If you're starting from scratch on your regulatory compliance program document, or starting over, you might be asking what some of our clients ask us:  "What should be in this?"

Here is a suggested outline that might help:

I.                   Governance

A.                 Compliance Officer(s)

B.                 Accountabilities/Reporting Structure

1.                  Administrative structure

2.                  Compliance Committee (if any)

3.                  Oversight of the compliance program by governing body

C.                 Reports

II.               Tracking of Laws, Regulations, Administrative Rules, and Accreditation Standards

A.                 Process for assessing existing matrix of laws, regulations, rules, and standards

B.                 Process for updating compliance matrix with changes to laws, regulations, rules, and standards

III.            Implementation of Compliance Program

A.                 Process for translating external standards into organizational policies and procedures

B.                 Training of governing body, employees, and agents in compliance program

C.                 Procedures for detecting non-compliant conduct by employees and agents

1.                  Audit and other monitoring mechanisms

2.                  Reporting mechanisms

D.                Disciplinary mechanisms for non-compliant conduct by employees and agents

E.                 Post hoc analyses of instances of misconduct to determine whether a systemic change is suggested by the problem

F.                  Systems for assuring that both hiring and compensation practices encourage the creation and maintenance of a compliant work force

IV.             Promotion of an organizational culture to encourage ethical conduct and a commitment to compliance with the law

V.                Periodic evaluation of compliance program