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Tip: Audit your compliance hotline

Healthcare Auditing Weekly, May 28, 2007

Audit your compliance hotline to make sure the compliance department investigates calls in a timely and thorough manner. Use your audit to identify whether employees need more education on using the hotline. Use the following steps to audit your compliance hotline:

1. Test employee knowledge

Survey staff to find out whether they know about the hotline, its number, what types of information they may report to the hotline, and whether they would consider using it.

2. Examine human resource (HR)-related calls

Either the HR or compliance department should follow up on each call to collect more information and determine whether there is really a problem.

3. Sample hotline calls

Choose a sample based on your organization's size and call volume. If your facility receives few calls, you can review these quickly. If your hotline is very active, use a probe sample of 25-50 calls to determine customer satisfaction.

4. Gather documentation

Examine the hotline log and files that document how your organization resolved each issue.

5. Review hotline policies

Review your organization's compliance plan and hotline policies. Interview the compliance staff responsible for the hotline.

7. Identify problem areas

Make sure the compliance or HR department investigates calls as soon as possible-usually within 30 days.

8. Measure effectiveness

Examine whether callers share viable compliance issues. Also, consider whether employees are using other practical avenues to report problems.

9. Review outside contracts

If you use an outside hotline company, make sure your organization receives the calls in compliance with its contract.

10. Monitor calls

Depending on your findings, you may have to monitor your hotline more closely. For example, if you find that the compliance or HR department is not retrieving calls timely, monitor this. If managers or other employees are retaliating against hotline callers, monitor future HR actions. Base monitoring on the size of your organization and the risk associated with the problems you identify.

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