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TOPIC: Standards of conduct for your compliance program

HIM Connection, December 23, 2003

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TOPIC: Standards of conduct for your compliance program

What exactly are standards of conduct? Some people see the standards of conduct statement as a glorified version of the mission and vision statements of an organization. Although it's true that the mission and vision statements are part of the standards of conduct, there's much more to it than that. The standards should outline in detail how laws, regulations, guidelines, and accreditation standards guide the way an organization conducts business. The standards need to address how these laws and regulations affect each employee in performing his or her job. Plus, they should provide the steps an employee takes if he or she is aware of any potentially noncompliant activity.

The standards of conduct statement is a document that staff read during orientation and keep with them as a reference throughout their employment with an organization.

An organization's standards of conduct should contain the following:

-Mission, vision, philosophy, core values, or similar corporate statements

-A statement that reflects the organization's philosophy on conducting business legally, ethically, and fairly

-An explanation of how laws, regulations, guidelines, and accreditation standards affect the way the organization conducts business

-Examples of how these laws and regulations affect employees' daily activities

-Steps that employees should take if they detect potentially noncompliant behavior

Before writing the standards, an organization needs to have a true understanding of its culture. Culture is defined as an organization's values. Once an organization identifies those values, it can translate them into principles that govern its business conduct--principles that are at the core of the organization--and encourage all staff to comply. It is very important that the standards of conduct reflect the corporate culture, rather than being a boiler-plate document that is simply borrowed from another organization or a consultant. Employees can easily spot standards that don't fit the organizations. But if they do fit, employees will take the standards seriously and follow them.

The standards should only change when a major event occurs. For example, organizations that merge or acquire other groups will need to modify standards of conduct to reflect these kinds of changes. Changes in the laws that govern the health care industry might also require standards to adjust. In general, however, an organization's standards of conduct statement needs to be an enduring document that reflects the way all employees should conduct business.

This weeks excerpt from "7 steps to HIM compliance," by Ruthann Russo, JD, ART. Click here for more information or to order.

Kate Alvarez
Editorial Assistant kalvarez@hcpro.com

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