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Grading Your Facility Compliance Plan

August 1, 2004
by root
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Is your facility above or below the bar in regulatory compliance? by Lawrence A. Fogel and Joseph M. Watt

Grading your facility compliance plan

Your corporate compliance plan takes time and effort. Is it worthwhile? Is it really protective? Here's a checkup list Just as an annual checkup enables an individual to receive an evaluation of his/her physical condition, a compliance program assessment (CPA), preferably by an independent consultant, enables healthcare organizations to evaluate the effectiveness of their compliance programs. In these days of regulatory and legal exposure, this is no small matter. In an article published last year ("Symptoms of an Ailing Compliance Plan," November 2003), we discussed how to structure a workable plan. In this article we offer a checklist that, when administered periodically, will show how effective the plan continues to be.

The CPA consists of three major phases:
    Phase 1: A compliance committee retreat
    Phase 2: Private interviews with key persons within the healthcare organization
    Phase 3: Review of pertinent documentation supporting the compliance program

After each phase, the organization will be given a report card. This requires that a grading system be agreed upon by the organization and consultant-for example, setting the maximum number of points attainable for each phase of the program and the percentage of those points actually achieved, with a grading scale of 95 to 100% being excellent; 90 to 94%, good; 80 to 89%, above average; 70 to 79%, average; and below 70%, needs improvement.

Compliance Committee Retreat
The primary objective of the compliance committee retreat is for the committee members to complete a scorecard evaluating 20 key areas of the compliance program. They grade each area using a point scale of 1 to 10, with 10 being the highest and 1 the lowest. Among the areas evaluated: Were the committee's meetings productive?

Did the committee meet as described in the compliance plan?

Did the committee meet its goals for the year?

Did the organization follow its compliance plan and code of conduct?

Are the compliance plan and code of conduct current and easy to understand?

Are the policies and procedures for each department effective?

Is staff training on compliance issues effective?

Were audits of risk areas conducted?

Were exceptions from audits properly resolved?

Were complaints processed according to the compliance plan?

Were investigations of complaints conducted and resolved?

Were disciplinary actions taken when necessary?

Were background checks conducted according to the plan?

Did the compliance program meet its objectives? Other areas can be added as necessary. The scores are tabulated for each area and a composite score is calculated.

The retreat also offers an opportunity to perform a risk assessment, if the compliance committee hasn't recently conducted one. Once again, using a scale of 1 to 10, the committee members have the opportunity to evaluate the degree of risk the facility has in areas such as: