Element #3- Developing Effective Lines of Communication

The last blog reviewed the requirement for developing compliance policy and procedures- now to tackle the next requirement: Communication!

As we are beginning to see, an effective compliance program is truly a team sport- truly a group effort. From the team owners lending support and creating a positive atmosphere down to every last member of the team ( even the beer vendors!) How can you as an organization create a mechanism that all staff, visitors, vendors, etc. can have a safe mechanism to express their concerns?

The third component of an effective compliance program is Developing Effective Lines of Communication. You are creating a culture that values ethics and doing the right thing. In order for your program to be effective, employees must be able to ask the questions and report problems. You are creating an environment that encourages and rewards communication within the organization. The Corporate Compliance Officer is the point person to develop your communication systems.

The organization must determine an effective mechanism or combination of approaches to allow employees, residents; visitors etc. report their concerns, including an option to report anonymously. Best practices for anonymous reporting include establishing a hotline, outsourcing the hotline, suggestion box, emails, or establishing a written methods of confidential disclosure.

A word about hotlines-they work! A hotline gives employees a mechanism to report their concerns 24/7 and place where always they always have opportunity to be heard. As managers we often feel like our heads are spinning with everything that needs to get done- and we may not be as accessible to our staff as we would like to be. A hotline gives the employee a safe place to report their concerns- even those about the manager with the spinning head!

In order to be as effective as possible, the hotline must be well publicized in the facility and made readily available to all employees, contractors, residents and family members. It has to be clear that there are non -retaliation policies in place to encourage communication. This can be with conspicuously postings of the number throughout the facility with a picture of the compliance officer on it. I like including a picture to remind the caller that there is a REAL person on the other side listening and looking to help resolve issues. Some other ideas include circulating a wallet card with the information, include in the admission packet, remind residents at resident council meetings or include with pay stubs.

So when does a hotline NOT work? When there isn’t the appropriate follow up. The OIG recommends the nursing create an intake form for all compliance issues identified through the reporting mechanism. The compliance officer should maintain a log that records such calls including the nature of the investigation and its results. The intake form could include information concerning the date that the potential problem was reported, the results of the internal investigation and as appropriate the corrective action implemented, the disciplinary measures imposed and outcomes.

The Grievance Log on the SNF Metric portal is a great tool to meet the criteria for tracking compliance and grievance issues. With this simple to use app, all you grievances are recorded in one place with an easy way to track resolution and follow up. This can be done per facility or and over view of your entire organization with ability to drill down to each grievance and view the status. Any way your organization chooses to track just be sure you have a policy and procedure for how you are going to be accountable!

One last thought on confidentiality. That’s always a tricky one for us investigating complaints and grievances- and we are often tempted to avoid investigation of those. While the nursing facility should always strive to maintain the confidentiality of the employees identity, the OIG states” it should be made clear that there may be a point where the individuals identity may become known or may have to be revealed in certain instances…The OIG recognizes that protecting anonymity may be infeasible for small nursing facilities.”

Questions to ask yourself:

1) Is my communication plan available and being effectively used?

2) Are the findings of the compliance hotline shared with the compliance committee with recommended follow up?

3) Are you asking your employees if they are aware of the organization communication plan and if they believe their concerns are being addressed in a timely manner?

Onward to the next element of an effective compliance program: Training and Education.

Now- go play ball!!