Better Together: How Nurses and Clinicians Can Collaborate with Compliance Teams

We’re back with another episode of Compliance Conversations!

We are excited to welcome Isabelle Garibaldi, DNP, RN, NEA-BC, CENP, CPPS, the Market Chief Nursing Officer for LifePoint Health / HighPoint Health System. Isabelle has 40 years of experience in nursing and has held executive-level roles in nursing and patient care for several healthcare organizations.

Tune in as Isabelle and CJ Wolf, MD, discuss:

• How compliance professionals can make a positive first impression with clinical colleagues
• Navigating the “gray” areas of healthcare compliance
• Insights from the various organizations Isabelle has worked for, and pros and cons of different approaches

As compliance professionals, it’s easy to operate within our function, but when we reach out and build relationships with the nurses and clinicians who work with patients day in and day out, we can all leverage each other’s experiences to build stronger compliance programs.

Episode Transcript

CJ Wolf: Welcome everybody to another episode of Compliance Conversations. I'm CJ Wolf with Healthicity and this is where we talk about compliance. You all know that if you're subscribed, if you're not subscribed, please do so. Hit the like button that helps us generate more interest in this podcast and other services and education we're offering.  
Today I'm so excited. Our guest is Isabelle Garibaldi, welcome Isabelle!  

Isabelle Garibaldi: Hello! 

CJ: We're so excited to have you and I'm so excited for our guests to hear from you cause, and I'll kind of preface this a little bit. A lot of times our guests are full-time compliance professionals. Isabelle is a clinical executive and has a lot of experience, and we'll let her introduce herself. But we're going to talk about that perspective, the individuals who make the systems run and take care of patients and their perspectives of compliance.  
Isabelle, we give our guests an opportunity to tell us a little bit about themselves and we'd love to hear a little bit about your professional life and kind of your journey and where you've been and where you are today.   

Isabelle: Sure, thanks! Well, this will tell you just how much of a not compliance officer I am, because it's truly a clinical background that I have. I've been a nurse for 40 years. This year has been 40 years, I started young. I hold a doctorate in nursing practice. I started out as a bedside nurse in the area of cardiovascular medicine and started my leadership journey back in the late 90s, and early 2000s and have been a chief nursing officer, Chief Nurse Executive, Vice president of patient care services, in one capacity or another, in about four organizations now, both not-for-profit and for-profit. So, both of those arenas, compliance and the clinical aspect is not something new, but it is certainly something very, very important that healthcare executives, especially in the clinical areas, need to be not only aware of but to promote in their practice.   

CJ:  Exactly! Sometimes as compliance officers, we get in our world and we sometimes forget why health systems and hospitals exist, right? It's to take care of patients, that drives, and any compliance officer or professional listening– don't forget that this is why these organizations exist, this is why we're there, compliance is there to help.  

So, we're excited to have Isabelle's perspective because as a non-compliance executive, but she worked, I'm sure and will ask some questions here, with and interacted with compliance folks, so we really would love kind of some of your perspective there, and really maybe we start there Isabelle, in your years of working as a clinical executive, what was your exposure to and interaction with the compliance department like? just tell us honestly and upfront, what was that like, those interactions? Would they be contacting you? Would you be contacting them? Share a little bit about that if you don't mind.   

Isabelle: Sure, it started off as something that we did as part of our annual education and I want to take a pause right there, because if this is the first exposure that a clinical person, physician, respiratory therapist, whomever that front line bedside person has to a compliance department or a compliance program and you're at the O level, the officer level, you've already missed the boat. So, starting early and getting that nomenclature to the frontline caregivers and having that as part of their practice toolkit is really, really important.  

How it came to me, and again remember, I said I was a nurse for now 40 years, compliance wasn't something that was formal, certainly when I first started out as a nurse and then it got to be just something we did, as a part of our annual education, whether it was online or classes that we took from our human resources department, but it was something to do and get rid of and get over instead of something to incorporate into our practice. So, it was a bother rather than a help. 

