What’s in a Corporate Compliance and Ethics Program Name?
By
David S, Barmak, JD, CEO
Imagine a skilled nursing facility (SNF) sends its assistant director of nursing to a seminar offered by the Department of Health. The speaker explains the importance of having a compliance and ethics program (compliance program). The assistant director of nursing calls the administrator and asks if the facility has a compliance program. The administrator almost drops off his chair because the SNF implemented a compliance program at the facility over a year ago. He reflects on the compliance program that was implemented and feels satisfied that the nuts and bolts of the program have successfully been included: preparing and publishing policies and procedures, three shift trainings on a periodic basis, establishing a compliance and ethics committee comprised of a compliance and ethics officer and department heads and a compliance attorney, putting in place a telephone hotline, and instituting an outside auditor among numerous other components of a formal compliance program. Nevertheless, the administrator cannot understand how this reality could be lost upon the assistant director of nursing who clearly did not remember or recognize the existence of the compliance program.
The Administrator immediately trains all three shifts again. The key message conveyed is that the SNF has a compliance program that addresses issues of concern to both the federal and state governments—issues that also include protecting the staff’s certifications and licenses, as well as protecting the residents. The staff welcomes the refresher in-service; however, the in-service director notices that when she says the words “corporate compliance and ethics program” it seems to her that the staff’s eyes register a lack of recognition and glaze over. Her conclusion: “compliance program” has specific meaning only to the administrator, certain department heads, and the in-service director, who have spoken of and are familiar with this particular nomenclature. For most of the other employees, in particular the line staff, the magic words “compliance program” in and of themselves have little meaning. Why? Perhaps because these words are not familiar to the staff on a day-to-day basis. Perhaps repetition on a periodic basis has not been enough to promote complete familiarization of the nomenclature. Perhaps because the words “compliance program” do not conjure up a tangible product or service. While the staff are very familiar with the nuts and bolts of the compliance program—fraud and abuse, HIPAA privacy, employment, etc.—“compliance program” doesn’t ring a bell for all of them.
Continuing with the staff training, the in-service director makes a concerted effort to focus on associating the fraud and abuse program, the employment program, the discrimination and harassment program, and the HIPAA privacy program as they pertain to the compliance program. A subsequent survey of the staff shows that the training, having emphasized the nomenclature of “compliance program,” paid off with nearly 100% staff recognition.
The point of this story is critical because when the federal and state governments come on site to conduct compliance surveys, they have been known to ask employees: “Do you have a compliance and ethics program?” and “Who is your compliance and ethics officer?” The need to associate the words “compliance program” with the specific compliance program topics (fraud and abuse, etc.) is critical. Staff must be reminded, over and over again, not only of the benefits of the compliance
program but the fact that the program is called a “compliance program.” The staff must be reminded as to who their compliance and ethics officer is. These word associations must be repeated firmly and often to the staff so the nomenclature is entrenched in their minds. Posters providing the hotline number at every nurse’s station and by the time clock promoting the existence of the compliance program are essential.
As always, to be successful in this effort, the SNF’s compliance and ethics officer needs to be fully involved and engaged in the program, approachable by all levels of staff and others, and focused on creating a culture of compliance by educating and inspiring others.
Previously published in Healthcare Matters February 2024.