Managers: Key to Compliance Program Effectiveness

April 1, 2024

By Sarah Couture (Principal at Couture Consulting LLC in Indianapolis, IN.)

Originally Posted on: Compliance Cosmos

It is essential that compliance programs engage their organization’s senior leaders. This is not only an expectation from a regulatory perspective but also critical to fostering compliance program effectiveness.

Engaging operations in compliance is vital to ensuring compliance. The March column discussed the importance of senior leadership compliance engagement.[1] Senior leaders drive operational compliance, setting the expectation for compliant functions. While senior leaders should “clearly articulat[e] the company’s ethical standards, conve[y] and disseminat[e] them in clear and unambiguous terms, and demonstrat[e] rigorous adherence by example,” managers—those who supervise departments and teams—work to implement these goals, “reinforc[ing] those standards and encourage[ing] employees to abide by them.”[2] This management compliance responsibility includes ensuring employees have the necessary resources to perform their jobs compliantly (i.e., policies and procedures, appropriate training), monitoring high-risk functions, promoting a culture of transparency and encouraging reporting, and being part of corrective action plans and remediation of risk where identified.

Engaging management is key to ensuring compliance. Managers oversee departments and teams of frontline staff, often performing very high-risk functions: billing and coding, patient care, patient access, IT, human resources, etc. Management engagement in compliance should result in frontline staff knowing how to perform their job functions compliantly and quickly reporting concerns that may impact compliance.

The first step in successful management engagement is effective communication and education. Managers must understand compliance expectations to be able to implement them. Consider developing compliance training specific for managers describing their compliance responsibility and its significance, including specific expectations such as those discussed earlier. These expectations would also ideally be included in managers’ job descriptions and as a component in performance evaluations and bonus calculations. Ensure regular communications with managers to reinforce expectations, as well as provide reminders, examples of compliance successes, and ways to further engage. Second, develop an approach to personally connect compliance team members with managers.

This may include regular “rounds” or visits by compliance and offering to participate in and/or present at department meetings. The approach should prioritize compliance visibility and reinforce that compliance is an available and approachable resource for managers. Respond timely to questions and requests for help, and mentor managers as they address concerns or complete remediation activities. Finally, consider—with other leaders, including HR—how compliance involvement by managers, such as serving as a compliance “champion,” can be part of a manager’s career advancement. This concept is also discussed in the 2023 updates to DOJ’s Evaluation of Corporate Compliance Programs.

1 Sarah M. Couture, “Senior leadership engagement,” Compliance Today, March 2024, https://compliancecosmos.org/senior-leadership-engagement.

2 U.S. Department of Justice, Criminal Division, Evaluation of Corporate Compliance Programs, updated March 2023, https://www.justice.gov/criminal-fraud/page/file/937501/download.

Copyright 2024 Compliance Today, a publication of the Health Care Compliance Association (HCCA)

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