You need to know several key points when designing an effective case management program. Having an effective case management structure will help a compliance program meet its responsibility to align with the Office of Inspector General’s Seven Elements of an Effective Compliance Program, keeping it audit-ready when regulators decide to visit. And regardless of the regulatory requirements, it just makes good business sense to do so.
When developing a case management program, defining requirements upfront and creating a system with the end in mind—such as determining what the system should ultimately be able to do, or deciding what metrics should be captured and for what audience—will produce long-term results from a functionality perspective, a reporting lens, and an overall higher quality management of the cases. Reducing variation is key; consistency and standardization are critical to maintaining an ongoing system. An organization must evaluate its case management structure continuously to make improvements and evolve with the times.
To ensure your case management system is as responsive as possible, it is helpful to look at three key areas: hotline intake and assignment; metrics and trends; and employee education and awareness. Here is how we approach them at Kaiser Permanente.
Hotline Intake and Assignment
Take advantage of opportunities to improve the hotline intake. When employees feel the need to call a hotline, they often want to remain anonymous. At this point, the situation has usually gone beyond where they are comfortable speaking with their direct manager or supervisor. (Perhaps the issue could be about the supervisor, and they fear retaliation.) In most cases, the hotline call could be the only opportunity to solicit information directly from the caller, should he or she choose to remain anonymous. All calls must be taken seriously, as this may be the critical turning point when the employee feels there are no other options before becoming a whistleblower.
Actionable information comes from the right intake script. It will resolve cases more quickly and reduce inconclusive outcomes, so spend the time to review and update call scripts on a regular basis. Test the system by calling the hotline. Go through the process and ask, “Did the intake make sense and flow properly?” Or after documenting an incident, think about the information that is missing or incomplete, and what the caller could have provided that would have helped the case; include those questions in the next round of updates. Ask for input and feedback from partners and users of the system. Not developing the correct intake questions to collect as much detail and information as possible could be costly in time and money.
At Kaiser Permanente, we recently changed our intake script as a result of an initiative named “Make the Right Call.” In our review and analysis of the hotline call volume, we saw an increase in callers reporting HR issues that could be managed much more efficiently if they were directed to the appropriate local resource at the outset. So we modified the intake script and worked with our training and HR partners to develop an online course outlining the difference between HR and compliance issues, and who to call when. We then worked with our communication partners to get the word out to our employee population, using a suite of communication tools and messaging opportunities. (More on this later.)
To ensure your case management system is as responsive as possible, try looking at three key areas—hotline intake and assignment; metrics and trends; and employee education and awareness.
Along with a well-planned script, policy and procedure documentation is extremely helpful. Inevitably, calls will come into the hotline that involve individuals in leadership positions, perhaps even individuals in the compliance department. Handling uncomfortable situations can be challenging, but written policies and procedures that address escalation protocols for these situations go a long way to help hotline employees navigate sensitive situations.
For instance, Kaiser Permanente implemented a policy called “Processing Allegations Involving Members of Compliance and/or the Legal Department.” The procedures outline the triaging process for the investigation to take place by an impartial third party. This process ensures that we avoid conflicts of interest and maintain the integrity of the hotline investigations process.
Efficiency is also critical in a successful case management program. Maintaining a dynamic assignment directory to triage the case to the right person, the first time, is crucial to closing out a case by the target date. Develop a process to stay on top of changes within the organization, to ensure the assignment directory has the correct associated parties, including leadership, who need to be involved and informed. Getting to the right high-level stakeholders quickly will ensure minimal interruptions. Proper triage also serves as notification to accountable executives, ensuring they are not the last to know and building a more credible organization. Having an assigned legal representative to consult on sensitive matters is also recommended.
GUEST COLUMNIST BIO
Marita Janiga joined Kaiser Permanente in 2008 and is the executive director of investigations within the National Compliance, Ethics & Integrity Office. In this role, Janiga oversees two groups, the National Special Investigations Unit that investigates alleged criminal activity, including vendor kickbacks, conflicts of interest, contract fraud, drug diversion, medical identity fraud, and employee and member misconduct; and the Hotline Operations Unit that triage more than 10,000 compliance cases yearly, monitor metrics, and provide data and analytical reports to Kaiser Permanente compliance partners highlighting trends and industry benchmarking.
