How to ensure a culture of compliance in your hospice

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1 2015 NAHC Annual Conference Session 904 How to ensure a culture of compliance in your hospice Bill Musick, BS, MBA, CHC, CHCP Senior Associate and Project Manger Your Trusted Business Partner in Post-Acute Healthcare A Matter of Focus CoPs/ Accreditation OIG 7 Elements Value Based Culture 1

2 Who s In the Room? Roles 1. Board Members 2. Chief Executive 3. Other staff 4. Consultant 5. Other A Matter of Focus CoPs/ Accreditation OIG 7 Eements Value Based Culture 2

3 A Matter of Focus CoPs/ Accreditation OIG 7 Elements Value Based Culture OIG 7 Elements 3

4 OIG 7 Elements 1. Policies, Procedures and Standards of Conduct Empowering or legalistic? Are you addressing all stakeholders? OIG 7 Elements 2. Compliance Program Design and Implementation Implementing an effective compliance program requires a substantial commitment of time, energy and resources by senior management and the governing body. Superficial programs that simply purport to comply with the elements that are hastily constructed and implemented without appropriate ongoing monitoring will likely be ineffective. - OIG Compliance Program Guidance 4

5 OIG 7 Elements 3. Training and Education OIG 7 Elements 4. Lines of Communication 5

6 OIG 7 Elements 5. Enforcement and Discipline OIG 7 Elements 6. Monitoring and Auditing 6

7 OIG 7 Elements 7. Prompt Corrective Action 8 th Element: Effectiveness "We Will Not Lie, Steal Or Cheat, Nor Tolerate Among Us Anyone Who Does" 7

8 OIG 7 Elements A Matter of Focus CoPs/ Accreditation OIG 7 Elements Value Based Culture 8

$cul ture noun \ˈkəl chər\ 1. the beliefs, customs, arts, etc., of a particular society, group, place, or time 2. a particular society that has its own beliefs, ways of life, art, etc. 3.$

9 cul ture noun \ˈkəl chər\ 1. the beliefs, customs, arts, etc., of a particular society, group, place, or time 2. a particular society that has its own beliefs, ways of life, art, etc. 3. a way of thinking, behaving, or working that exists in a place or organization (such as a business) Tone at the Top Peer and Supervisor Support Culture that encourages speaking up Embedded Values 9

10 WEAK PROGRAM EFFECTIVE PROGRAM Commitment to Integrity Recruit for integrity Train proactively on integrity Discuss examples of: Poor and good decisions Transparency Roz Woodward/Photdisc Green/Getty Images 10

11 IDT Meetings Focus on Integrity Stimulate discussions in IDT meetings Share examples of moral courage Spend at least 10 times the energy in reinforcing training as in delivering it. Ken Blanchard, author of The One Minute Manager Meetings Model Integrity Acknowledge ethics lapses and failures Be forthright about how such situations have been addressed MISTAKES ARE THE PORTALS OF DISCOVERY -JAMES JOYCE ( ) 11

Leadership Emphasizes Integrity Be present at ethics and compliance training Reinforce good decisions and recognize positive role models Give ethics and compliance stature through its placement on

12 Leadership Emphasizes Integrity Be present at ethics and compliance training Reinforce good decisions and recognize positive role models Give ethics and compliance stature through its placement on agendas and organization chart Strive for transparency and trust in all actions Integrity is an Important Aspect of All Supervisory Relationships Ensure ethics and compliance is an important aspect of: Hiring Performance evaluations Rewards David De Lossy/Photodisc Green/Getty Images 12

13 Interview for Integrity How would you describe a person of integrity? What types of situations have you experienced where to speak up or hold to your values, there as a potential cost to you? How did you handle those situations? Describe a situation in which you felt it might be justifiable to ignore company policy or a standard procedure. What did you do? What would you do if someone asked you to do something unethical or you observed or heard about something that you thought might cross ethical boundaries? Your Trusted Business Partner in Post-Acute Healthcare Interview for Integrity We sometimes face situations of having to choose between what is ethically or legally right versus what is best in terms of financial results or public relations for the organization. Can you give us two examples of situations in which you faced this dilemma and how you handled them? Describe how you think a person in a leadership/peer role can convey to the staff of the organization that ethical behavior is a high priority? Your Trusted Business Partner in Post-Acute Healthcare 13

