Corporate Compliance

Tip: Reviewing policies and procedures

Compliance Monitor, December 31, 2008

The HHS-OIG Supplemental Compliance Program Guidance for Hospitals recommends considering the following questions when reviewing compliance policies and procedures, including standard of conduct:

  • Are policies and procedures clearly written, relevant to day-to-day responsibilities, readily available to those who need them, and reevaluated on a regular basis?
  • Does the hospital monitor staff compliance with internal policies and procedures?
  • Have the standards of conduct been distributed to all directors, officers, managers, employees, contractors, and medical and clinical staff members?
  • Has the hospital developed a risk assessment tool, which is reevaluated on a regular basis, to assess and identify weaknesses and risks in operations?
  • Does the risk assessment tool include an evaluation of federal healthcare program requirements, as well as other publications, such as the OIG’s guidances, work plans, special advisory bulletins, and special fraud alerts?

This tip is adapted from The Compliance Program Effectiveness Handbook. For more information about the book or to order your copy, visit HCMarketplace.

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