10 Tips for Building a Compliance Culture in Healthcare

10 tips for building a strong healthcare compliance culture

How to create a strong culture and make a valuable impact

Compliance officers in healthcare organizations are responsible for building or strengthening culture. It’s a daunting task, especially if you lack support from the top or are new to the organization.   

The tips below explore how you can convince leaders that a strong compliance culture adds value to the organization. These best practices can help you establish a healthy compliance culture with effective training and measurement and, in turn, enable your organization to better manage and control risk.  

What is a strong culture of compliance in healthcare? 

A positive compliance culture enables healthcare organizations to effectively manage and control risk. Yet it may not look the same across every healthcare organization. 

It’s partly because compliance officers do different things in different settings, such as a cancer hospital versus a behavioral health organization. Defining culture may be more art than science, yet healthy cultures share several characteristics.  

Positive cultures that help organizations manage and control risk are created when compliance officers embrace metrics, build relationships, emphasize education, and connect their work to better patient care. As Jay Anstine often tells us, a culture of compliance is a commitment throughout all levels of an organization to do the right thing and do things right.   

10 Tips for Healthcare Compliance Leaders   

Prioritizing these activities can empower you to build a healthy compliance culture and help your whole organization more effectively manage and control risk. 

  1. Build relationships 

Cultivating solid relationships across the organization is crucial to building a culture of compliance and to helping manage and control risk. It involves building relationships with executives and operational leaders as well as front-line staff. 

donetta horseman healthcare compliance, 10 Tips for Building a Compliance Culture in Healthcare
Donetta Horseman, CCO, Moffitt Cancer Center

“One person doesn’t make or break the culture,” says Donnetta Horseman, chief compliance officer, Moffitt Cancer Center. “The CEO definitely has a huge impact on what the culture is but if you’ve cultivated relationships with leaders across the organization, you can still build a culture even without CEO support.” 

Invest in relationships with leaders by having regular touchpoints, so you’re not just reaching out if there’s an issue. For example, reach out to leaders when you have positive audit results, or ask what challenges they’re facing and how you can help.  

  1. Lead with empathy  

Maeve O’Neill, national compliance, Circa Behavioral Healthcare Solutions, emphasizes the importance of leading with empathy. Her approach stems from her belief that people want to be compliant and do the right thing.  

“Assume that employees are doing their best with what they have, and lead with that,” says O’Neill. “If there’s an issue, it’s often because employees have not been given the right information, resources, or skills. Our job in compliance is to give employees the information, resources, skills, and support they need – not to assume they’re bad or lazy.” 

Maeve O’Neill, national compliance, Circa Behaviorial Health
  1. Anticipate resistance  

Resistance is to be expected when you change existing processes or policies to build culture. Recognize that the change management process is an ongoing effort; it takes time to get everyone’s buy-in.  

“To overcome resistance, communicate the why behind what you’re doing,” O’Neill advises. “Communicating and doing a lot of listening builds trust. If you’re changing policies or processes, explain why you have a better way to do it. Emphasize the importance of following the OIG’s seven elements and integrating them into daily workflows.”  

  1. Know the business side 

To influence and shape culture, it’s critical to understand the organization’s strategic direction and serve as a business partner. Know how the business generates revenue and where risk resides, so you can help operational leaders to do the same. 

“If you want to connect with leadership or anybody in operations, you have to be engaged in their work,” explains Jay Anstine, compliance program director, Western Division, Banner Health. “And that means understanding how the organization makes money and how each department contributes. It’s about getting to know the business side of the environment, not just the compliance side. You need to be able to climb in the head of a business or operational leader and understand things from their perspective as you try to shape culture and find resolutions to issues. Shadowing staff and doing department walk-throughs can help show employees that compliance officers understand operations.” 

  1. Engage front-line workers 

Embedding yourself into each operational area is a helpful way to influence front-line employees. Be part of each area’s initial orientation with staff, go to trainings, do mock surveys, and attend team meetings.  

The more visible you are, the more that colleagues see you and trust you as a partner. They’ll appreciate what you bring, and in turn, they’re more likely to bring issues to you.  

Also, rounding can be helpful for engaging front-line employees and for measuring their compliance awareness. 

