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Recent Compliance Updates & Tips

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Everywhere one looks, compliance officers are called to be effective – but how can one meet this challenge? A number of compliance experts were interviewed in searching for answers and ideas to this question. All have had years of experience in building, managing, evaluating, and enhancing compliance programs, and a common denominator for all of them is the notion of compliance officers being the “sales agent” for the compliance program.

Tips from the Experts

Suzanne Castaldo, JD, specializes in providing clients with temporary compliance staffing needs. Many of her Interim Compliance Officer engagements have been to cover gaps between an organization’s departing compliance officer and a permanent replacement. These organizations report dysfunctional problems that resulted from broken communication channels with relevant stakeholders including executive leadership, the Board, program managers, and employees. In fact, this type of problem often contributes to a vacancy in the compliance office. Repairing and building new communication bridges often becomes the first priority in getting the program back on track – which suggests that a compliance officer is not viewed as being effective when communication channels are ineffective. The lesson for compliance officers is to focus considerable energy on working with all stakeholders.

Tom Herrmann, JD, retired from the HHS OIG Office of Counsel to the IG and subsequently serves as an effective compliance officer and consultant to many organizations. He believes that compliance officers need to make every effort in cultivating sound working relationships with other functions that overlap with compliance including HR, HIPAA Privacy and Security officers, legal counsel, and internal audit. If these functions operate at cross purposes, it can overshadow the good work of the compliance office and diminish how the compliance officer’s effectiveness is perceived. The starting point for developing cooperation and coordination of effort is with establishing protocols (i.e., policy documents) that define working relationships and methods of cooperative effort.

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Al Bassett, JD, a retired Deputy Inspector General and nationally recognized expert on healthcare compliance programs, believes compliance officers must always remain in a “selling mode,” preaching the benefits of a successful program and consequences for not having one to the Board and executive leadership. Once they are on board, the selling must continue with first line managers, and finally with rank-and-file employees, physicians, and medical staff.

Carrie Kusserow has 15 years of experience serving as a compliance officer and consultant. She sees the Board as the biggest sales target. Once Board members are sold, executive leadership with follow suit to empower and support the compliance officer. This will require education on enforcement and regulatory agency expectations, as well as the personal risks for ignoring fiduciary compliance oversight responsibilities. Kusserow suggests that the whitepapers the OIG and American Health Lawyers Association have issued relating to Board member obligations, the most recent of which is the Practical Guidance for Health Care Governing Boards on Compliance Oversight, are a great resource in making this case. She notes that the OIG is now incorporating this guidance into its mandates for CIAs.

Steve Forman, CPA, served as Director of Operations for the HHS OIG in addition to having more than twenty years experience as a compliance officer and consultant. He agrees that top-down support is needed, but sees the ultimate success for an effective compliance officer dependent on the first line managers carrying the compliance message to their subordinates by word and example. Through conducting compliance program effectiveness evaluations for dozens of organizations, he has found that the best indication of program strength is when first-line managers are found to have supported and carried the compliance message directly to their staff. Their endorsement and support is more powerful than pronouncements for the compliance officer, or even executive leadership. Compliance officers need to sell compliance by personally meeting with and talking to first-line managers about the compliance program.

Jillian Bower has worked with dozens of compliance officers in advancing their programs. She points out that it is important to maintain ongoing metrics to benchmark progress of the compliance program. This reassures executive leadership and the Board that the compliance officer is being effective in protecting the organization from unwanted events or acts that could give rise to liabilities. She has found that one of the most useful means of doing so has been employing a professionally developed and independent administered compliance knowledge survey that evidences employee understanding of the program. The best surveys are anchored in large databases to permit comparison to other healthcare entities; used periodically, they can also benchmark progress in the program and further evidence compliance officer effectiveness.

Connect with an Effective Compliance Officer Today

Strategic Management Services has decades of experience building, assessing, and monitoring compliance programs. If you have questions about your compliance program, or what makes an effective compliance officer, contact us online or give us a call at (703) 683-9600 to speak to an expert.

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