Compliance departments have really done a great job and officers have done really a great job getting the "Hey, we're here to help you" message out in recent years, but I would say that is still pretty fresh, maybe only in the last five to seven years has that been the tenor of the compliance departments. If you're contacting me for the first time because something happened or something's wrong, that's not a relationship builder, so getting to folks early, starting the first day of orientation and talking about compliance programs during the onboarding process, is very important.  

I think maybe someone who is a little newer to their career, maybe 20 years or less, had a lot more exposure than I did early on, but things have gotten a lot better. It's not just something we do once a year to tick the box.   

CJ: You're hitting on some really important things here. It's like there's kind of different relationships that compliance professionals have. There's kind of the relationships and exposure they should be having with every employee, or at least giving some sort of impression, not that they have to have a one-on-one sit down with every employee, but they need to be looking at it from the employee's perspective of, "why is compliance talking to me? What's the purpose of this and giving that exposure?"  

The other thing I'd be interested in, if you have thoughts that are any different that we've already shared, as an executive working with, let's say, the compliance officer, which is probably also a relatively high-level position in the organization, is opposed, like the frontline employee, right? How are those interactions? How have those been? is it when they're coming to you, cause a concern was raised? Maybe HIPAA concern or billing or coding or documentation concern? What times have they reached out to you?   

Isabelle: Yeah, you hit the nail on the head. The concerns that, it's almost a retrospective rather than proactive behavior. What I would maybe have like to have seen was some more proactive initiations of relationship topics between the clinical person and the compliance folks. It's getting better, but not still not great, but most of the time it's still, "Hey this happened!" and then there's the course the investigation and the dissection of what happened during that issue and then is the what level does this rise to? Is this a reportable issue? Is it not? What is the reeducation or education that we have to do in order to make sure that our employees have the tools that they need in order to act compliantly in the clinical setting.   

CJ: That's great perspective and insight. I've worked in my past jobs as a compliance officer. One thing I tried to do proactively and I'm interested in hearing if you would say this is even welcomed, because I know clinical executives like yourself are so busy doing all this other work.  

Couple of things I try to do; One, we'd have committees, like a compliance committee and we had an Executive Compliance committee, where we had the executives of the organization participate in that committee maybe once a quarter, so that they were hearing kind of what our proactive work was that we were trying to do, as well as the reactive, you get both of those in compliance programs.  

The second thing that we would try to do is we would try to do annual, what we call risk assessment. And in those risk assessments, we'd like to reach out to people in the operational lines to hear their perspectives, “our nurses at risk for exposing for HIPAA breaches and what's the reality on the ground for that type of thing.”  

So, one compliance committees and two kinds of getting executives and others involved in a risk assessment, maybe on an annual basis. Would either of those be welcomed by clinical executives like yourself. Do you just not have time to do that? What are your thoughts on that?   

Isabelle: My first thought is I would rather make time upfront to have that education as part of my toolkit and that of those who report to me, then have to learn it on the back end when the stress level of everyone is heightened, because something happened. The committee and having either quarterly or even semiannual committees to not only just do the retrospective analysis of what happened, but to have some education time on the agenda, so that the agenda is not 90%; "Here's how we didn't do such a great job," and 10% learning, I wouldn't say 50-50. I think that's a little altruistic, but an agenda that is maybe 60-40 or 70-30 where at least third of that meeting is proactive and educational.  

And again, that is the time for the relationships to be built between the compliance officer, the committee members and where trustful communication happens. Because, I'll tell you, I thought a bit about this as I was preparing for the podcast and no one goes to work as a clinician, thinking, "Oh yeah, I don't care. I'm just, Do I need to do?" No one thinks like that, everyone understands what HIPAA is. We understand the importance of what that is to not only our professional life, but how important that is to our patients and safety of our patients. And the well-being of our patients. 

CJ: That's right.   

