With over a decade of experience in the healthcare industry as a policy and contracts management solutions vendor, we have engaged with several hospitals and healthcare workers, such as compliance officers. From such engagements, we have noticed that starting as healthcare compliance officers may at first seem a bit nerve-wracking. This is mainly due to the critical nature of the position as its primary role is to ensure the healthcare facility is safe from non-compliance. Thus, we decided it would be a good idea to help shed some light on the matter and give advice to those that are just starting out as compliance officers.
So, you have just joined an organization as the new Healthcare Compliance Officer. Congratulations, to both you and the hospital!
It is very likely that this is your first time covering this position, and I am sure you have many questions. Do you know your roles and responsibilities? Do you understand how you are supposed to “fit” into the organizational structure of the hospital? Do you know how to get the staff to be on your side?
Unfortunately, the answer is not in the organizational chart they hand you during your employee orientation session. If only it were that easy!
If you have received training in becoming a Healthcare Compliance Officer, you may have your own ideas and expectations based on what the school curriculum covered. Nonetheless, in most cases, textbook information is not realistic either. You need to figure out how to transform the guidelines you obtained from your education and mould them to fit your new organization’s structure and expectations. Essentially, that is what you need to figure out:
What Type of Healthcare Compliance Officer Are You?
A Corporate Compliance Officer often addresses the business ethics, billing fraud, EMTALA, code of conduct, privacy laws and other business relations. On the other hand, a Regulatory Compliance Officer is often responsible for the standards and accreditation requirements for a variety of agencies. It is important that the type of compliance for which you are responsible be articulated clearly.
Your understanding of the position should accurately reflect your job description, and your hospital should clearly outline expectations for you. Ideally, there would also be some preferred educational requirements. Such as a starter guide to “Becoming a Certified Healthcare Compliance Professional/Officer.” I would also highly recommend that you go to the HCCA website, where there are tools and resources to help you in your role, as well as opportunities for continuing education and certification. They also have an excellent document titled “Evaluating and Improving a Compliance Program – a Resource for Healthcare Board Members, Healthcare Executives, and Compliance Officers.”
The Attitude Toward Compliance
When I am “out on the floors”, I frequently hear staff say that they do things to be
“compliant” with the Joint Commission, or the next survey. Instead, I try to explain to them that we do things to prevent patient harm and to be ready for the next patient. However, just hearing the way they refer to compliance gives me some insight into why some people have a tendency to shy away from those who are in compliance roles.
To clarify these reasons, let’s look at some standard definitions for compliance. Webster’s definition of “compliance:”
- A) The act or process of complying to a desire, demand, proposal, or regimen or to coercion. B) Conformity in fulfilling official requirements.
- A disposition to yield to others.
- The ability of an object to yield elastically when a force is applied; flexibility.
Concerning the first definition (compliance being the act of complying with a regimen or coercion), you can see how staff would be a bit resistant to you approaching them about an issue if they perceived you as the “enforcer of conformity.”
Regarding the second definition (a disposition to yield to others), staff may behave submissively knowing they have to listen to you and go along with what you say and want implemented.
Finally, according to the third definition (the ability of an object to yield elastically when a force is applied – flexibility), there is nothing more disheartening than working with a member of the healthcare team who uses their title to “bend staff into shape.” When healthcare staff regards the word “compliance” with those connotations, they are hardly going to be “flexible.”
For those of you – like me – who are visual learners, think about what happens when you put enough force on something that is rigid and not resistant to change: it will break. This is why the integration of a Compliance Officer is met with such tension.
After the break, often a mess is left behind, and there will be pieces to pick up. How do you prevent these clean-ups from occurring in the first place? You need to change the perception of resistant staff, and to do that, you need to understand capacity and capability.
The IHI (Institute for Healthcare Improvement) has an excellent series on leadership as it relates to Quality Improvement.
In this series, they discuss capacity as:
- The ability to receive, hold or absorb
- The maximum or optimum amount of production
- The ability to learn or retain information
- The power, ability, or possibility of doing something or performing
- A measure of volume; the maximum amount that can be
Do team players under your supervision have the capacity to participate in the issue that is non-compliant?
Moreover, in this series, IHI describes capability as:
- The power or ability to generate an outcome
- The ability to execute a specified course of action
- The sum of expertise and capacity
- Knowledge, skill, ability, or characteristic associated with desirable performance on a job, such as problem-solving, analytical thinking, or leadership
Also, some definitions of capability include motive, beliefs, and values
Are your team players “capable”? Can they impact the issue you are raising? Do they have the necessary skill sets and/or experience to do so?
If the team that you have assembled – or were handed – has the capacity and capability to address your compliance issue, then you have made a significant step in the engagement of key stakeholders.
Let’s go back to Webster’s definitions again, but let’s review them through a perspective that is to your advantage. In the first definition (the act or process of complying to a desire, demand, proposal or regimen or coercion), the keyword is DESIRE. You need to communicate your plans and expectations in a way that promotes a willingness to make the change versus having to do it to be compliant. R. Lloyd from the IHI has a great slide on Continuous Quality Improvement (CQI). It discusses the three elements that are necessary to drive capacity. One of those elements is WILL (aka, desire): having the will to change the current state to one that is better. The second is IDEAS: developing ideas that will contribute to making processes and outcome better. The third is EXECUTION: having the capacity to apply CQI theories, tools, and techniques that enable the execution of those ideas. Implementation of practices involving compliance requires change and continuous quality improvement. These principles are critical to your success.
The second definition of compliance was a disposition to yield to others. If you engage your audience, and they have the will, capacity and capability, then compliance will most likely follow.
The third definition is flexibility when force is applied. Moulding and shaping your team comes from your leadership style. Your values, beliefs, and efforts using CQI will be apparent and have a ripple effect on your team. Keep trying rapid cycles of change until you achieve the behaviours you want from your team. Transparently define what your represent so that staff will not have to walk on “egg shells” around you. Building a relationship on false expectations will not promote a collaborative relationship. If that means analyzing your leadership style, then so be it.
Become a Change Agent, Not a Compliance Agent
As you sit in your new desk chair in your new office, please remember that your role is to help the organization that hired you to meet the needs of the patients and the community that it serves. Your new employer has its own values and belief systems, and has its own culture, and part of your job is to learn to be “compliant” with that culture. However, you are in a position to assess the environment of the organization and lead your peers toward your goals and vision, so you may become a change agent, not a compliance officer, to help move the culture to where it needs to be.
At PolicyMedical, we strive to develop and build solutions that help compliance officers and healthcare workers remain in compliance with the rules and regulations established by the boards. With that said, we realize that despite our best intentions and efforts we are not always the best fit for every healthcare facility. Regardless, we are more than happy to help you come to a conclusion even if it means you are better off with another vendor’s solution. Please, do not hesitate to contact us, should you need further clarification or assistance in choosing a policy management solution. Alternatively, you may book a demo to see our offerings in action.