standard of conduct

The Most Important Piece: Integrity & Standard of Conduct

David Way MAIS, CHC

What Drives Us to do the RIGHT Thing

Effective ethics and compliance programs

are key factors in achieving a culture of integrity

within your Community Center.

ETHICS• Ethics is about doing the right

thing, every time.• Ethical Behavior is rooted in values

by which people live their lives, not the regulations

• Compliance is about following the rules.

COMPLIANCE

Compliance & EthicsWhat is the Difference?

Ethics and compliance are different from each other, and both are critical to our organization’s success

MUST HAVE BOTH

• Focusing training and establishing procedures that clearly articulate your organizations ethics shapes peoples behaviors.

• Quality is a vitally important measure of compliance. If people want and strive to do their best excellence will be the by product.

• Compliance will happen.

The ContinuumA natural progression to compliance.

Standards and Procedures• The pathway to create a culture of

integrity is to communicate to employees the standards and procedures to which they should adhere. Organizations were urged to develop and distribute these standards and to further communicate their high importance. Today, these standards are commonly called an organization’s Code of Conduct. They are the expression of expected behaviors, and often become a key element in the evaluation of employees.

Education and Training

• Crucial to a company’s ability to create a culture of integrity is to communicate to employees the standards and procedures to which they should adhere. You are urged to develop and distribute these standards and to further communicate their high importance. Today, these standards are commonly called an organization’s Code of Conduct. They are the expression of expected behaviors, and often become a key element in the evaluation of employees.

Risk Based TrainingIs your training relevant?

• From a design perspective, training is often created in an utterly wholesale manner, so that, for instance, case managers, those in finance and senior managers are all being given the same compliance training even though their risks and responsibilities differ significantly. Perhaps worse, from a deployment perspective, training is often disconnected from risk-causing events or other contexts in which C&E messages could be more effectively conveyed.

Auditing and Monitoring• Organizations should employ a means to

audit and monitor internal systems and verify compliance. Many monitoring practices can be used, but regular audits performed by either an internal or external auditors are recommended. These audits should focus on all Center divisions, specifically relationships with third-party contractors and compliance in relationship to laws governing kickback arrangements, false claims act, financial and accounting procedures, and Medicare, Medicaid, and other federal health care programs.

Reporting• To empower every employee as a

member of the compliance team, organizations should create a reporting mechanism for employees to voice allegations or concerns without fear of retaliation. This standard has, of course, grown into an even stricter guideline with introduction of the Sarbanes-Oxley Act of 2002 that governs publicly traded companies. Today, many organizations utilize unbiased third-party vendors who offer anonymous telephone and Web site reporting for allegations of fraud, misconduct, and noncompliance.

Enforcement and Discipline

• To set up these rules and standards there must be consequences and those consequences should be levied consistently regardless of the employee’s stature within the organization. The Sentencing Guidelines state specifically that enforcement should be consistent with appropriate disciplinary action.• Use your Standard of Conduct as focal

point.

Response and Prevention

• Finally, the organization must respond. Even with standards and procedures in place and an avenue for employees to voice concerns, progression and improvement will not occur unless the organization responds to the offense and continues to make concerted efforts toward preventing similar conduct.

Practical Approaches

• Education must be relevant and, yes, exciting.• CEU program• Rewards/recognition• Monthly Focus…Commitment, Stewardship etc.• What is the role; case manager, accountant, volunteer?• What are you doing?

Innovative education


• Incentives help drive behavior!• There is certainly controversy regarding incentives…

BUT• The Federal Sentencing Guidelines 2004 revisions state

• (6) The organization’s compliance and ethics program shall be promoted and enforced consistently throughout the organization through (A) appropriate incentives to perform in accordance with the compliance and ethics program. USSG section 8B1.2 (b)(6)

Using Incentives


• People should not be rewarded for doing their jobs• How can you possibly evaluate someone’s virtue or

ethics• The area is too subjective

• Incentives can be used against the organization• Does this put the compliance profession in the role of human

resources?

Objections to incentives


• The United States Government tells us to use them.• The Working Group on Bribery of the Organization for Economic

Cooperation and Development, representing 38 nations issued the “Good Practice Guidance” listing 12 elements

• (9) appropriate measures to encourage and provide positive support for the observance of ethics and compliance programs or measures against foreign bribery, at all levels of the company;

Reasons for Using Incentives


• Peter Drucker • [C]hanging habits and behavior requires changing recognitions and

rewards. People in organizations, we have known for a century, tend to act in response to being recognized and rewarded—everything else is preaching…The moment they realize that the organization rewards for the right behavior they will accept it.

Reasons for Using Incentives


• Incentivizing • Personnel Evaluations

• Uses the code of conduct• Actively takes steps to implement the compliance program and the code of

conduct• What else?

• Input on Promotions• The reverse: Sentencing guidelines for item 3, goes on

to state that companies need to avoid promoting

people who have engaged…in conduct inconsistent

with an effective compliance and ethics program.

Putting it all together

Put the most important piece in place

standard of conduct

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