Compliance Culture Building Block #7: Engage leadership


Compliance Culture Building Block #7: Engage leadership

Margaret ScavottoBy Margaret Scavotto, JD, CHC
Director of Compliance Services
Management Performance Associates

In too many healthcare organizations, compliance stops with the Compliance Officer. The Compliance Officer implements policies, conducts training and audits, and gets the Compliance Committee together. But if little (or no) compliance activity gets reported to the board, a provider’s culture of compliance hits a glass ceiling.

Does board compliance education address each board member’s duty to their organization? Is legal counsel involved in educating the board on their liability?

Leaders and executives can’t set the tone for compliance if they don’t know what is going on. Educate them on compliance—not just once a year. The board—or president/CEO, etc.—can’t incorporate compliance into the operations and dialogue (and culture!) of the organization unless they are truly informed. How do you do this?

Yes, the board needs training on what a compliance program is and what yours look like. They also need ongoing education on changing risks and how you are responding to them. There are a lot of metrics you can report to the board, just as you report to the Compliance Committee. For example: number of hotline calls and how they were resolved; results of audits scheduled for that month or quarter; training that was done; special initiatives that address new OIG guidance; and, of course, quality assurance. QA is perhaps the most essential piece of info to communicate to the board, as providing quality care is the primary goal of every nursing home.  A dashboard can be a good mechanism for routinely sharing this information with your board.

Board members and other leaders typically are in these roles for a reason: use their expertise. These individuals can be a good source of compliance strategy if they know what is going on. If your staff, patients and the community hear about compliance from your leaders, a culture of compliance will follow. The first step is keeping the board informed.

[clickToTweet tweet=”The buck stops with the board @mpaCompliance” quote=”The buck stops with the board ” theme=”style3″]


  1. Margaret- v nice series!! One thing I would add=> The CCO should be prominent in educating the Board on compliance and culture, which allows the CCO to discharge her roles of Subject Matter Expert and Ethical Leader at the top, where it counts most. All part of Building the Ship. As the CCO uses every opportunity to engage and build subject matter expertise, the organization gets stronger and ethical culture more embedded- which is one enormous benefit and role of the compliance champion network.

Comments are closed.