If you are a healthcare compliance officer (or wearing that hat), it is inevitable you will eventually need to conduct an investigation. While on the surface that may not sound like a swell time, there are benefits to conducting investigations. You will know your organization, the employees, and how it functions. The downside can be, you will know your organization, the employees, and how it functions.
Reported issues come in all shapes and sizes, therefore you need to have a process adaptable to any set of circumstances. Throughout my career, I have conducted numerous investigations ranging from simple employee theft to complex billing fraud. In this article, I will provide an overview of the steps I follow and offer some tips I have picked up over the past 15 years.
Investigational Process. When I am conducting an investigation, my process includes the following steps:
1. Stopping the questionable practices immediately
2. Developing an Investigation Plan
3. Gathering Facts
4. Conducting Interviews (when appropriate)
5. Documenting Findings In a Written Report
6. Implementing corrective action (when appropriate)
The remainder of this article will cover these steps in detail.
Developing an investigation plan. After halting the questionable practices (whenever possible), one of my first steps is developing an investigation plan. This helps give me a roadmap for where to go procedurally and factually with the investigation. In developing this plan, I will create an outline of what steps I need to take to investigate and what information I need to resolve the issue.
Gathering Facts. Evidence will come in many different forms such as documentation, interview statements, and other sources such as video surveillance. When gathering facts, it is important for me to obtain information from more than one source. If I can cite to multiple sources to corroborate a point I am making, this helps me in defending my findings.
Conducting Interviews. As I am conducting interviews, I first spend time preparing for the interview before I meet with the individual(s). I think about who I need to interview, the sequencing of the interviews (e.g., do I need to interview one person before the other?), and the interview environment (e.g., should the person feel comfortable so they open up or does the environment need to send a stronger message). I then develop a list of topics and major questions to address in the interview. As I develop the topics, I don’t want to be too scripted with my questions. The reason is that interview should be somewhat conversational, so I don’t want to box myself into pre-determined questions and overlook ones that naturally would have developed.
Interviews with witnesses are purely informational gathering and tend to be non-adversarial. Interviews with the subject of the investigation tend to be more structured and have greater potential to turn adversarial because the subject will eventually be confronted with the allegation made against him/her. To help ease the tension with either type, I will let the interviewee know my role is to independently gather information and obtain his/her version of events. Additionally, I want to establish rapport with the interviewee to increase the chances of an open and honest discussion. One way to establish rapport is starting the interview by talking about a topic unrelated to the case such as local news, weather, sports or asking how they got into their role.
Writing the Report. I tend to think of the investigation report as the telling of a story of what happened from beginning to end. The real trick is being able to tell it in a way that is clear and complete, accurate yet concise, so you don’t lose the reader. It’s very easy to get bogged down in providing too much detail. A good rule of thumb is sticking only to the detail that determines the outcome of the investigation. When I write a report, I include the following sections:
1. Introduction (e.g., background or history)
3. Finding(s) (e.g. conclusion)
4. Recommendation(s) (e.g. corrective action if any)
Final Thoughts. For any compliance officer, conducting investigations is a constantly evolving process. As you become more and more experienced, you will discover new and innovative ways to effectively collect information. Keep in mind that as a compliance officer, your role is to conduct an independent investigation. You do not need to prove your case beyond a reasonable doubt. You simply need to objectively gather information to determine with reasonable certainty, whether or not the allegation can be substantiated.