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27Journal of Health Care Compliance — November–December 2020 27

Giovanni Gallo / Nick Gallo

Ethical Frameworks Contribute to a Healthy Culture across the Organization

T here has been a movement afoot in the provision of health over the past decade, formalized more recently in the past two years, to drive increased

health in a population by looking at drivers of health out- side direct health care interventions. Here we explore applying that kind of framework for building an ethical culture in your organization.

We all know that the various efforts, policies, programs, etc. that we drive in our ethics and com- pliance organizations are ultimately meant for some- thing outside our compliance team. Compliance is meant to inform and drive decisions and behaviors that contribute to a comprehensive effort across the workforce. When this works right, employee actions align with the intended culture and mission of the organization.

It is so much more than just “a culture of compli- ance.” It is a sense that “compliance is culture” and is most effective when ethical frameworks contribute to a healthy culture across the organization.

The conversation around social determinants for health has broadened our approach to improving health for patients. For example, it includes consid- erations for transportation. If someone cannot get to a doctor’s appointment, they cannot get that health care, even if it is technically available to them. In simi- lar ways, a well-written policy is much less effective if it is not recalled and referenced (that is, available) by employees. Ethics leaders of the next decade will realize that, just like transportation in light of a doc- tor’s appointment, there are barriers and conflicts that prevent employees from engaging with and supporting compliance efforts.

Read on for steps and considerations that will help you build a more strategic compliance function that gives consideration for all of the environmental, social, physical, and other determinations of whether your ethics efforts drive a healthy culture.

Social Determinants of an Ethical Culture

Giovanni Gallo and Nick Gallo are brothers and lifelong students of workplace culture, ethics, and

values-based leadership. As Co-CEOs of ComplianceLine they lead a

mission to make the world a better workplace through hotline report-

ing, case management software, credential monitoring, e-learning,

and comprehensive solutions to data integration and employee engage- ment. Residing in Charlotte, North Carolina, you can frequently find them sharing their expertise and

suggestions to improve workplace culture on LinkedIn, as speakers at

conferences, in industry magazines, and on complianceline.com.

Giovanni can be reached at ggallo@ complianceline.com, and Nick can be

reached at ngallo@complianceline. com.

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Social Determinants of an Ethical Culture

a fresh PersPeCtive oN ethiCs Let’s start by considering the overall man- date. Healthy People 20201 highlights the importance of addressing the social deter- minants of health by including “Create social and physical environments that pro- mote good health for all” as a major goal.

Do you have a mission or purpose statement for your compliance team? We often prefer to jump to tactical efforts and tweaks to our existing programs, but it is wise to at least annually consider how all your team’s efforts drive toward a com- mon definition of your impact. Borrowing from the perspective above, you might consider expanding your perspective on policies, monitoring programs, and train- ing. Push these to include consideration for all of the environmental and social fac- tors that lead to compliance-related deci- sions. Consider them, even if you cannot directly influence them all. It is a small change in perspective that can lead to a large increase in innovation and improved execution.

ACTION: Set a 30- or 60-minute meeting with formal leaders, forward-thinkers, and ambitious change-makers on your compli- ance team to explore how this perspective could be shifted to better define where com- pliance can have an influence.

Another key aspect of the social deter- minants of health approach is an increased level of collaboration and integration across previously disparate disciplines and programs. Consider these diverse influences of behaviors that define your culture. Then proactively expand the purview of what your program impacts to include working together with other departments more. Start by choosing the ones which have traditionally had more direct influence over these determinants.

Be prepared to build relationships and coordinated programs with departments you may have never formally worked with before—supply chain, finance, build- ing services, HR, communications and marketing, patient billing and more might

be key allies in building a comprehen- sive approach that pays attention to any- thing that influences behavior within your organization!

■ Explore how programs, practices, and policies in these different departments affect the decisions of individuals, teams, and departments.

■ Meet with your peers to establish com- mon goals, complementary roles, and ongoing constructive relationships between the compliance team and their main areas.

■ Maximize opportunities for collabora- tion among company-, division-, and location-level partners related to social determinants of an ethical culture.

the five DetermiNaNts of ethiCal Culture The determinants are usually split into physical and social factors. It is helpful to consider this new framework in light of these five areas of influence. While not comprehensive, and there is plenty of room for gray areas, going through this framework can help you and expand your consideration to be a more successful and influential compliance leader.

Your program and activities are already driven by a list similar to this. There is some starting point you and your team have built off of over time. Maybe it is the seven elements of a compliance program from the Centers for Medicare & Medicaid Services (CMS). Maybe it is just the way that your company has organized depart- ments and roles. Or maybe it is just a mix of different things in the past growth of the company that have led your efforts to be organized the way that they are.

