such as intervention by regulatory and enforcement agencies, bad publicity, law suits, injuries, and loss of protected health information (PHI). Open communication assists in prompt identification and response to concerns.
The HHS Office of Inspector General (OIG) compliance guidance and the Federal Sentencing Guidelines (FSG) calls for organizations to develop a compliance hotline to help create a culture that encourages workforce members to report concerns that may violate laws and regulations. OIG guidance, in particular, provides considerable attention to this subject. The agency “encourages the use of hotlines (including anonymous hotlines), e-mails, written memoranda, newsletters, and other forms of information exchange to maintain these open lines of communication…An open line of communication……is important to the successful implementation of a compliance program and the reduction of any potential for fraud, abuse and waste.” The OIG comments also state that “employees should be permitted to report matters on an anonymous basis…Such information should be included in reports to the governing body, the CEO and compliance committee.”
The FSG state, “The organization shall take reasonable steps to have and publicize a system, which may include mechanisms that allow for anonymity or confidentiality, whereby the organization’s employees and agents may report or seek guidance regarding potential or actual criminal conduct without fear of retaliation.”
A common lament by compliance officers is that what they receive through the hotline are not violations of laws and regulations, but mostly human relations matters. The question is whether this is all there is to report or whether employees are reluctant to use the hotline to report serious matters. In any case, the compliance office is charged with overseeing all action in responses to the concerns reported through the hotline.
Carrie Kusserow, a health care expert with 15 hears experience with hotlines and other compliance communication noted that “despite code and policies references that assure employees against retaliation, the fear of reprisals is most often the reason that serious concerns are not reported, particularly if they involved senior offices. This lack of trust can result in a hampered communication process.” In order to have an effective hotline as a communication link to employees, the OIG notes that it must offer confidentiality and/or anonymity to provide the added assurance against retaliation. This assurance can provide a safe way for employees to promptly report concerns and it helps maintain open lines of communication.
Al Bassett, J.D., a nationally recognized expert in health care compliance advises “compliance officers need to know how employees feel about the hotline. It is their obligation as part of ongoing monitoring of that program to take steps to find out about the attitudes and perceptions of employees toward the hotline.”
The challenge is for the compliance officer to find methods by which to learn about how employees view the hotline. The OIG provided a solution to that challenge when it stated in its compliance guidance that “the compliance officer…should consider questionnaires developed to solicit impressions of a broad cross-section of…employees and staff”. In addition, the FSG notes “organizations are increasingly making use of employee perception and knowledge surveys. And more and more board directors, given their oversight duties and personal exposure, are requesting such surveys be undertaken.”
Jillian Bower, an expert on measuring compliance program effectiveness through employment of compliance knowledge and culture surveys, states that “some surveys can measure employee knowledge of the compliance program and others can focus on ethical outcome, or the impact of their program activities.” She cautions that internally developed and administered surveys may be questioned as to potential bias or reliability and notes “it is far better to use a valid and independently administered survey that has been tested over many organizations that is administered through a web-based system that ensures confidentiality of participants. The most useful surveys are those that are anchored in a database of organizations that has employed the instrument to permit ‘benchmarking” the organization against that universe.”
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.
Copyright © 2015 Strategic Management Services, LLC. Published with permission.