Partner in Post-Acute Healthcare 27 Adapted with permission from: The Five Dysfunctions of a Team, Patrick

14 Focus on Collective Goals Build Trust by being vulnerable Assure Accountability by confronting difficult issues Mine for Healthy Conflict Forge Commitment by forcing clarity and closure Your Trusted Business Partner in Post-Acute Healthcare 27 Adapted with permission from: The Five Dysfunctions of a Team, Patrick Lencioni, 2002 John Wiley & Sons Basic versus Advanced CoPs/ Accreditation OIG 7 Elements Value Based Culture 14

efforts to set the tone at the top in the following areas: A.

Creating an atmosphere where it s encouraged to speak up about questions or

Including ethics as an element in the selection of staff and leadership? 2.

A best intentional practice of your organization? OR B.

15 Tone at the Top 1. Take one minute to rate (Strong/Medium/Weak) your organization s intentional efforts to set the tone at the top in the following areas: A. Recognizing and rewarding positive ethical behavior? B. Creating an atmosphere where it s encouraged to speak up about questions or concerns regarding ethical or compliance lapses? C. Including ethics as an element in the selection of staff and leadership? 2. In groups of two for one minute each share: A. A best intentional practice of your organization? OR B. B. What s getting in your way of higher performance? Commit to Action What three things can I do this month to move my board forward in creating and reinforcing a culture of integrity? Your Trusted Business Partner in Post-Acute Healthcare 15

Assess.Don t Assume Staff Knows What to Do?

that raising an issue would be welcomed by your

16 Assess.Don t Assume Staff Knows What to Do? If you were to observe what you think is a clear ethical or compliance issue, are you confident that you know what to do? that raising an issue would be welcomed by your supervisor? that raising an issue would be welcomed by your peers? 16

17 How Often do Lapses Occur? In the last three months, how frequently have you observed compliance lapses? If you observed a compliance concern, did you bring it to the attention of someone else in the organization? If so, do you know that action was taken to address the issue? Was the action effective? If you did not raise the issue with anyone else, what held you back? References Gould, S. (2013) Ethical Leadership and Developing a Code of Conduct for Organizations. Retrieved from knowledgegateway/ethics/discussion/ethical leadership and developing code conductorganization. Killingsworth, S. (2012) Modeling the Message: Communicating Compliance through Organizational Values and Culture. The Georgetown Journal of Legal Ethics (Vol.25:96) LeBlanc, R. (2015) Integrity? The buck stops at the board. Listed. Retrieved from the buck stops at the board/. Eichinger, R.W. and Lombardo, M.M. ( ) The Career Architect. Lominger Limited, Inc., a subsidiary of Korn/Ferry International. OIG Compliance Guidance for Hospices. Retrieved from The seven pillars of an effective ethics and compliance program Compliance Today, Health Care Compliance Association. Retrieved from pillars of effective ethics and complianceprogram.pdf Your Trusted Business Partner in Post-Acute Healthcare 17

18 References (cont d) Sustaining an Organizational Culture of Compliance, SAI White Paper. Retrieved from Utilizing Hotline Benchmarking Data. Retrieved from: The 2013 Ethics and Compliance Hotline Benchmark Repport.pdf Best Practices in Ethics Hotlines. Retrieved from: SAI Whitepaper. Retrieved from: GLOBAL whitepaperdevelop engaging effective code program.pdf Your Trusted Business Partner in Post-Acute Healthcare Bill Musick Senior Associate/Consulting Services Project Manager Your Trusted Business Partner in Post-Acute Healthcare 18

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LEARNING OBJECTIVES LEARNING OBJECTIVES. Session 11. Ethics, leadership and culture

LEARNING OBJECTIVES LEARNING OBJECTIVES. Session 11. Ethics, leadership and culture Session 11 Ethics, leadership and culture LEARNING OBJECTIVES Define the term corporate culture and understand its relationship to ethical culture. Define the term ethical culture and understand the key