Consider this five-part framework as a guide. It shouldn’t cause you to ques- tion whether you should continue the activities you are doing now, necessarily. But it can drive thoughtful discussion on whether the programs you are running now are failing to consider externalities that are working against you.

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Social Determinants of an Ethical Culture

You might go through this list and realize, for example, that no matter how well-written your policy is, if the social environment in a division is driven toward a completely different incentive set, no amount of training is likely to break that stronger force. (Here we maintain the for- mal names of the social determinants of health framework and describe the related relevant considerations in your compli- ance program.)

Remember: The intention as we review the below is not to assume that compli- ance is responsible for or in some cases can even drive material changes to these issues. Importantly though, if our teams are to be successful, we need to be aware of the impact of these determinants on the behaviors and decisions of the employees we all have a role in taking care of. By considering these, we may at times feel like a civil engineer build- ing a bridge or tunnel through an existing obstacle. Other times we may be more like a pilot, charting a different course around turbulence or rough weather in order to smoothly get to our destination of an ethical culture.

Economic stability (compensation and incentives):

■ Formal economic incentives (commis- sion, bonus, etc.)

■ Pay equity, market benchmarks ■ Employment benefits ■ Family turmoil, life stage changes ■ Local/regional economic challenges ■ Path to promotion

We do well to recognize how strongly these economic drivers can influence employee behavior. Of course, these are already at consideration when conducting travel and expense audits, teaching and monitoring for bribery and corruption, etc. But there is a much wider set of eco- nomic impacts that are likely to influence an employee’s behavior toward or away from an ethical culture.

If someone considers themselves underpaid, are they more or less likely to advocate on behalf of the company to

uncover or report financial misconduct? How might a tight budget at home make someone less willing to report an inci- dent that they think could lead to retalia- tion or losing their job? If a local manager ignores ethical behavior when determin- ing promotions, an employee is likely to take cues from people who have been pro- moted before. On the other hand, ethical culture ambassadors (e.g., local leaders, visible successful whistleblowers) who have been recognized for their ethical behavior influence the actions of others. But in a “to the victor go the spoils,” “the ends justify the means” or worse yet “the ends justify the meanness” type of envi- ronment, things can be much different. If everyone “knows” that you have to break a few ethical eggs to make a promotion omelet, what uphill battles is your ethics program fighting?

Beyond these near-universal consider- ations, compliance leaders will need to continue to improve their ability to drive regionalized and localized considerations. We do well to realize that risks or drivers of an ethical culture frequently diverge on a location or individual basis. Local job mar- kets, short-term economic or environmen- tal fallout, etc. can all put employees at higher risk for making unethical choices and should be taken into consideration by complianceline leaders looking to have their greatest strategic impact.

Education (training and knowledge): ■ Experience in the role/industry (or other

jobs with differing ethical standards) ■ Formal compliance training ■ Formal division training (e.g., sales,

patient services) ■ Informal, learned behavior

It is quite common for the compliance department to have at least some input into (or even completely be responsible for) training and development. If nothing else, we usually are driving learning ini- tiatives around our code of conduct and relevant regulations (HIPAA, discrimina- tion, etc.).

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Social Determinants of an Ethical Culture

But as we expand our consideration to these social determinants of an ethi- cal culture, we should recognize that a wide range of influences in the area of training and knowledge can affect employee behavior. If employees have a lot of experience in their role or the industry, they might have privacy pro- tocols or consideration for patient con- flicts in their blood, so to speak. That said, if their region or industry has a ten- dency toward questionable behavior in a certain area, an experienced or highly educated employee in an area might be steeped in bad habits that we would do well to be wary of.

Similarly, we should be conscious that there is a lot of training and education, both formal and informal, in our organiza- tion that has potential to conflict with our compliance training on two levels.

■ Attention: First of all, and nearly uni- versally, training specific to a division or role is likely to get more attention both from managers and from employ- ees. This can drive a reduced focus on or recall of specific ethics training and make it harder for our teams to get our message across.

■ Preference: Secondly (and this one might be more on your radar but also even harder to correct), formal or infor- mal job training may nudge employees toward unethical behavior. If a division pushes a “do what it takes to get the job done,” or “the real rules are the ones that get enforced” attitude, it can create deci- sion conflict and competing expecta- tions on the ethics department without you knowing it. ACTION: You may only be able to do this

on an exception basis, but if you notice a hotspot of a certain type of misbehavior, you should consider examining the different for- mal and informal education that employees got that might be driving the exact behavior you work so hard to prevent.