Isabelle: But there are things that happen in circumstances, that happen every day in hospitals and other healthcare settings, where we could learn from that, where it may be not as cut and dry or black and white as "I went into a record I shouldn't have gone into." Well, there are things that may happen that are a little more gray, but could be HIPAA breaches and we need to talk about those, so that it gives people at the bedside in their everyday clinical lives pause and they take that extra step to be careful to ensure patient information safety.   

CJ: That is such great perspective, I love that. Let me ask, you mentioned earlier the messaging is getting out a little bit more about compliance programs are here to help, Is that believable? Like I've said that to people and they're like, "yeah, here I'm the government. I'm here to help you." How do you message that, so that it's believable? What are your thoughts on that?   

Isabelle: I've thought about that too. Having a trustful relationship throughout the organization is certainly going to help the cause, if there is already a tenor of mistrust with executive leadership when the compliance folks have to come in to investigate or reeducate, that while well can work, it just is a little more difficult.  

So, having and working toward a trustful and open transparent, however, whatever you want to call it, relationship with frontline caregivers is going to be the basis for this believability around compliance, and "Hey, we're here to help." Also, having just culture, educational opportunity so they understand, "Hey, if this happens, this is what happens to me on the job," so that there is an appropriate level of reaction to whatever is going on. Or there is an understanding that "Okay, I'm not going to be in serious trouble here that I can't recover from." And there are things we all know that are serious enough that you cannot recover from them on the job, that's not what I'm talking about.  

Every interaction with the compliance officer or with the Compliance Committee should not be a career-ender panic kind of situation. They are truly there to help in most cases because the gravity of whatever is going on is a teachable moment instead of a career-ender.   

CJ: That's a great insight. Thank you for sharing that. This might be a good time for us to take a short break, and we'll be back in a moment.  

CJ: Okay, welcome back everybody again. We're here with Isabelle Garibaldi, who's a nurse executive, with many years and decades of experience, and we're chatting about compliance from the perspective of an executive that is not the compliance officer, and that's such a valuable perspective for us as compliance professionals to take into account, we need to see things from others viewpoint instead of from our own.  

I think it's helpful to get out. One thing that I've shared in many past podcasts is-- get out of your office. Don't sit there and be sending emails and this and that. Meet with people and build relationships. And so far, I've been hearing from Isabelle a lot of that, that how important that is from her executive perspective of don't let the first time that she meets the compliance officer be some investigation, right? Building those trust relationships beforehand and that takes time and it takes effort and it's just not going to happen sitting in your office.  

Isabelle, you mentioned in your introduction that you've worked at other various healthcare organizations, I think you said two nonprofits and two for-profits. That to me is a really valuable experience because you've probably seen then four different compliance programs, or at least some different compliance programs, right?      

So, any pros and cons of different approaches? Have you seen things that you liked better or worse than others that we haven't already covered?   

Isabelle: No, I would have to say that they're surprisingly similar. I know that we think of the for-profit healthcare system and non-profit healthcare systems to be vastly different. But having worked in both, I can tell you the strive toward doing the right thing, quality and compliance and meeting patients’ needs, it is really all the same. The rest is just the tax bracket. So, I find them surprisingly similar. I guess maybe not so surprisingly now. 

But both the not-for-profit and for-profit systems have grown tremendously and their compliance programs are much more robust. They have gone outside of healthcare to other experts and consulting experts to refine and hone what they have, so they understand how important this is, and they do translate it well to healthcare executives.   

CJ: I was mentioning before we started that I do some consulting as well, and so I've seen a lot of organizations, different cultures for profit, not-for-profit, and I can't agree with you more. They're very similar, of course, there may be the one-off here and there, but in general, my experience has been that both types of organizations value quality, and value doing the right thing. And so, I have to agree with you fully and wholeheartedly about that.   

Isabelle: Well, we're all trying to meet the same level of responsibility, whether it's HIPAA or value-based purchasing or harm reduction, we're all trying to reach that. It's the same rules whether you're for-profit or not-for-profit, so it's not surprising that compliance programs need to be similar to meet those same rules.      

