Hotlines - Mathias · Microsoft PowerPoint - Hotlines - Mathias Author: KLuitjens Created Date: 5/13/2008 5:43:48 PM

2008 © UPMC | University of Pittsburgh Medical Center. All Rights Reserved. 1

Managing Hotlines

Ann G. MathiasDirector Research Policy and Compliance

Office of Sponsored Programs and Research SupportPrepared April 2008

2008 © UPMC | University of Pittsburgh Medical Center. All Rights

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Hotlines

• Why you should establish a compliance hotline

• Considerations in establishing and managing a hotline

• Survey on Hotlines


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What

• A telephone line dedicated to receiving calls from employees (and others) who want to report a compliance concern, sometime anonymously.


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Why

• US Sentencing Commission Guidelines • Sarbanes Oxley Act Section 301• Support open communication


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Why continued

• US Sentencing Commission Guidelines– (a) To have an effective compliance and ethics

program, for purposes of subsection (f) of §8C2.5 (Culpability Score) and subsection (c)(1) of §8D1.4 (Recommended Conditions of Probation -Organizations), an organization shall—

• (1) exercise due diligence to prevent and detect criminal conduct; and

• (2) otherwise promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law.


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Why continued

• US Sentencing Commission Guidelines– The organization shall take reasonable steps.

. . . • “to have and publicize a system, which may

include mechanisms that allow for anonymity or confidentiality, whereby the organization’s employees and agents may report or seek guidance regarding potential or actual criminal conduct without fear of retaliation


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Sarbanes Oxley

• Doesn’t apply to non-profits but many are following guidelines

• Requires a mechanism for anonymous reporting of questionable practices


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Why continued

• Open communication


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Internal vs. External

• Cost• Functionality• Confidence level


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Cost

• Cost for internal service:– Establishing dedicated phone line – Staffing

• Cost for external service:– Per month– Per FTE


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Functionality

• Internal– Concerns about confidentiality– Availability of staff to answer– Staff training – ability to elicit information– If answering machine – effectiveness

• External– Confidentiality– Live person– Opportunity for ongoing communication


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Publicize• New employee orientation • Employee handbook • Posters throughout building • Periodic reminders in newsletters • Website for employees • Notice of Privacy Practices • Website for the public • Compliance training• E-mail


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Supporting Policies & Processes

• Compliance Program• Non-retaliation• Confidentiality• Investigation


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Compliance Program

• Program encourages open communication, reporting of concerns through chain of command and other avenues

• Hotline is just 1 element


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Non-retaliation

• Consistent with state and federal laws on whistle - blowing

• Provide protection from retaliation for “good-faith reporting” of concerns

• Retaliation is prohibited • Encourage use of chain-of-command• Discourage false allegations


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Confidentiality

• Protect the confidentiality of callers to the extent possible– Investigation could lead to identification of the

caller


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The Call

• Script• Ongoing communication• Reporting to the entity for follow-up


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Script

• Advise caller that they may remain anonymous

– Advise of risk that investigation may reveal their identity

• If willing to be identified gather as much information as possible:

– name, department, phone number, location, etc.


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Script continued

• Ask if they have reported the issue to anyone already

• If not, may want to encourage them to do so

• Try to identify calls that should go elsewhere (such as Human Resources)


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Script continued

• Elicit information– Location– Dates– People involved– Business units involved– Ongoing activity or history


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Script continued

• Does caller want to remain in contact?• Provide code so that caller can call back

for continued communication and update


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Investigating Allegations

• All allegations should be reported to central office – preferably the Compliance Office

• Authority to conduct investigation• Timely• Thorough


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Investigating

• Identify all that need to be notified• If an area other than compliance is

investigating be clear about importance of a through and timely investigation – give a deadline, offer assistance

• Require a written response• Document


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Response

• Critical that calls are not “swept under the rug”


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Action

• Is this an isolated incident?• Is education necessary?• Do policies need to be changed or

clarified?• Is disciplinary action appropriate?• Does communication need to back to the

hotline?


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Analyzing

• Track calls• Trends?

– Department– Activity– Individuals


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Reporting

• Inform the leaders of the organization• Tone at the top


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Mini-Survey

• Survey sent to Compliance Officers in Hospitals that are members of the Hospital Council of Western Pennsylvania

• Received 10 responses• Organization size varied

– 1,000 – 2,499 employees: 6– 2,500 – 4,999 employees: 2– Over 10,000 employees: 2


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Survey Results

• Who manages your hotline?– In-house staff: 4– External: 6

• If outsourced, what is the payment arrangement?– Annual fee: 5– Per call fee: 1


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Survey Results continued

• How do you publicize your hotline?– New employee orientation: 10 – Employee handbook: 9 – Posters throughout building: 8 – Periodic reminders in newsletters: 8 – Website for employees: 7 – Notice of Privacy Practices: 4 – Website for the public: 2 – Patient handbook: 1– Other: Annual compliance training: 3


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• What percentage of calls fit into the following categories?– Human Resource issues: 100, 90, 66, 55, 50, 47, 46,

40, 25, 22% – Allegations of unethical conduct: 50, 10, 5%– Allegations of illegal conduct: 10, 5%– Conflict of Interest concerns: 5, 5, 4%– Allegation of mis-use of organizational resources:

10%– Allegation of fraud: 50, 15%– Quality of Care concern: 25, 24,18,4%


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• Other types of calls:– Privacy and security: 62, 50, 8%– Policy Violation: 20%– Conditions of facilities or equipment: 13%– Billing issues: 11%– Theft: 10%– Workplace violence: 6%


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• What percentage of calls result in the following actions:– Retraining/Education: 98, 90, 50, 33, 15, 10,

7%– Disciplinary action: 50, 50, 33, 10, 5, 2%


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• Who in the organization is responsible for managing the hotline calls:– Chief Compliance Office: 9– Compliance staff: 1– Other: Internal audit; call initially received by

the CEO’s secretary and sent to the appropriate person


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• Do you report hotline call activity to:– Board of Directors: 9 – President / CEO: 8 – Compliance Committee: 7 – Other: HR director


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• Do you find the hotline to be a valuable tool? – Yes: 8– No: 2


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• Why: Yes:– Calls have resulted in identification of serious

issues– Calls have resulted in identification of issues

that may not have been known otherwise– Important to have a means for anonymous

reporting– Easily used


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• Why: No:– Too often hotline is used as a form of

retaliation against others– Legitimate issues are already reported directly

to managers, vice presidents or to compliance officer directly


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Questions?


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References

• US Sentencing Commission http://www.ussc.gov/guidelin.htm

• Ethics Resource Center, National Nonprofit Ethics Survey http://www.ethics.org/

Documents

Hotlines - Mathias · Microsoft PowerPoint - Hotlines - Mathias Author: KLuitjens Created Date: 5/13/2008 5:43:48 PM