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Tip: Enforcing standards through well-publicized disciplinary guidelines

Compliance Monitor, November 14, 2007

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The OIG recommends that an effective compliance program include guidance and guidelines regarding disciplinary action for corporate officers, managers, employees, physicians, and other healthcare professionals who fail to comply with the hospital's standards of conduct, policies and procedures, or federal regulations.

To maximize the effectiveness of your compliance program, include a written statement defining the levels of disciplinary actions that may be imposed upon those who do not comply with regulations and the hospital's standards and policies. Intentional or reckless noncompliance should subject transgressors to significant sanctions. Such sanctions could range from warnings to suspension, privilege revocation (up to or including termination), or financial penalties. The standards of conduct should specify who is responsible for handling disciplinary problems. Department managers can handle some disciplinary action, whereas others may have to be resolved by a senior hospital administrator. Employees should be made aware that disciplinary action will be fair and equitable. Managers should know that they are responsible for disciplining employees appropriately.

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