Find a friendly format to ensure compliance guidance is followed

Modify the HHS Office of Inspector General (OIG) Compliance Program Guidance (CPG) documents so they make more sense and will be followed by the organization, according to Frank Ruelas, Facility Compliance Professional at St. Joseph’s Hospital and Medical Center/Dignity Health, during a webinar hosted by the Health Care Compliance Association (HCCA).CPGs, particularly for hospitals, provide valuable guidance for compliance professionals to follow in assessing their compliance programs and can be used by compliance officers of all types of facilities. The key is to make sure some sort of guidance is being followed and that assessments are verifiable.

Making use of the CPG

CPGs provide valuable information but few people read them and follow them, according to Ruelas. The problem is often that the original format of the OIG CPGs, from the Federal Register, is hard to read and navigate. Ruelas suggests taking the “text” format document from the Federal Register website and reformatting it into a “friendlier” format to help drive effectiveness. The revised format could contain a table of contents (to act as an inventory or checklist), hyperlinks to resources, headings, and anything else that would make the document more useable to perform an assessment of the organization’s compliance program.

When it comes to using the reformatted document to perform an assessment, Ruelas suggests going through and highlighting each action item contained in the CPG in one of three colors: green (acceptable demonstrated compliance), yellow (some demonstrated compliance), or red/pink (no demonstrated compliance. This will demonstrate the level of compliance and will easily show which items need additional attention. Ruelas stressed the importance of self-assessments being verifiable. Compliance officers must be able to show how he or she reached their assessment, right down to each item.

Just how many elements are there?

Ruelas warns that depending on which guidance you are following, the elements may vary slightly. The OIG has seven elements in a compliance program. The Affordable Care Act (ACA) (P.L. 111-148) and the Federal Sentencing Guidelines have eight and nine elements, respectively, but most elements overlap. All guidances are applicable, and no matter which framework you use—there is no established framework—it provides instructions on how to move forward to make your compliance program more effective, Ruelas noted.

How to get started

Ruelas stressed the importance of a supportive mindset when assessing an organization’s level of compliance. It could be that a compliance officer is coming into an already established program, so it is important to expect challenges. Then, Ruelas says to use the “plain, simple, old school” tried-and-true “5W1H Model”—start by identifying Who, What, When, Where, Why, and How regarding the compliance program, down to each item. If those are not identifiable, start with the compliance officer requirements of a compliance program, Ruelas noted, because that forces the compliance officer to focus on his or her own role and responsibilities. It also provides an opportunity to optimize the compliance officer’s job description and to meet with organization leadership.

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