Kusserow on Compliance: Getting ready to evidence program effectiveness in 2018

In its compliance guidance, the HHS Office of Inspector General (OIG) calls for periodic evaluation of compliance program effectiveness. This can be done by a full field evaluation by experts, however, there are other methods that can help accomplish this end. One way to evidence effectiveness is measuring the compliance culture of the organization with a compliance culture survey. However, to obtain meaningful results requires using a professionally developed and independently administered instrument. Internally developed surveys have little value and are often considered suspect by those asked to participate in the process.

Dr. Cornelia Dorschmid, PhD, advises that a culture survey should be professionally developed, tested, and validated in order to obtain reliable and useful results with the best results being anchored in a larger database for comparison of results. She was instrumental in developing the Compliance Benchmark Survey©, along with a PhD behavioral scientist and a former HHS Inspector General that has been in use since 1993. It uses a Likert Scale model, wherein respondents are asked to rate the question on a scale of one to five. Mean scores are computed for each item. Some questions items are reverse-scored to control for response set (the tendency to respond in a given pattern), “halo effect”.  The survey also includes items known as validators that ensure that respondents are being candid in their responses and not trying to manipulate the survey.

Jillian Bower Concepcion, VP for the Compliance Resource Center explained that the Compliance Benchmark Survey© has been widely used by hundreds of health care organizations with more than a half million employees surveyed. Results of this survey will assist identifying compliance program strengths, as well as opportunities for improvement. Reports present employee perceptions with respect to five different dimensions and four compliance themes. The results by question, panel, and overall results can be compared and benchmarked against the universe of those who used the survey.  The overall score level (i.e., sum of individual item scores) of the company is evaluated against the Health Care Compliance Index (HCCI©). An organization using the same survey over time can also benchmark their progress and measure improvement in the organization’s culture. For more information on compliance surveys, see https://www.complianceresource.com/publication-topics/compliance-surveys/

Steve Forman, CPA, a nationally recognized healthcare compliance consultant whose experience includes serving as an executive in the OIG and the CCO for one of the nation’s largest healthcare system has used the Compliance Benchmark Survey© since it was first introduced.  He has found survey results assist in identifying areas where attention is needed that is very useful in the maintenance and enhancing an effective compliance-program. The results can tell you the “what”, but not the “why” and as such he uses the information in talking to employees and conducting “focus group” meetings that can provide additional insights as to the full meaning of the information derived from the survey.

Al Bassett, JD, is another nationally recognized expert on healthcare compliance, who has been building and evaluating compliance program for over 15 years. Prior to his work in compliance, he was a Deputy Inspector General and FBI executive. He noted that he has found the survey is very valuable in assessing compliance program effectiveness. Results provide compliance officers with a road map to improving the program effectiveness and the costs of using the survey in evaluating the compliance program is only about only 10 percent of a full field assessment by experts.

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 © 2017 Strategic Management Services, LLC. Published with permission.