CJ: Earlier you mentioned kind of a lot of your exposure and a lot of what we know our frontline workers’ exposure to compliance programs are basically the training, right? Because it's something that's usually mandated. Most frontline workers are not involved in investigations and reporting, of course, there are hotlines and they may report occasionally, but they're just not intimately involved in that side of compliance. So, their kind of perception of compliance is probably going to be that training.  

And I'm interested in your thoughts on in-person training versus maybe computer training, when is one right? when is the other right? I've worked with doctors before, this was back before we had a lot of online types of training and one surgeon, who said, "I can't meet with you. I can't be trained on these coding rules, I'm too busy all day. I start my surgeries at 5:00 AM and unless you want to meet with me at four, I'm not meeting with you." I said, "Okay, I'll meet with you at four." And so I showed up and met with him at 4:00 AM. I think things have changed a little bit, but do you have thoughts or perspectives on training methods that you think are good and when is in-person versus online better or worse?   

Isabelle: I think there are two levels here. Again, if we're all waiting till people, whether it's physicians or nurses or respiratory therapists, whoever are in their employment arena, we missed the boat, we already missed the boat, Okay?  

And I don't know about your training, but my training. First of all, I started out as an associate degree nurse. Went through bachelor’s, master’s and then doctoral programs, and until that doctoral program, the compliance piece of this was not emphasized and I can tell you for sure at the associate degree level, I didn't even know what the word compliance in this arena meant.      

So, having that as part of, even if it's a one-off lecture, part of that curriculum is so very, very important. And whether you're a physician or not, it really is something that should be foundational to your practice, because it touches what you do every day because you have to act in a compliant manner in order to treat your patients. And the same thing with nursing and as a healthcare executive, the ability to really integrate that into our daily work life, again, can't start when they give me the C&O title, that has to start earlier on.  

Now, you asked about online or lectures, all of that should be part of whatever compliance program you and your entity have decided to construct. There is a piece where you just need some foundational knowledge and online education is just fine. Get the basics and have time to move through the slide deck back and forth and really understand what's going on.    

CJ: Right.   

Isabelle:  Then there is a time to ask questions and you said something about getting out of your office earlier. I would encourage that informal type of communication. The one-off dialogues, the chance to ask questions, not just in a classroom format, but on a one-to-one basis. We all know that there's sometimes a little bit of hesitancy to raise your hand in class because you don't want to ask the dumb question. But you may ask someone in a one-to-one type of situation.  

So as nurse executives, medical executives have had to get out of their office, so they weren't that administrator in the office pontificating to the rest of us, that kind of situation holds true for the compliance folks as well. I already know your face, and have a relationship with you. You weren't scary when I talked to you, so now I feel free to ask questions and be very forthcoming with information that's really, really important. And if you want to get there, that's how to get.   

CJ: I agree, and it's kind of, there's no quick way to do it, and this is really just true with any relationship, right? It's built over time, people have to see your response. So, when you ask a question, do they scoff and like, "how long have you been in healthcare? You should know that by now," right? Or is it, "Oh, great question and let me try to find the answer If I don't know or here is the answer." 

When I was a leader in healthcare compliance, I always said, "Look, everyone in this organization is our customer. They don't bow down to us, we serve them and so get to know them. What is their day like? What do they do day-to-day?" Because they don't do compliance day-to-day, right? They're doing. All the important things in patient care and we just get a little bit of sliver to kind of communicate and you kind of have to have your elevator version of these are the most important things. One thing that I always focused on was not having them drink from the fire hose on that first day of work.   

Isabelle: Right!  

CJ:  And I'd be like, "Don't read them all these laws and this and that." The one thing that I wanted them to take away was– How they can reach me when they have a question. Because they may not remember all this stuff a year from now, but they need to know and understand that there is a compliance program, they're there to help answer questions, and if you have concerns, maybe you're seeing something that's non-compliant or potentially, you might not know the whole story, you're just seeing the tip of the iceberg, but in a speak-up culture, you should feel comfortable in reaching out to somebody, even if like there's some hesitancy, because a supervisor or coworker and "can you reach out anonymously?" You just want the right thing done, you're not trying to get people in trouble. And that was like one of the main messages that I always wanted to get across was kind of that hotline or communication channel if you will.   

