Chapter 4: Evaluation Processes, Investigations, and Noncompliance Response

Program Self-Assessment

A healthcare compliance program assessment involves the analysis of an organization’s internal data to refine and improve the organization’s compliance function. It is the process of gathering, reviewing, and discussing information from multiple sources in order to develop an understanding of the compliance program’s strengths and weaknesses, such as the following:

  • Development and implementation of the compliance program

  • The level of working compliance knowledge

  • The existence of a culture of compliance throughout the organization

Assessment methodologies for healthcare organizations should include several fundamental components:

  • Target definition: What is being assessed and what is the scope of the assessment?

  • Identification of necessary data: What information is needed for the assessment?

  • Information collection: What is the process by which information will be requested and compiled for review?

  • Data analysis: How will the information be reviewed, analyzed, and scored?

  • Development of conclusions and recommendations: What are the results of the assessment and what action steps are available to improve the compliance program?

  • Responsibilities: Who will be responsible for each prioritized step and within what time frames?

  • Prioritized process changes: Of the identified recommendations, what is top priority for compliance program improvement?

  • Reevaluation: How did the changes affect the compliance program, and what adjustments are needed in the future?

To successfully perform an assessment, it is essential to form a comprehensive understanding of what a compliance program is and what it means to that organization. This understanding will drive the assessment process for not only the evaluators, but also for the recipients of the assessment results.

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