Brenda K. Manning (bkmanning@carilionclinic.org) is Privacy Director, Privacy Officer, and Kristin Meador (klmeador@carilionclinic.org) is Compliance Director, Interim Compliance Officer, at Carilion Clinic in Roanoke, VA.
In 2017, a group of compliance professionals and staff from the U.S. Department of Health & Human Services Office of Inspector General met to develop Measuring Compliance Program Effectiveness: A Resource Guide, a guide that discusses what to measure and how to measure with respect to the seven essential elements of a compliance program.[1] To help assess program effectiveness, the resource guide recommends organizations engage in an assessment of organizational risk and develop an annual compliance work plan in response to that assessment.
While it may sound like a relatively straightforward concept, constructing a functional annual work and audit plan is often a struggle for many organizations, given that so much of the day-to-day work in compliance can often seem like a game of whack-a-mole, leaving little, if any, time to accomplish other things. While there is no one-size-fits-all work and audit plan for every organization, regardless of the size of your organization, staffing level of your compliance department, or the maturity of your compliance program, the process for developing a work and audit plan is the same. We have broken that process down into seven easy-to-follow steps to help you and your teams succeed in developing and carrying out your plan by working smarter, not harder.
Working smarter is about setting goals that are specific, measurable, attainable, realistic, and time bound while recognizing the need to evaluate and reevaluate as necessary. In this article, we have used the well-known SMARTER methodology and SMART goals to develop effective annual compliance work and audit plans.
Step one: Avoid obstacles to plan success
Nobody plans to fail. They just fail to plan. – Anonymous
The first step to effective annual work and audit plan success is embracing the concept that you need a plan. Your plan will need to be more than a to-do list. Ideally, your plan should be a formal risk-based work and audit plan approved by your board with the expectation that you will provide them with regular updates on plan progress. Having no plan, aspirational plans, overly ambitious plans, or plans that fail to account for new and emerging risk are the types of plans that present obstacles to success and should be avoided.