Written by: Sam Jones
Last month, we kicked off this new series, walking through the 7 elements of a compliance program, starting with Standards, Policies, and Procedures. This element serves as the foundation and beginning of your compliance program, but you can’t stop there. Having a binder on the shelf or a document on the company intranet isn’t sufficient. To truly put this into practice, it leads us to our next element: Dedicated Compliance Officer and Compliance Committee.
A dedicated Compliance Officer and Compliance Committee may appear daunting on the surface. Every team needs a leader; otherwise, they have no direction. This is where your CO and committee come in to set the direction and lead your organization. The CO serves as the program’s champion with the support of the committee.
If you are starting or revamping your program, you’ll want to ensure that the CO is involved in each step of the process. They will be the individuals implementing the program and serving as the go-to source for the organization. According to DOJ guidelines, the CO should report directly to the CEO and the board, not to the general counsel. Independence and the ability to ensure fairness in investigations throughout the organization are crucial when setting up or updating your program.
The CO will be responsible for developing, implementing, conducting, and participating in regular compliance training (which we will delve into more in a future blog). Your compliance committee plays an essential role in this process. They serve as advocates throughout the organization and as a team to brainstorm ways to make compliance more engaging and impactful. Compliance can be a lonely endeavor, so it is important to provide support for your CO, not only through a committee but also by engaging the organization’s board and leadership.
Within the CO’s oversight duties, they will need to conduct background checks, review the exclusion list (a government list of those who are currently not allowed to work in healthcare due to previous violations), ensure that third-party vendors are aware of your compliance standards, conduct an annual compliance review, and staying up to date on any changing government regulations. As you can already tell, being a CO is a significant responsibility, which is why leadership support and a committee to act as their team members in the field are essential.
Your compliance program will continue to evolve over time as you identify gaps or as your organization changes. Having a CO and committee taking the time to provide oversight and monitor the program ensures that your organization won’t fall behind or be caught off guard. Regular monitoring can spot issues as they arise or even before they become problems. Without taking the time to assess the organization’s compliance status, you run the risk of missing an issue before it escalates into a problem. When you have a CO, a committee supporting them and independence to provide accurate and accountable compliance information your organization is well on their way to an effective compliance program.
Most business leaders get frustrated when employees don’t do the right thing. You shouldn’t have to convince people to do what is right. MCA builds a compliance program and a culture where employees do the right thing, the right way, at the right time so you can focus on taking care of the people you serve.
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Midwest Compliance Associates
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