Proactive Assessments of Health Care E&C Programs and Culture

Not every health care organization has a good handle on how effective their compliance program is and whether the culture of the organization is such that compliance risks are likely to be promptly identified, mitigated and remediated. However, an independent integrity monitor can help health care participants perform a thorough, proactive assessment of a the organization’s ethics and compliance program and culture.

An independent compliance expert can bring a fresh set of eyes to any organization or entity.

Such an expert can provide several valuable inputs to any organization including demonstrating to the board an organization’s ethical culture and effective compliance program or identifying gaps or weaknesses in the compliance program when a health care organization has a problem. For instance, in a compliance problem where the government becomes involved, providing recommendations for remediation demonstrates to government regulators the seriousness and effectiveness of the organization’s compliance program.

Educating an organization’s workforce and sending a strong, positive message throughout the entire organization confirms that the company takes compliance serious and expects the workforce to take it seriously as well.

There are multiple ways to conduct a proactive assessment of an organization’s ethics and compliance program, and Affiliated Monitors (AMI) selects the style and techniques that best fit the situation. Some of these techniques can include reviewing applicable policies, procedures and whether the organization has a hotline and compliance training. However, such techniques can only get you so far.

This means an organization may need to also perform an assessment of its compliance program effectiveness by a variety of mechanisms, such as determining if the compliance policies and procedures are effectively implemented, whether its staff are familiar with and truly understand their compliance obligations and even whether they feel they can communicate compliance and ethical concerns or questions without fear of adverse consequences.

So how can you conduct such an assessment? There are several ways. It can include interviews with individual employees; focus groups with larger numbers of employees; visits to not only the corporate headquarters, but also remote company locations; and, of course, the analysis of all relevant data.

One example included an assessment where AMI tested a hotline on how complaints were handled when they came in. This testing combined all these techniques, including employee interviews, focus groups meetings and review of data on hotline complaints and case closure rates and data.

A proactive assessment can be used when an organization has reason to believe it has an ethics or compliance problem.

This may encompass a situation when there is a change in leadership and the new team wants to drill down and see more precisely where the company may lie on the ethics and compliance scale. It can also be used when there is a major acquisition or a health care provider establishes new business units or even expands into new markets.

In some situations, an independent evaluation team may be called to work collaboratively with others such as outside counsel.

It all starts with the value of the proactive assessment, which leverages independence, and an unbiased perspective, which increases credibility with key stakeholders.

It is critical that the organization and evaluation team work collaboratively to develop the work plan and target potential risk areas. There should also be collaboration in deciding findings and recommendations of the assessment to be communicated. All of this helps to provide an independent, unbiased proactive assessment of a compliance and ethics program and can make the organization stronger and the workforce more engaged in compliance.

One of the key differences in health care from perhaps the energy or tech sector or another commercial enterprise is that the government and the regulators would prefer not to exclude health care providers from the health care industry.

This means even if a health care provider has a compliance issue, the government and regulators may be loath to deliver an ultimate sanction and put a health care provider out of business. Access to quality health care providers is a continuing issue within the industry and particularly within government programs like Medicaid. This is in part because not every health care provider is willing to participate in Medicaid programs and there can be an inadequate number of health care providers available – an issue that’s particularly prevalent for vulnerable patient populations.

From a public policy perspective this means the government wants to have as many quality providers as possible so patients can receive adequate access to health care services.

This can sometimes run up against the tension of health care providers in those areas of medical services that have run into difficulties that could pose a threat to patients and the public or that could pose a threat to the public financing by misusing or abusing the funds being paid. Therefore, the government or regulators will want assurance that any problems have been remediated or will be addressed so the issues don’t continue going forward.

If using an independent integrity monitor can help the government by meeting these two objectives of both quality providers and sufficient access for citizens, it is a win for all involved.

Please join me next week as I explore how monitors can be used in licensing and disciplinary proceedings.

In case you missed the earlier installments of this ongoing series, please see the links below.

Everything You Always Wanted to Know About Monitors But Were Afraid to Ask

Part 1, Part 2, Part 3, Part 4 and Part 5

Potential Issues in Corporate Monitorships

Part 1, Part 2, Part 3, Part 4 and Part 5

Suspension and Debarment in Monitoring

Part 1, Part 2, Part 3, Part 4 and Part 5

Monitoring in the Health Care Sector

Part 1