Kusserow on Compliance: Measuring culture using compliance benchmark surveys

– Evidencing compliance program effectivenes

– Provides quantifiable compliance program effectiveness metrics

– Internally developed and administered surveys lack credibility

The Sentencing Commission in its Federal Sentencing Guidelines states that businesses must “promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law.” The OIG in its Compliance Program Guidance for Hospitals noted that “as part of the review process, the compliance officer or reviewers should consider techniques such as…using questionnaires developed to solicit impressions of a broad cross-section of the hospital’s employees and staff.”  Daniel Peake of the Compliance Resource Center explains that a culture survey can identify gaps between the compliance culture that is intended and the one that employees actually experience. Importantly, it can identify whether the investments in the compliance program and employee attitudes and perception are truly aligned.  Surveys of this type can measure employee perceptions regarding the day-to-day management behavior.  However, to be truly useful, the culture survey should be a professionally developed, tested, validated, and independently administered. It would be best if responses to the individual questions can be evaluated, analyzed, and benchmarked against a large universe of organizations that have used the same questions. This permits comparisons to industry peers and national averages. Using the same survey every couple of year can assist in benchmarking and monitoring progress of a compliance program against its own results (i.e., trending historical company survey data). Results from a survey report should provide enormous value in identifying organization strengths as well as opportunities for improvement. This can help ensure the organization is on a track towards creating an organizational compliance culture of the highest quality. It can provide great insights into how effective the compliance program has been in changing and improving the compliance of an organization and signal not only strengths in the compliance program, but areas of potential weakness warranting attention. Culture surveys can measure:

  • beliefs and values that guide thinking and behavior of the workforce;
  • outcomes or the “impact” of compliance program activities;
  • the extent to which individuals and leaders demonstrate commitment to compliance; and
  • the current state of the compliance climate or culture.

 

For more information, contact Daniel Peake at (dpeake@complianceresource.com) (703-236-9854).

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 © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Meeting sanction checking mandates

As the HHS Inspector General, I created what is now referred to as the List of Excluded Individuals and Entities (LEIE) that was followed by OIG compliance guidance documents which call for checking employees, physicians, vendors, and contractors against the LEIE. The OIG considers all claims and costs associated with an excluded party as potentially false and fraudulent and can lead to significant financial penalties and more. The OIG Special Advisory Bulletin on the Effect of Exclusion provides very useful information in assessing this risk area. CMS mandates, as a condition of enrollment, providers may not employ or contract with individuals or entities that are excluded from participation in any federal health care program and call for checking not only against the LEIE, but also the General Service Administration’s (GSA) Excluded Parties List System (EPLS), now part of the System for Award Management (SAM). CMS further called upon State Medicaid Directors to establish their own sanction data base and requires providers to check it on a monthly basis. To date, 40 states have moved to establish their own Medicaid sanction lists with other states in the process of doing the same. This has increased the sanction screening burden exponentially, not only for the compliance office but other departments as well. HR often has responsibility of sanction checking new hires and periodically current employees. Procurement is also affected because they handle the screening of vendors and contractors. The Medical Credentialing Office must ensure checking on physicians who have been granted staff privileges.  Other federal sanction databases worth screening are maintained by the DEA and FDA, as well as the Department of the Treasury Office of Foreign Assets Control (OFAC) Terrorist Watch List.

Daniel Peake, of the Compliance Resource Center (CRC), works with clients to provide a variety of CRC services that includes providing sanction checking services, as well as the investigation and resolution of potential hits. He noted that the time and resources necessary for developing and maintaining a search engine, along with regularly collecting and updating sanction information from many databases is not very cost effective. This high cost of using internal resources to develop and manage the sanction checking has resulted in the great majority of health care entities subscribing to a vendor service that provides a search engine to their established databases. Vendors can afford the high cost of maintaining the currency of the data because they amortize the costs over many clients. The problem is that that vendor quality, cost, and reliability can vary enormously.  From experience, he offered the following tips for those considering a vendor:

 

Tips on choosing a vendor search engine service

  1. Know the cost up front with a fixed rate, not based upon per click searches.
  2. Contract should permit cancelling without cause at any time, if dissatisfied.
  3. Ensure vendor has liability insurance ($ 1 to 3 million preferably).
  4. Determine other services included (e.g. policy templates, regulatory updates, etc.).
  5. Determine how much “help desk” assistance is available to resolve potential hits.

