Compliance in healthcare serves as the foundation for trust, safeguards patient safety, and ensures the integrity of organizational operations. Establishing a culture of compliance involves proactive efforts to embed ethical practices and regulatory adherence into the fabric of the organization. It thrives on active participation at every level, transparency, and a commitment to continuous education. Through key strategies and actionable steps, healthcare organizations can build and sustain a strong culture of compliance.
The Framework for Compliance: 7 Elements from the HHS OIG
The U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) identifies seven essential elements of an effective compliance program:
These elements form the foundation of a compliance-driven culture. However, their full effectiveness is realized when they are fully integrated into the day-to-day operations of a healthcare organization. In doing so, organizations can ensure stronger regulatory compliance, protect patient safety, promote ethical decision-making, uphold their reputation, and meet government expectations for compliance programs.
Leadership’s Role in Compliance
Leadership plays a pivotal role in fostering a culture of compliance. It starts with owning their role in the compliance program by supporting the compliance officer, participating in audits, and ensuring that investigations are thorough and transparent. Leaders must demonstrate their commitment to ethical practices through consistent alignment of their words and actions, setting a clear standard for integrity and accountability.
It’s also crucial for leaders to engage actively in the compliance process, from department audits to serving on the compliance committee. Their visible involvement reinforces the importance of compliance as a shared priority rather than an afterthought.
Accountability Across All Levels
A culture of compliance depends on holding everyone equally accountable, regardless of title or seniority. This ensures that no individual is above the organization’s standards of conduct. One effective strategy is implementing ways for employees to share concerns and report issues comfortably and safely. Anonymous hotlines or open-door policies foster trust and transparency. Equally important is enforcing a strict policy of non-retaliation, ensuring employees feel protected when voicing concerns.
Compliance Policies in Practice
Policies are most effective when they are actively followed and consistently reinforced. In fact, having a policy and failing to enforce it can damage trust more than not having one at all. Leaders must take ownership of their department’s policies, ensuring they’re consistently upheld.
A comprehensive compliance plan, coupled with robust policies, serves as the foundation of any compliance program. But the real impact comes when policies are operationalized and integrated into daily workflows and decision-making processes.
Compliance Education and Training
Training is the cornerstone of any effective compliance program. New hire orientations and annual refresher courses should cover compliance requirements and the organization’s Code of Conduct. But education shouldn’t stop there—targeted, specialized training should also be provided as new challenges arise or regulations evolve.
Accountability is crucial, with leaders and employees expected to complete training on time and acknowledge their understanding of compliance policies through annual attestations or testing. Shared ownership among HR, compliance officers, and department leaders ensures that training is meaningful and impactful.
Making Compliance Everyone’s Responsibility
At its core, compliance is everyone’s responsibility. While leadership sets the tone, every employee has a role to play in maintaining ethical practices. This shared ownership creates a culture where compliance becomes second nature, fostering trust among employees, patients, and regulators alike.
By embracing transparency, accountability, and ongoing education, healthcare organizations can build a culture that prioritizes compliance not just as a requirement, but as a critical component of delivering quality care.
