Written by: Sam Jones
From time to time, it is important to revisit the fundamentals of your compliance program. If you’ve already gone through the 7 elements of the compliance program and implemented them, congratulations! You’re on the right track and taking proactive steps for compliance effectiveness. If you’re just starting this process, this is a great place to start. This month’s blog marks the initiation of a series that will walk you through the 7 elements of a compliance program, providing practical guidance for each one.
To begin, this month we’re starting at the very foundation: Standards, Policies, and Procedures.
Most organizations have a binder on their shelf, or a digital file labeled “Policies and Procedures,” and sometimes even “Code of Conduct.” Possessing this document is a positive initial step However, if these policies aren’t put into action, your program remains dormant within the organization. It’s crucial to take action based on these documents. Let’s direct our attention to three areas: language, review, and enforcement.
Imagine pulling up the document or dusting off the manual from the shelf and reading through your standards, policies, and procedures. What would your experience be? Do you easily comprehend the content, or do you wish you had a legal degree to decipher every line? The 2017 HCCA-OIG Compliance resource offers insights into the language that should be used for your standards, policies, and procedures:
“Are policies written in plan language, appropriate grade reading level and written in applicable languages for the organization? Policy review, Word grade level review and interviews with staff to make sure they understand”
If you can’t understand it, how can you expect your staff to do so? Take the time to determine the appropriate language to use so everyone in your organization, from top to bottom of the organizational chart, can easily explain each policy and procedure to someone else. Once you’ve accomplished this, invest some time in spot-checking with a diverse group of staff members to ensure that you’ve achieved accessibility and clarity.
Possessing a set of easily understandable standards, policies, and procedures lays a robust foundation. However, similar to any structure you build, regular maintenance is essential. The standards, policies, and procedures should be reviewed at least annually. This ensures your organization remains up to date with technology, government regulations, and organizational changes. Make sure to present these updates to the board for review, keeping leadership informed and aligned. One suggestion: if you’ve mentioned specific individuals in the document, replace their names with their roles. This minimizes the need for extensive changes when someone changes positions or leaves the organization.
As mentioned earlier, having a solid set of standards, policies, and procedures is crucial and forms an integral part of a compliance program. Yet, if these policies aren’t put into practice, they serve little purpose. Enforcing these policies is essential for the overall effectiveness and success of the compliance program. It’s not only about enforcing the policies and procedures but also about maintaining consistent enforcement from the highest to the lowest level. Regardless of an individual’s role within the organization, they should be held accountable for following the organizations policies, procedures and the Code of Conduct. Regularly take the time to evaluate your enforcement actions. Did they adhere to the consistency standard? Conduct interviews to gauge whether staff perceives the enforcement as fair and appropriate.
Your standards, policies, and procedures constitute the bedrock of your compliance program. They serve as a point of reference for employees and a guiding principle for the entire organization. By ensuring accessibility through language, regular reviews to stay current, and equitable enforcement, you’re establishing the basis for a strong and compliant organizational culture.
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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