 

For more information, contact Daniel Peake at (dpeake@complianceresource.com) (703-236-9854).

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Board compliance expertise needed to protect against liabilities

– OIG “White Papers” and CIAs are must-reads for compliance officer

– CIA board member certification mandates is a “game changer”

– Boards need “compliance literate” members

– Compliance officers should not wait for boards’ engagement of experts

Government regulators have advised for decades that effective Compliance Programs begin at the top with the Board and cascade down through the executive leadership and the compliance officer to all employees. The OIG and American Health Lawyers Association (AHLA) issued three communications that underscore the Board compliance duties and responsibilities. The most recent is “Practical Guidance for Health Care Governing Boards on Compliance Oversight” which advised Boards to have compliance expertise available to make sure they meet all fiduciary duties and obligations in overseeing corporate compliance.

Carrie Kusserow, with 20 years experience as a compliance officer and consultant who brought organizations through CIA mandates, has found the Practical Guidance particularly significant.  It calls for Boards to engage Compliance Experts to assist them in meeting their obligations and it is noteworthy that it provides almost identical language to the language used in CIAs regarding Boards’ use of Compliance Experts. In cases where the OIG finds that the Board has not been providing the proper oversight of the compliance program, the OIG really nails the organization down in the CIA mandates, which now require personal certifications of board members. She suggests that Compliance Officers should review recent CIAs to learn what the OIG considers as best practices for a Board in engaging a Compliance Expert to be on call for advisory services.

Steve Forman, a CPA with more than twenty years experience as a Compliance Officer, compliance consultant, and has been engaged on many occasions as Board Compliance Expert.  He notes that the CIA mandates for Boards to engage a Compliance Expert because most board compliance oversight lacks members who are experts in compliance. Whereas Board Audit Committees always include “financially literate” members, most Board committees providing compliance program oversight lack members who are “compliance literate.” The result is relatively few boards have with anyone with compliance expertise to assist in proper oversight and support for the Compliance Program. His best advice for Boards is to include someone who is “compliance literate” that knows what questions to be asked and assess program effectiveness.

For more information on this subject, contact Carrie Kusserow (ckusserow@strategicm.com)

 

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: The cost-benefit of engaging interim compliance officers

Carrie Kusserow is COO for Strategic Management, which provides interim compliance officers (ICOs) for health care organizations. She noted that in making the decision about engaging an ICO, close consideration should be given to the return on investment (ROI). In fact, most decisions of this type are made around this time of the year, as organization begin thinking about revitalizing their compliance program in the New Year. The best results from engaging ICOs come from having several different related tasks in a single engagement. First and foremost is managing the program. However, that by itself may not gain the best ROI. She recommends that the ICO engagement include cost avoidance from incidents and event that could give rise to liabilities. Part of this task would be include a “gap analysis” on the status of the program.  Another task should be to help define what is needed in the recruitment of a permanent compliance officer. Also, before the ICO leaves, it is highly advisable to have a full report provided to the executive leadership and board on what was found with regards to the program and anything needed to ensure that it operates in a manner to achieve the desired outcome.  Additionally, the ICO can assist in identifying the education, skills, leadership experience and personality needed in the permanent replacement.

Kashish Parikh-Chopra, J.D., MBA, CHC, CHPC notes that a growing number of health care provider organizations have been turning to her firm to find an Interim Compliance Officer (ICO) to fill temporary vacancies, evaluate status of the compliance program, and mentor current compliance office staff.  Her firm, Strategic Management provides such services with individuals who have all the necessary experience, technical skills, proven leadership and personality to properly fit into the senior management team. Often, executive leadership or the Board decides it is necessary to engage an expert to make improvements or to keep operations running smoothly and addressing issues, while the organization searches for the right permanent candidate. It also provides a fresh set of professional eyes examining and testing the compliance program for any potential deficiencies. By including these evaluations and reporting requirements in the ICO engagement, the organization receives a benefit, which if contracted for separately, would cost twice as much. What this means is that for the cost of a full compliance program evaluation, the ICO would also manage the program for the gap period.

 

For more on Interim Compliance Officers, Kashish Parikh-Chopra can be reached at kchopra@strategicm.com or via telephone at (703) 535-1413.  Also visit https://compliance.com/services/interim-compliance-officer/ or see Journal of Health Care Compliance at https://compliance.com/publications/understanding-the-role-of-an-interim-compliance-officer/

 

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.