Ethics - Compliance Survey
Measuring Compliance Program Performance
The most important questions in the minds of your executive leadership and your board are:
- Is our compliance program as good as we want it to be? How would we really know?
- Are we spending too much on compliance – or too little?
- How do we compare to other organizations with respect to our compliance effort?
If you can not answer these questions, support for the compliance program will always be limited. Executives do not spend money on things that can not be measured. Even an external program assessment is someone’s opinion.
Is there a metric that is accurate, reliable and supportive of true bench marking?
We believe that the Ethics-Compliance Survey provides the only empirically substantiated, reliable measure of a compliance program – short of a government investigation.
The Ethics-Compliance Survey is an empirically validated survey instrument designed to allow organizations to assess their own compliance environments. Development of the Ethics-Compliance Survey began in 1986, with the instrument first administered in 1988. Our goal from the outset was to allow organizations to assess their own compliance environments and generally, to identify best compliance practices. It took two years (1986 – 1988) to validate the Survey and establish the database. Since that time, the Survey has undergone continuous refinement. The most recent refinement is the introduction of a scale focusing on employee commitment to maintaining the privacy of protected information.
The survey has been administered to healthcare organizations of all types for more than a decade. Each administration allows an organization to assess the responsiveness of employees to ethical and professional standards, the responsiveness of employees to organizational policies, the willingness of employees to utilize internal reporting channels, and employee perception of the organization’s compliance climate.
Survey results have been published by the U.S. Sentencing Commission, the Bureau of National Affairs (various publications), and the Federal Ethics Report, among others.
Survey administration allows you (at your option) to compare your organization to all healthcare organizations in the database, to all providers in the database or to all health plans in the database. You can also compare locations and functions within your organization and assess differences among employees by level of responsibility and experience. The Survey also allows you to track a number of other factors of potential interest (responsiveness to HR, awareness of the Code of Conduct, attitude toward the “hotline”, etc.). Additional topics may be explored to fit the needs of particular organizations.
Specifically, in all administrations the Survey allows assessment of the:
- responsiveness of employees to written policies and procedures, including those with which they disagree
- responsiveness of employees to values and ethical principles in circumstances in which written policies and procedures may not resolve an issue
- whether employees understand and accept the Code of Conduct
- level of risk (by location, employee tenure, function) that employees will use external reporting mechanisms such as qui tams
- confidence of employees in the commitment to ethics and compliance by:
- their immediate supervisors
- higher level managers and leadership
- the organization as a whole
- level of fear of retaliation for reporting legitimate concerns
- perception that ethical and legal conduct is appropriately recognized and rewarded
- employee commitment to protecting private health information
- employee belief that there is a common standard of conduct for all members of the organization
- adequacy of policies, including policies in specialized, compliance sensitive areas
A common use of the Survey is to establish a baseline assessment of the organization’s compliance environment. Many organizations also use the Survey on a “test-retest” basis to measure the progress of the compliance program. Survey results help focus compliance program resources where needs and risks are greatest. If there have been changes in the compliance program, such as training updates or new policies, the Survey allows you to determine the impact of these changes.
The Survey can be administered in two formats, via a paper form or in an online format. The online version takes about 5 minutes to complete while the paper form takes about 12 minutes to complete. We encourage distribution to all employees. Our experience has shown that employees enjoy participating in the Survey and respond in unusually high numbers, especially when using the online format.
We tailor the Survey to each organization. In addition to validated scales, “back page” items allow you to explore key issues in depth. A comment page helps identify employee input absent from other reporting channels. We assess all back and comment pages and organize them by function/location, topic and acuity of concern.
The product of the Survey is a written report consisting of an executive summary, detailed Survey findings, and practical recommendations. We can also provide an additional in-person presentation of results to executive management and/or compliance program staff. This creates an opportunity to discuss interpretation of the results and informal conclusions.