After a nurse left Trinity Health for a new job, she exploded a potential bomb in an exit survey that she apparently hadn’t been comfortable doing with the compliance officer or hotline while still an employee.
“Dr. [X] noted in a patient’s chart that he had done a full exam, which he did not. We then billed Medicare for the full exam. This is not the first time this has occurred with Dr. [X],” the nurse wrote in her response to the question on the exit survey, which asks outgoing/former employees whether, in their opinion, there have been “any compliance issues related to fraud, abuse, unethical or illegal practices or any other misconduct” at the hospital or other facility where they worked.
Although an internal audit of the physician’s billing and documentation practices exonerated him, if the nurse’s perceptions had been accurate, Trinity Health could have continued to pile up overpayments or perhaps faced a whistleblower complaint, says Andrei Costantino, vice president of integrity and compliance. “In this situation, it came down to a misunderstanding of billing and coding, so nothing more came of it,” he says.
Sometimes, however, the reports are accurate, underscoring why exit interviews are a valuable adjunct to the hotline and other reporting methods used by health care organizations to encourage employees to expose possible errors and misconduct, compliance officers say. Without exit surveys, organizations may never learn of certain problems in their organizations. “This is a chance to sit with an employee who is voluntarily going somewhere else and see what they have to say,” Costantino says. “I think it’s a best practice.”
Exit surveys can be time consuming and lead compliance officers and human resource managers down blind alleys, but on balance, the information they provide is enlightening. “Sometimes people leaving the organization are more open than people in the organization,” says Rebekah Stewart, chief ethics and compliance officer at Diamond Healthcare in Richmond, Virginia.
Hospitals use various approaches to exit interviews. Some surveys have one direct question about compliance, while others ask similar questions in different ways and use them to evaluate the overall culture of the organization. “There is so much richness you can build through your questions,” Stewart says. The way questions are asked also may affect the quality of the information that organizations glean. “How questions are framed avoids putting people on the defensive,” she says.
‘Sometimes There are 10 Sides to the Story’
Like with hotlines, some of the complaints that come in through exit interviews are gripes about supervisors or performance evaluations, but compliance officers say they’re still reviewed by human resources, compliance or jointly, depending on the nature of the report. Sometimes when the onion is peeled, there’s a compliance issue underneath.
The challenge is reserving judgment until all the facts are in, Costantino says. “You never take anything on the face of it,” he says. “If it’s important for someone to put down, we should step back and take it seriously enough to look at it. It’s a learned skill to be able to clear your head and say, ‘That’s one piece of it.’ Sometimes there are 10 sides to the story.”
The beauty of exit interviews is they give organizations another chance to expose misconduct when people are reluctant to use the hotline or talk to compliance professionals. “You want to have some way to allow exiting employees to express a concern,” says Wade Meyer, chief compliance officer at ATI Physical Therapy in Bolingbrook, Illinois. “You want to address it even though the employee is moving on.”
At many organizations, HR manages the process of employee separation from the organization, and exit interviews are one part of this. “A really good question to ask is, how did this job match up to your expectations?” says Kim Danehower, chief compliance officer at Baptist Memorial Health Care Corporation in Memphis, Tennessee. “Then segue to, ‘Were there any compliance issues that made your job not meet your expectations?’” Even when people are angry about how the job turned out, they may have actionable information. “You are asking someone who has no filter at this point,” she notes. Danehower knows of one case of a fired employee who griped during an exit interview about a boss doing bad things, and it turned out to be true. The boss was also fired. “Never be afraid to hear what’s wrong,” because departments can’t be managed perfectly, and “there are not enough people in compliance to go around in any organization to make sure everyone is following all the regulations.”
Open-Ended Questions Get More Honest Answers
At Diamond Healthcare, the exit interview with employees is a multistep process, Stewart says. It’s designed to find out about concerns that affect the company culture and put employees at ease so they will be forthcoming in sharing their experiences about what went well and what can be done better. “We have trained our supervisors to have an inquiry-based conversation with employees at the time they notify them of their resignation,” she explains. “This is a time to show appreciation for the work done and provide the first opportunity to capture any experiences or outstanding issues the employee may be willing to share as well as letting them know other avenues for reporting.”