“You can talk about compliance messaging if there’s a particular point you need to hit on – maybe a reminder to complete staff training or something HIPAA related,” Anstine says. “But spend the time being curious about their operations and getting to know them. Taking this approach is a sign of engagement and helps you connect with employees on a personal level.” 

jay anstine compliance program director banner health, 10 Tips for Building a Compliance Culture in Healthcare
Jay Anstine, Compliance Program Director, Western Division, Banner Health

“You can talk about compliance messaging if there’s a particular point you need to hit on – maybe a reminder to complete staff training or something HIPAA related, but spend the time being curious about their operations and getting to know them. Taking this approach is a sign of engagement and helps you connect with employees on a personal level.” – Jay Anstine, Compliance Program Director, Western Division, Banner Health

  1. Emphasize education   

An example of ongoing training is Horseman’s manager-level training for Compliance. Her meetings involve sharing compliance resources and outlining which policies are most relevant to managers in their respective operational area.  

They discuss what it would look like if there’s an investigation involving one of their departments. It’s educational, plus it cultivates relationships and builds awareness of how Compliance partners with operational areas.

10 Tips for Building a Compliance Culture in Healthcare
  1. Establish a liaison program  

Implementing a compliance ambassador program, often called a liaison program, enables Compliance to partner with individuals outside the department to promote compliance organization-wide.    

In an earlier role, Horseman ran a 10-month liaison program, where managers nominated front-line employees. They met monthly with groups of 10-20 employees and talked about compliance topics, provided education, and explained various requirements. When the program concluded, participants were certified compliance champions.  

“They took the information they learned back to their departments, and functioned as liaisons for folks in their areas, if they had questions about compliance or issues to report,” Horseman says.  

It was a meaningful way to both amplify Compliance’s messaging and to identify compliance issues.  

  1. Participate in Compliance Week 

Participating in Compliance Week engages the entire organization. Being part of a national event gives credibility to the compliance field, and it’s an opportunity to interact with employees outside of their day-to-day work.  

“We always have an in-person event at our bigger locations. It’s probably the most popular thing we do. We plan lots of activities, play games with prizes, and offer snacks.”  – Donetta Horseman

  1. Use the OIG’s seven elements 

Building financial and other metrics – such as revenue reclaimed because of audits – into the culture helps the organization better manage and control risk. Prioritizing metrics is important even if you aren’t demonstrating a hard financial impact. 

O’Neill recommends using the OIG’s seven-elements framework as a checklist, particularly in behavioral health settings.  

“Start by assessing which of the elements you already have,” O’Neill advises. “Most behavioral health organizations find that they have the seven elements in some iteration. If you have all seven elements met – even if it’s minimally, as long as you have something in place for each of them – you have a good foundation for a compliance program. With the seven elements in place, you can build over time to create a strong compliance culture.”  

  1. Connect Compliance to patient care 

Emphasizing how culture is interconnected with better patient care helps show Compliance’s impact on managing and controlling risk.  

O’Neill emphasizes with operational colleagues that her job isn’t to make them simply check off boxes on forms; it’s to help them streamline their operations and more effectively control risk.  

“The goal is giving everyone more time to focus on patient care and better serving patients,” O’Neill says. “In the end, it makes the organization more money and more profitable.”  

Manage and Control Risk

Earning recognition as a value creator and establishing a healthy culture can be challenging. Yet as these 10 tips show, you can successfully shape culture to help the larger organization better manage and control risk. 

For in-depth insights on how to establish a culture that helps the organization minimize risk and demonstrates how Compliance adds value, download our white paper.  

YouCompli enables the compliance officers to assign ownership and oversight of tasks to different department heads, functional leaders, or specialists. The solution prompts users to accept, reject, or reassign the task by a stated deadline. Manage the rollout and accountability of new requirements with the best workflow in the business.

Subscribe to weekly emails from YouCompli to make sure you get our expert articles

We never sell or share your contact information.

Jerry Shafran is the founder and CEO of YouCompli. He is a serial entrepreneur who builds on a solid foundation of information technology and network solutions. Jerry launches, manages, and sells software and content solutions that simplify complex work. His innovations enable professionals to focus on their core business priorities.