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Recent Compliance Updates & Tips

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The burdens of being a Compliance Officer continue to grow with the increasing healthcare regulatory and enforcement environment. Being a Compliance Officer is not simply about developing the seven standard elements of a Compliance Program, but also changing the culture of an organization to embrace compliance. This mission to develop a culture of compliance requires a lot of effort. Whether you call this aspect of compliance “preaching” or “selling,” it amounts to the same purpose and mission. A group of experts, all credentialed and with years of experience as Compliance Officers, was asked to comment on this topic.

The following highlights their key points:

Jillian Bower: “It is important to maintain ongoing metrics to benchmark progress of Compliance Program effectiveness. Some organizations use a compliance culture survey to monitor employee perceptions and attitudes towards compliance, while others opt to use a compliance knowledge survey. In either case, surveys need to be professionally tested and administered, as well as anchored in a large database to permit comparison to other health care entities. Taken periodically, they can benchmark progress in the Compliance Program as well as empower and add to the effectiveness of the Compliance Officer.”

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Camella Boateng: “One of the keys for Compliance Officers being effective is to continue to persevere in the face of skepticism and sometimes resistance in a business environment where leadership, employees, and medical staff consider compliance to be a distraction to their mission of delivering service. Yet, the Compliance Officer also has an important mission to support the organization by helping keep it out of trouble and reducing risks of bad things happening that could give rise to liabilities and loss of reputation that would interfere with the medical mission. The challenge is working day-in and day-out in selling that message.”

Carrie Kusserow: “To be effective, the Compliance Officer must always be selling the program to the Board, to leadership, and to the rank and file employees. This must include selling the benefits of a successful program, as well as consequences of failing with it. The biggest ‘sell’ is to the Board – once the Board is sold, executive leadership with follow suit. It therefore pays to present a very professional and informative presentation to the Board on what is expected of them by enforcement and regulatory agencies; and the risks of liability for ignoring their fiduciary responsibilities for providing proper oversight of the Compliance Program. They need to understand what is expected of them and need to understand that when they meet those responsibilities, there will be positive benefits to the organization.”

Al Bassett: “It is only with the achieving ‘buy-in’ by the executive leadership and the Board that the Compliance Program can move ahead. Without their support and commitment there will never be sufficient empowerment for the Compliance Officer to effectively carry the message to others. Once they are on board with the Compliance Program, selling the program must continue with managers of operations, first line supervisors, and the rank and file employees, as well as physicians and medical staff.”

Steve Forman: “To be truly effective, Compliance Officers must reach and convince first line managers to carry the compliance message to their subordinates, by word and example. What they say and what attitudes they project to their staff is powerful, more so than pronouncements for the Compliance Officer or even the executive leadership. The Compliance Officer can quickly check on the program’s effectiveness by talking to first line supervisors and managers about the program.”

Suzanne Castaldo: “It is critical to act upon information received from the workforce. One of the most important things a Compliance Officer can do is promoting proper receptivity of information that is received by management, HR, the Compliance Office, or the hotline. If the work population is not sold on the organization being receptive to hear from them and believes that nothing happens from their input, the Compliance Program will never be effective. This means actively and promptly investigating and resolving matters raised by the work force in a competent and professional manner; however, responding to registered employee complaints is not enough. The Compliance Officer needs to be visible and available to hear what concerns people have and to take appropriate action to address them promptly and efficiently. It is good to walk around and just talk to people about their jobs, thoughts, concerns, etc. It is all part of selling the program.”

Tom Herrmann: “The Compliance Officer should make every effort in selling compliance cooperation and coordination of effort, not competition with other functions that may overlap with compliance, including HR, HIPAA Privacy and Security, Legal Counsel, and Internal Audit. In far too many organizations, these functions operate at cross purpose with one another and engage in turf battles so much as to have a serious negative impact on the effectiveness of the Compliance Program. A lot of benefit can come from developing protocols (policy documents) that establish working relationships and methods of cooperative effort.”

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