This work program is intended to provide an internal audit team with steps and questions for reviewing a hospital's compliance program. It lists key project execution steps for designation of a compliance committee, written policies and procedures, conducting effective training and education, developing effective lines of communication, enforcing standards through well-publicized disciplinary guidelines, and auditing and monitoring.
A review of hospital policies and procedures should consider the following: Are they clearly written, relevant to day-to-day responsibilities and readily available? Are they re-evaluated on a regular basis? Does the hospital monitor staff compliance with internal policies and procedures? Are policies monitored for their implementation and compliance? Has the hospital developed a risk assessment tool, which is re-evaluated on a regular basis, to assess and identify weaknesses and risks in operations?