Best Practices Process

Best Practices Selection Criteria:
Response to Internal Investigations of Improper Conduct & Corrective Action Procedures
Summary
Achievement in the appropriate corporate response to internal investigations concerning potential corporate wrongdoing, and implementation of appropriate procedures ensures consistent disciplinary action and corrective actions to prevent the recurrence of such improper behavior.
Definition
An essential element of an effective compliance program is the implementation of consistent disciplinary actions and corrective action plans to assure that corporate wrongdoing is promptly corrected, the implicated parties receive the appropriate discipline, and the wrongdoing does not recur.
Achievement to Warrant Finding of Best Practice
In evaluating whether a program has achieved a “Best Practice” in this element, look for the existence of the following criteria for the response to internal investigations, and the adoption of necessary discipline and corrective action procedures:
1. Policies and Procedures. The Compliance Program should have the appropriate policies and procedures in place concerning:
  1. time frames for the investigation, resolution of reported issues or concerns, and adoption and implementation of corrective action plans;
  2. investigation protocols detailing procedures to follow, and responsible persons to conduct, in investigations of possible compliance issues;
  3. standards for documentation of investigations, results and follow up;
  4. establishment and application of consistent disciplinary standards (including application of disciplinary action under any existing union contracts), which include the input of the Compliance Officer in disciplinary decisions as a result of compliance violations;
  5. the monitoring of implementation of all corrective action plans, and follow up procedures as a result of discovered corporate wrongdoing;
  6. resolving compliance issues potentially involving Board members and/or senior executives/officers of organization;
  7. retention of compliance counsel as appropriate;
  8. background and exclusion checking of all employees, physicians and other applicable individuals or organizations.
2. Follow up to Investigations. There should be documentary evidence that the compliance program:
  1. receives all reports of compliance violations in a timely fashion;
  2. documents all intake, and requests for assistance in the investigation of all compliance violations;
  3. works with other appropriate departments/disciplines to investigate and resolve concerns (e.g., HR, Audit, Risk Management, etc.);
  4. coordinates the organization’s use of the government sanctions lists to assure employees, physicians and others hired by the organization (or under contract with the organization) are not excluded;
  5. compiles appropriate data on compliance reports, investigations, and resolution for presentation to Board of Directors/Compliance Committee;
  6. maintains data base of all investigations including documentation of steps taken, interviews, etc for appropriate retention period.
3. Compliance Program. The Compliance Program should:
  1. assure that all compliance concerns are investigated thoroughly;
  2. gather and maintain appropriate documentation in a confidential way;
  3. coordinate all disciplinary actions, following compliance violations, and the creation and implementation of corrective action plans;
  4. ensure the organization’s non-retaliation policy is fully implemented and followed.