Element #6- Monitoring and Internal Audit Systems

We finally got to my favorite part- monitoring and internal audit systems. This is truly the heart of any effective compliance program. We have covered the first five elements including Corporate Compliance Officer/Designee, Compliance Policy and Procedures, Effective Lines of Communication, Training and Education, Enforcement and Discipline . Certainly, all elements of a compliance program are critical but monitoring and internal audit systems is the real “meat” of the program? Simply put- does your organization have a system of checks and balances and our you able to find your areas of risk? Let’s explore what this means.

How do we monitor our facilities effectively? There is a well-known statisticians credo – In God we trust- all others must use data. As an organization, you must have an objective way to establish performance baselines. You want to compare yourself to the average, but you also want to compare yourself to yourself. Do you have methods in your facility to collect the data and analyze a deviation? Certainly, reviewing your Casper report is one way, but that might be too late. You want to catch deviations before they become REAL problems.

Is the data “real” and meaningful? A well-known fact- garbage in and garbage out. Do you have a method to objectively collect data? As an operator one of the greatest struggles I had was determining if the data was reliable from month to month. With each change of staff there seemed to be a different interpretation of how to collect the data! It was also very time consuming for the staff so it was the first thing that didn’t happen.

We have all this data- now what? In a recent article in the Wall Street Journal, Steve Bennet, former CEO of Intuit stated, “A big challenge… is that organizations tend to focus on the metric as the objective instead of gaining insight to improve.” Having the data, but not acting on it is not enough. We need to make sense of it and examine trends. This is true in all areas of operations- clinical, staffing, financials, etc. From a compliance perspective, you want examine outliers that can be potential risk factors and ask the hard questions.

Are we asking the questions? We have the data, we know its reliable, we examined trends- now comes the real work. Conducting root cause analysis is the key to your program- knowing the WHY. How often to we try to fix a problem by throwing more staff at it or quickly putting a plan of correction into place. This is only a bandaid- I think we have all learned this the hard way. A key piece in compliance training should be teaching your staff how to conduct root cause analysis- dig deep and find the cause of the problem. It’s often a shift in mindset but I encourage you to start training your staff from the bottom up to think beyond the obvious and get to the root of the problem.

Well folks, we are heading to the finale of our seven-element journey! Stay tuned for Response and Corrective Actions!