Deeper Than the Headlines: Is Your Compliance Committee Even Effective?

If you have a compliance program, you most likely have a full-time compliance officer or an individual who is accountable for your organization’s compliance program, even if it’s only a portion of that person’s overall duties. But, does your organization have a compliance committee?  And if there is a compliance committee, is it really effective?

For most organizations, “the OIG recommends that a compliance committee be established to advise the compliance officer and assist in the implementation of the compliance program.”

Unfortunately, some organizations hire a compliance officer and then mentally check off “compliance program.” Though designating a compliance officer is a very important and significant step, establishing a compliance committee to “advise the compliance officer and assist in the implementation of the compliance program,” is essential in taking your program to a higher level to strengthen its foundation for longevity.

Why a Compliance Committee Matters More Than You Might Think

Compared to the singular perspective of just one compliance officer, a “compliance committee benefits from having the perspectives of individuals with varying responsibilities in the organization, such as operations, finance, audit, human resources, utilization review, social work, discharge planning, medicine, coding and legal, as well as employees and managers of key operating units.”

In my experience, an effective committee can infuse the organization with a stronger culture of compliance than an organization without a committee. Many of the individuals on a compliance committee are often organizational leaders that the rest of the workforce already looks to for guidance.

What Does a Compliance Committee do?

So, what exactly does a compliance committee do? Well, the OIG has suggested some possibilities, which include:

• Analyzing the organization’s industry environment, the legal requirements with which it must comply, and specific risk areas.
• Assessing existing policies and procedures that address these areas for possible incorporation into the compliance program.
• Working with appropriate departments to develop standards of conduct and policies and procedures to promote compliance within the institution’s program.
• Recommending and monitoring, in conjunction with the relevant departments, the development of internal systems and controls to carry out the organization’s standards, policies and procedures as part of its daily operations.
• Determining the appropriate strategy/approach to promote compliance with the program and detection of any potential violations, such as through hotlines and other fraud reporting mechanisms
• Developing a system to solicit, evaluate and respond to complaints and problems.
• Address other functions as the concept of compliance becomes part of the overall hospital operating structure and daily routine.

How do you know if your compliance committee is effective?

How do you know if your compliance committee would be deemed effective by an enforcement agency? An effective committee would demonstrate authority and autonomy. To this point the OIG has stated, “Evidence of that commitment should include active involvement of the organizational leadership, allocation of adequate resources, a reasonable timetable for implementation of the compliance measures, and the identification of a compliance officer and compliance committee vested with sufficient autonomy, authority, and accountability to implement and enforce appropriate compliance measures.”

Many of my clients ask me, what objective measures might a compliance program track and/or report to demonstrate that their compliance committee is engaged and effective?

Again, we can turn to the OIG for areas your program can measure and how, as it relates to the compliance committee:

So much has been written elsewhere about the importance and effectiveness of compliance committees. But a quick review of the concepts might allow you to do a quick survey, or “kick the tires,” as I like to say, regarding your compliance committee’s effectiveness.