Prior to joining Kaiser Permanente, Janiga had over 20 years of federal law enforcement experience investigating criminal activity, the last ten years as the special agent in charge of the Office of Labor Racketeering & Fraud Investigations, U.S. Department of Labor (DpL), Office of Inspector General (OIG).
Janiga began her law enforcement career in 1986 as a special agent with the Naval Criminal Investigative Service, where she focused on investigations involving white-collar crime and procurement fraud. In 1993, she was promoted to senior special agent with the U.S. General Services Administration Office of Inspector General (GSA OIG), and in 1995, to the assistant special agent in charge for the GSA OIG Office of Investigations in the San Francisco Field Office. In 1998, Janiga was promoted to special agent in charge of the U.S. Department of Labor Office of Inspector General in San Francisco where she managed field offices in San Francisco, Los Angeles, Seattle, Las Vegas, and Honolulu.
Many of the DoL OIG cases managed by Janiga focused on healthcare fraud in union health plans as well as medical provider fraud in the federal Office of Workers’ Compensation Programs. She retired from federal service in 2007.
Metrics and Trends
Defining metrics and identifying trends are essential to demonstrating program effectiveness and uncovering opportunities for improvement. But numbers do not–and should not–exist in a vacuum. When determining what metrics to benchmark, and how to report on trends, consider the following:
Form a broad internal workgroup. Having the group agree on enterprise-wide metrics will help address disparities and force the program to operate as one entity with a common set of standards. Inconsistent metrics lead to fragmentation of standards and difficulties when it comes to prioritizing risks.
Consider external benchmarks. Organizations look at internal data and compare trends, identify areas of concern, and see what is currently working well. But often the question becomes, “What does working well really mean?” In many organizations, leadership and boards want to know how their program compares to others. External benchmarking helps organizations determine if they are in or out of range with industry norms, to see if certain trouble areas are currently endemic in their industry, or if they point to an issue closer to home.
Provide context. When reporting on trends, do not rely solely on the numbers to provide the full picture. Data without the story behind it can end up looking like a bunch of line graphs on a piece of paper. Stating that the hotline call volume decreased by X percent does not provide any insight into why it decreased, and whether the decrease is good or bad for the organization.
For example, as a result of the “Make the Right Call” campaign, we reported an 18 percent decrease in call volume over the previous year. The significance is that we gave context to this data: how we achieved this decrease, and more importantly, that issues were getting resolved more efficiently at the appropriate level. This increased efficiency not only boosted employee confidence that they were being heard and that reports were handled quickly; it ultimately resulted in cost savings for the organization.
Employee Education & Awareness
Most companies want to convey the message that reporting issues of non-compliance helps everyone, but broad-brush messages do not help educate employees on what is defined as non-compliance. HR issues can at times be confused with compliance issues. To educate our workforce about when to seek the help of the HR department versus when to contact compliance at Kaiser Permanente, we worked with our HR, training, and communication partners to develop examples of situations that were best handled by each resource. For instance, witnessing someone falsifying government documents is a compliance issue, while inappropriate cartoons or posters in a workspace is better suited for HR.
Leveraging the training course mentioned earlier, we also paired real-life HR and compliance scenarios with catchy slogans and vignettes to be used in a variety of ways to engage employees, while directing them to the right resource. For example, every 18 months, the National Compliance, Ethics & Integrity Office holds an internal educational summit for more than 600 compliance professionals across the organization. The compliance communications team presents these materials as a showcase booth during the summit and offers packets for attendees to take back with ideas on how to further educate the compliance community throughout the year.
We feel that by educating employees on who to contact for specific types of concerns and issues (through clever break-room posters; newsletter articles; training scenarios; worksite ID badges that are customized with the compliance officer’s photo and contact information; and conversational website content) we are able to direct them to the most appropriate resource. That ultimately resolves issues more quickly, saves time and money, and gains our employees’ trust.