of the organization, but also an area that has
easy access for all staff. If the office is located
in the C-suite, employees will be less likely to
“just stop by to chat.” This is how I often find
out about issues that need to be investigated,
and then I can be effective in promoting a
Having an open door policy is not enough
to address this standard. There must be a confidential, toll-free hotline in place to encourage
reporting by those employees who are too
shy or afraid to file a report in person. I recommend that you set up a toll-free hotline
number through a vendor or this can be set up
internally if the Telecommunications department of your organization is robust enough.
If you do attempt setting something up internally, you should be mindful that it should
have all call identification functions disabled.
All reported concerns must be taken seriously and investigated in a timely manner.
If the employee provided his/her name,
you should make every effort to contact the
employee with the findings and outcomes.
During any investigation, you must remember
to maintain as much confidentiality as possible. If the reported issue is substantiated and
there are corrective actions necessary, you
must remind the department managers and all
employees that there is a non-retaliation policy
and that this policy must be followed.
Following the Federal Sentencing Guidelines
and OIG Voluntary Compliance Program
Guidance is a great start to building an
effective compliance program. I call this the
skeleton of the compliance program. Once
these seven elements are in place, it is up
to you, as the compliance officer, to add the
muscle and skin to the program. Some key
· Ensure that you have direct access to the
board, that there is high-level oversight,
and that you have established a direct
reporting line to the CEO or president.
· Maintain an open door policy, guaranteeing a non-punitive, non-retaliatory
program, and educate the employees so
that they know what needs to be reported.
· Finally, make it a collaborative program,
engaging all key department managers so
that they support you and encourage the
staff to depend on Compliance when there
is a question of unethical or illegal behavior within the organization.
1. U.S. Sentencing Commission: 2016 Guidelines Manual. Available at
2. HHS Office of Inspector General: Voluntary Compliance Program
Guidance. Available at http://bit.ly/2vdBYtR
Auditing & Monitoring Tools
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