Two tips for enabling a speak-up culture in your healthcare organization 

Open lines of communication healthcare compliance

Most compliance programs strive for a safe “speak-up” culture in their organizations, and for good reason.  It is not possible for compliance professionals to be in all places at all times.  Even more important, compliance is everyone’s responsibility, not just those who work in the Compliance department.  Empowering individuals to speak up is an essential part of any compliance program as it facilitates open lines of communication. This, of course, is one of the well-established seven elements of an effective compliance program. 

Recently, I spoke on this topic at the SCCE’s 2022 Compliance, Ethics, and Organizational Culture Conference.  In preparation for the conference, I performed a literature search on research and theories associated with the development of a speak-up culture.  There is a lot of wonderful research in this area.   

Here are two highlights that you can put into practice in your work: 

Avoiding the “Deaf Effect” 

One very important thing an organization can do to encourage a speak-up culture is to listen.  Sounds simple, right? But demonstrating that an organization is actually listening means taking action on issues that are raised.  If the organization does not investigate the issues raised, those who speak up once, might be reluctant to do so again.  

Mark Keil and Daniel Robey of Georgia State University have written about a similar cultural problem they called the “Deaf Effect.”  When individuals in positions of authority are not receptive to messages, especially bad news, those who report concerns may choose not to do so again in the future.  Even though bad news might not be welcomed, it is essential to hear it and react to it to prevent serious harm to the organization. 

If you are in a boat in the middle of the water and a passenger sees a leak with water coming in, wouldn’t you want to know about it sooner, rather than later?  It may be inconvenient or interrupt an outing, but the sooner the issue is raised, the quicker it can be resolved.  Ignoring it, or choosing to not hear the message, does not make the leak go away. 

In the healthcare setting, the Department of Health and Human Services (HHS) believes that whistleblowers, or those who speak up, should be protected against retaliation. This concept is also found in the provisions of the False Claims Act. In many cases, employees sue their employers under the False Claims Act’s qui tam provisions. They are frustrated by the company’s failure to act when a questionable, fraudulent, or abusive situation was brought to the attention of senior corporate officials. 

Predictive personality characteristics 

Do you know how to spot the personality characteristics that contribute to speaking up? Wouldn’t you like to look for them in candidates applying for employment with your organization? The more people you employ with a speak-up mindset, the more of a speak-up culture you’re likely to have.   

In the Journal of Applied Business Research, Marc Street wrote about two predictors to this kind of behavior.  Specifically, these include Organizational Commitment and Cognitive Moral Development. 

Organizational commitment, also described by R.T. Mowday, includes three things on the part of the individual: 

  1. Buy-in to the organization’s mission, goals, and values 
  2. Willingness to put forth significant effort on behalf of the organization 
  3. Strong desire to remain a part of the organization 

Cognitive moral development relates to the level of moral and ethical maturity that an individual possesses.  Contributions to the concept moral development is the work performed previously by Lawrence Kohlberg.  Kohlberg outlined stages of moral development with the early stages as less developed as the later stages.  

This work also clarifies that not everyone develops the higher levels.  But the higher the development the more likely the individual will speak up.  The higher levels of moral development include those who demonstrate: 

  • A social-contract legalistic orientation—which includes a belief in upholding the basic rights, values, and legal contracts of a society, even when they conflict with the concrete rules and laws of a group. 
  • A universal ethical principle orientation—which means they are guided by universal ethical principles that all humanity should follow. 

In healthcare compliance, deciding when to speak up is not always black and white.  Sometimes it can be grey.  For example, demonstrating medical necessity for services provided is an essential element of patient care.  However, medical necessity can be defined differently by different parties. Medicare may have a published policy that explains what is considered medically necessary for reimbursement purposes. But a physician may feel the service is in the best interest of the patient even if it is not reimbursed.  The physician might proceed with providing the service because she feels it is medically necessary, but the payor might not reimburse the physician for the service. Payor policies typically address reimbursement, not whether the physician is legally allowed to perform the service.  Speaking up with a concern about a lack of medical necessity must be evaluated in the context of a payor reimbursement policy compared to medical decision making.   

 A HIPAA concern can present a more black and white issue.  Consider the case of a clinician who is snooping in the medical record of a patient they are not assigned to or taking care of. It’s important to keep this in mind when you incorporate predictive personality traits into hiring decisions. 

To-dos for healthcare compliance professionals 

What can compliance professionals implement in their organizations now?  

  1. Discuss and promote the importance of avoiding the “deaf effect.”  Many issues reported to supervisors or the compliance officer might not be substantiated. That’s okay. Dealing with them openly demonstrates a culture where speaking up is valued. 
  1. Develop strategies to hire individuals with predictive traits for speaking up or implement training sessions to instill these traits in existing employees.  Two important predictors are organization commitment and higher levels of cognitive moral development. 

Consider using tools to measure organizational commitment, such as the Organizational Commitment Questionnaire. The Defining Issues Test (DIT) a moral development tool from the University of Alabama’s Center for the Study of Ethical Development, is another option. 

A speak-up culture is definitely earned, not bought or mandated. Invest time in your colleagues to help them hire well and manage issues responsively, transparently, and gratefully. Because when they do that, their teams will notice and be more likely to speak up when something seems not quite right. The time invested will pay off in a more effective compliance program, a healthier culture, and fewer fires for you to put out as you manage regulatory change. 

Check out the compliance culture page on the YouCompli blog for more tips and suggestions.

CJ Wolf, MD, M.Ed is a healthcare compliance professional with over 22 years of experience in healthcare economics, revenue cycle, coding, billing, and healthcare compliance. He has worked for Intermountain Healthcare, the University of Texas MD Anderson Cancer Center, the University of Texas System, an international medical device company and a healthcare compliance software start up. Currently, Dr. Wolf teaches and provides private healthcare compliance and coding consulting services as well as training. He is a graduate of the University of Illinois at Chicago College of Medicine, earned a master’s in education from the University of Texas at Brownsville and was magna cum laude as an undergraduate at Brigham Young University in Provo, UT. In addition to his educational background, Dr. Wolf holds current certifications in medical coding and billing (CPC, COC) and healthcare compliance, ethics, privacy and research (CHC, CCEP, CHPC, CHRC).

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