Responding to Detected Offenses and Developing Corrective Action Initiatives: Element 7

One of the most important aspects of an effective compliance program is making corrections to the systems or processes of the organization when something does go bump in the night. The Department of Justice, in its March 2023 Evaluation of Corporate Compliance Programs document specifically addresses this essential element. As stated by the DOJ “One hallmark of an effective compliance program is its capacity to improve and evolve.” In other words, providers are expected to learn from situations where things may not have gone as planned or expected, and to use that lesson to change the program to make it better at detecting and deterring bad activity.

Everyone will agree the world of healthcare is ever changing. Technology advances at a very rapid rate, and the expectations of the individuals providers serve, and their families, change just as fast. It is vital that providers engage in meaningful efforts to review their compliance program and ensure it isn’t stale. 

One of the most effective methods to ensure proper corrective action initiatives are taken is to utilize a well-executed root cause analysis process. Done properly, root cause analysis allows a provider to “understand both what contributed to the misconduct and the degree of remediation needed to prevent similar events in the future.” The Justice Manual directs prosecutors who are evaluating the effectiveness of a compliance program to reflect on “the extent and pervasiveness of the criminal misconduct, the number and level of the corporate employees involved, the seriousness, duration and frequency of the misconduct and any remedial actions taken by the corporation, including, for example, disciplinary action against past violators uncovered by the compliance program, and revisions to the compliance program in light of lessons learned” (emphasis added).

What this all boils down to is the fact providers must understand why something goes wrong, and take actions to change the systems or processes being used to prevent the same thing from happening again. The concept of “lessons learned” is very important!

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.

Call today to schedule a consultation

Midwest Compliance Associates

(319) 553-0258