The direct supervisor thanks the employee for their service and asks questions, such as why the employee is leaving, what the company could have done better and whether the manager missed something. “If something is said during the conversation of concern or is a learning opportunity for the organization, the supervisor connects with compliance and/or HR,” Stewart says. Employees also are informed by their supervisor that they will receive a survey, which includes compliance questions, and that they are free to call the compliance hotline after they have left the organization.
Stewart has found people may answer the exit-survey questions differently depending on how they’re asked. It may take a combination of open-ended and closed questions (e.g., ranking items around managerial communication, resolution of complaints and morale) to get a more accurate picture of what the data reveals about compliance, the ethical climate of the organization and where follow-up is necessary.
For example, instead of asking whether “there are any compliance, legal or ethical violations you failed to disclose during your employment,” which can be perceived as accusatory, Stewart recommends asking for the same information in a more open way: “Were you provided an opportunity to raise ethical or compliance concerns? Did you feel comfortable raising compliance concerns? What questions may have arisen throughout your employment that were not addressed? Were all your concerns fully resolved?” The questions also should be phrased to prevent people from becoming defensive. If they’re asked whether they failed to report a compliance concern, they may not respond because they’d be admitting they didn’t follow company policy, Stewart says. It’s more effective to phrase questions in a way that doesn’t point fingers. For example, ask employees, “What questions or concerns may have been raised that were not addressed by your manager or leadership? What could be done better to make it easier to report potential or actual violations?”
When employees notify ATI that they’re leaving, they receive an electronic exit survey, Meyer says. “It’s not geared toward identifying compliance [issues] per se, but we have a couple questions,” he says. Only one is a blanket question—do departing employees have any comments or concerns?—but the other questions are indirect avenues toward potential compliance problems, Meyer says. For example, ATI asks whether employees feel there is a lack of leadership support or problems in the work environment and, if so, to explain.
It’s preferable for employees to use the hotline and other methods (e.g., email address) to report potential errors and misconduct in real time, Meyer says. They promise in writing to report concerns when they read and sign the ATI code of conduct. “You don’t want to get to the point where they have issues when they are leaving, whether it’s billing, coding or documentation,” he says. “But when somebody does express something in an exit interview, make sure you take the time to investigate. It obviously has been missed.”
Employees May Be Contacted Up to Six Times
Trinity Health uses a vendor for exit interviews, Costantino says. When employees resign, they hear from Work Institute, which conducts online and phone surveys. If the outgoing employees don’t complete the exit interview in two weeks, the vendor calls up to six times unless the employees say they don’t want to participate. Reports of compliance issues “related to fraud, abuse, unethical practices or misconduct” on the exit interviews are forwarded to Costantino, but they are investigated by the integrity and compliance officer at the hospital or other facility mentioned in the report.
Sometimes people use the word “fraud” too cavalierly—an error is not fraud—but “it’s important to verify what’s actually taking place,” he says.
University of Kansas Health System is resuming exit interviews, using an automated process, and it will add compliance questions, says Christine Hogan-Newgren, chief compliance and internal audit officer. As soon as the system receives a termination notice from employees, they will receive exit interviews. The compliance questions will be something to the effect of, “Did you ever report a concern? If so, was it resolved? Did you ever have a concern you did not report? If so, do you care to share it now?” Hogan-Newgren believes in getting to the heart of the matter quickly. “The longer a survey, the less likely a person will fill it out,” she says.
The answers to the compliance questions will be walled off from HR, just as the answers to the HR questions will be shielded from compliance. That encourages employees to report concerns to compliance even if they don’t feel comfortable reporting to HR and vice versa, Hogan-Newgren says. She hasn’t been impressed by the response rate to exit surveys in the past, but that was when they were done by mail. Automating the process and asking the questions before employees are offsite hopefully will yield better results.
Contact Costantino at costanta@trinity-health.org, Meyer at wade.meyer@atipt.com, Hogan-Newgren at chogan-newgren2@kumc.edu, Stewart at rstewart@diamondhealth.com and Danehower at kim.danehower@bmhcc.org.