Social and community context (rela- tional culture):

■ Employee engagement and trust in leadership

■ Internal factions, underrepresented groups

■ Personal and professional support, coaches, mentors

■ Social rewards (recognized) and punish- ments (ostracized)

■ Informal influence and authority structures Outside of the more formal efforts in

the next category, this social element is experiencing the most growth in atten- tion, and rightly so. The relational culture of your organization, not only with respect to your ethics initiatives but also univer- sally across levels in between employees, is considered by some to be the stron- gest force for an ethical culture available. Assess the level of trust that employees have with their direct manager (and the disembodied corporate structure) to gain a good start on a plan to improve in this area.

ACTION: You can benchmark2 your proportion of compliance reports to your total employee count, or your proportion of anonymous and substantiated reports to your overall incidents. That is going to be a good starting point to get a sense of how con- cerned employees are with retaliation and, alternatively, how open they are to identify- ing potential misbehavior for the better of the entire organization.

As you dig further into this determi- nant, it is helpful to be aware of how infor- mal relationships and mentorships can strengthen or conflict with your desire for an ethical culture. Do you have eth- ics ambassadors and people in influen- tial roles who echo your team’s messages about the importance of ethical behav- ior? Or are the people in positions most respected and talked about in the organi- zation known for their desire to win at all costs, use their power, or try to get away with questionable behavior in the name of growth or advancement? Employees are likely to pick up informal examples and

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Social Determinants of an Ethical Culture

cultural messages from these visible lead- ers. Beyond that, these leaders are likely to have formal influence as managers, coaches, and mentors. As you better inte- grate an understanding of organizational social dynamics, you can build a more thoughtful approach to recruiting influ- ential leaders into your efforts to drive a more ethical culture.

Health and health care (formal com- pliance efforts):

■ Ease of access, reference to ethical guidance

■ Availability of leaders and communica- tion channels

■ Ethical relevance and literacy This section is for the core, formal efforts

of your compliance and ethics team. While this determinant already gets the lion’s share of attention, headcount, and invest- ment, there are still some ways to improve your consideration of an ethical culture within this framework. Consider how easy it is for your employees to access not just your generic code of conduct but also guid- ance and policies specific to actions they take throughout their workweek. As travel distance and wait times are essential con- tributors to a patient’s ability to get the care they need, as ethics experts, we need to make an effort to improve the accessibility of our expert guidance within the context of the employees’ work.

Additionally, consider what you can do to make your leadership and frontline compliance team available and positioned as helpful advisors to employees across divisions. When paired with reminders and formal guidance about how compli- ance can prevent mistakes and wasted effort, these initiatives can go a long way to building ethics literacy across your organization.

Neighborhood and built environment (physical culture):

■ Physical barriers, chance collaboration ■ Visibility and privacy ■ Environmental stressors ■ Quality of work areas

As we get into this last category, con- sider how the physical environment in your workplace affects ethical decisions. A push for data privacy and high cubicle walls might make sharing passwords or seeing patient records less likely. It also might make it easier for somebody to vio- late policies in private.

If the layout of workspaces, ambient noise, or a general high-stress environ- ment exists for employees in a certain division, you should be conscious that these will likely reduce the attention and mental processing available to make good decisions about complex com- pliance issues. As mentioned earlier, issues in this category might be mini- mally available for the compliance team to impact. It is not likely that building architects are coming to you and asking how desks should be laid out. If noth- ing else, though, you should be aware of how the physical environment affects employees’ behavior. That way, you will better understand how tough of a job you are up against.

takiNg soCial DetermiNaNts of ethiCal Culture iNto aCCouNt We have gone over the five social determi- nants of health in the context of a stron- ger ethical culture. As you can see, each of these areas that have been brought into consideration for the provision of health care can also be interpreted in light of your compliance program. Both perspectives are aimed at a more comprehensive under- standing that ethics and health are related to the whole person.

Whether it is a patient or an employee, decisions about behavior do not exist in a vacuum. The physical environment, social influences, economic contact, education, and direct compliance interventions all work together to result in the culture you end up with. If there are challenges and breaks in a culture of ethics in your orga- nization, you should definitely continue to do your annual strategic compliance

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Social Determinants of an Ethical Culture

plan and execute your existing programs as well as possible.

Beyond that, though, you will do well to recognize that the behavior of employ- ees is based on much more than your spe- cific program. Whether you are looking to advance to Compliance v3.0 or to simply solve a seemingly intractable ethics issue, looking at these five determinants of an ethical culture can help you uncover con- flict and issues in your environment that might be working against you.

In some cases, you might be able to change those determinants outright. In

others, you will have to craft a solution in consideration of them. In any case, this comprehensive approach to a strong com- pliance program will be something that continues to make your team more rele- vant, more in-tune, and more of a strategic advisor to your entire organization!

What step are you going to take this month to get stronger at this?

Endnotes 1. www.healthypeople.gov/2020/topics-objectives/topic/

social-determinants-of-health#one. 2. solutions.complianceline.com/2020-compliance-

benchmark-report.

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