Compliance Program 101: Seven Elements, No Jargon

If you’ve ever sat in a leadership team meeting where someone says: “We need a compliance program” and everyone nods without quite agreeing on what that means, you’re not alone. The good news is that the OIG has provided excellent resources to help including the General Compliance Program Guidance⁺ that lays out seven elements every effective compliance program should have. None of them are complicated.  Here they are in plain terms.

(1) Written Policies and Procedures. Not a binder that sits on a shelf. Policies and procedures that describe how your organization operates, that employees can find, and that get updated when your operations or regulations change.

(2) Compliance Leadership and Oversight.  Compliance is everyone’s job, but it doesn’t work without leadership behind it. A senior leader appointed as a Compliance Officer with real authority, stature, access, and resources to do the job and a board that exercises genuine oversight are both vital to an effective compliance program.

(3) Training and Education. Not a once-a-year click-through. Training that’s tied to the risks your organization faces, delivered to the people who face them, and refreshed often enough to ensure relevancy.

(4) Effective Lines of Communication. Employees need a way to raise questions and concerns without fear of retaliation and they need to trust that the reporting process works. This means logging, investigating, and following up on good faith reports.

(5) Risk Assessment, Auditing and Monitoring. You can’t effectively manage what you don’t measure. Regular internal audits not only let you find your own problems (often first) and handle them, but also identify opportunities for operational enhancement.

(6) Enforcement and Discipline. When a compliance violation is identified, appropriate disciplinary action must be taken. Every disciplinary action should be documented including what happened, what was done about it, and why.

(7) Prompt Investigation, Response and Corrective Action. When a compliance concern is identified, you should investigate it, fix it as needed, and follow up to make sure it stays fixed. The way your organization handles this element can be the difference between an issue remaining isolated and one that becomes systemic.  

Here’s the takeaway: none of these seven elements are complicated and none of them exist purely as a defense strategy. Together, they’re a snapshot of a well-run company. The question to ask is how much of this snapshot matches your organization? That’s the clarity an effective compliance program provides and it’s what can help you lead with confidence.

Not sure where your organization stands against the seven elements? Catapult Healthcare Consulting, LLC provides compliance program

assessment services.  Click here to schedule a consultation.

⁺ The OIG's General Compliance Program Guidance is available at General Compliance Program Guidance | Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services.