A compliance program must be tailored to fit the organization. There is no one-size-fits-all program. So how do you know if the program fits and is working? Your program must be assessed to determine if it is truly effective.
You can start with your compliance plan, which should be reviewed periodically. A new regulation or law or new guidelines from regulatory agencies could affect your plan and changes will need to be made. Ask whether what you’ve put in writing (i.e., procedures and policies) is occurring. Is it effective? Could it be improved? The compliance oversight committee should take an active role in this process.
In addition, all compliance-related policies and procedures need to be monitored. A complete review of each policy should be done at least every other year. Annually reviewing these policies is best practice, but in most cases doing so is unrealistic. Such a task can obviously become overwhelming, so you may want to consider having a predetermined schedule for reviewing policies and procedures. Certain policies can be reviewed in January, for example, and another batch in April, and so on. Here, too, the compliance committee can help. As you look at compliance-related policies and procedures, consider if they are still necessary. It’s possible a new policy has superseded an existing one. Have circumstances changed to warrant revising a policy or procedure? Are the policies and procedures effective? And as discussed, policies that are written and not followed can lead to trouble. Be sure to evaluate whether all employees are aware of the policies and procedures pertinent to their positions. You can’t expect them to follow policies if they don’t know about them.
Benchmarking against yourself is also a good way to measure program effectiveness, evaluate and support continuous evaluation, and improve the compliance program. Evaluating your current practices compared with other organizations can help identify standards for achieving best practices. HCCA provides benchmarking statistics that can be used. Your annual report provides one regular statistical summation that can be used to develop benchmarking statistics. You might, for example, track and compare the number of educational programs delivered or number of employees trained in a given period. Or compare the number of issues reported and the number of issues later substantiated. Just be sure to collect consistent data so result comparisons are viable. Set goals and objectives for improved performance.