Isabelle: Yes, I would wholeheartedly agree. One suggestion I do have and this was done by one of the not-for-profits that I worked with, they did an annual survey because remember there's turnover, especially in nursing, lots of turnovers. So, they did an annual survey of people's compliance knowledge and it was just ten questions. I can't even tell you what the questions were because I don't remember that far back, but I remember the survey because the chief compliance officer wanted to level set where they were every year, and then that was part of the facility strategic plan. I thought that was very forward-thinking.   

CJ: That's such a great insight. Thank you for sharing that. That's the kind of stuff that I really am appreciating hearing from you because you have this unique perspective and as compliance professionals, we need to hear from others outside of our bubble, right? And how can we make it better? So, thank you.  

Isabelle: Right, if you're not on the strategic plan, you should be.   

CJ: Yeah, right, absolutely. That's just great advice. Let me ask you too about kind of this concept of speak-up culture. I occasionally lecture in a master's degree program at my alma mater, the medical school where I went in, it's a patient safety leadership master’s degree program and we have a lot of nurses in there, we have physicians just working on a master’s towards patient safety leadership and we often talk about this speak up culture and making it safe. What are your thoughts on developing that kind of culture? I know we need to do it, like, for patient safety, right? And for quality improvement. I think it's pretty rare to feel safe to speak up for patient safety, but then you don't feel safe for speaking up on a potential compliance issue, like to me it's like the culture is either safe or not safe, or it's developing. Any thoughts on that? I'm sure you've seen that over the years.   

Isabelle: I have and again I'm at the risk of repeating myself. I'm going to go back to what I said about relationships. If all of a sudden, we're putting this program together, that's a wonderful compliance program and it's got great elements, but the foundation of the relationship between staff, the compliance department, and executive leadership is not great, I think again, you've got another hill to climb, if not a mountain before true speak-up, true transparency and true compliance conversations are actually had.   

CJ: I agree with you. I've seen programs that look great on paper. When I do consulting, I go in and I will like to assess the compliance program with a fresh set of eyes, right? Somebody from outside the organization and a lot of people are so proud, "look all our policies. All our paper and look at all this stuff" and then I just ask frontline employees how they feel about the culture, so I just ask a few or we'll do a little survey and it's like a totally different story, right? So, I love what you shared because it's like, no matter how many elements and pieces of the program you have in place if there's not that underlying culture... 

Isabelle:  Your best resource for this, I'll be transparent with you, is when you go into an organization to ask to see their employee engagement and employee satisfaction scores, the survey that they take at least every one to two years depending on the organization, ask what those latest scores were and where they not just compared to like organizations within their structure but nationally and that will give you a very good idea about what you're starting out with and the hurdles that you have to overcome.   

CJ: That's great advice because it's a practical thing to do. And if they say," Well, we don't have one," that tells you something too, right?   

Isabelle: Exactly yes, if they're not serving their folks and we're talking about a compliance program, we have a very shaky foundation, to begin with.   

CJ: Well Isabelle, we're getting towards the end of our time, it has been such a pleasure talking to you. I want to give you a moment if you have any last-minute thoughts. Here you get the stage, you get to tell us compliance professionals; how can we do better? what do you appreciate about it or anything? If you have any last-minute thoughts we would love to hear some of your last comments here.   

Isabelle: I appreciate the interaction with that particular officer and the department, and again, when it can be in a proactive situation, rather than a reactive situation, it's always a little more meaningful. It also helps the nurse executive, and the physician executive understands what information you will need when things do happen, so there can be that level of efficiency, but that also that level of transparency in order to make sure that when something does happen that we're both on the same page and presenting a united front, that is very, very important to not have a tenor of working against each other, but certainly working with each other as a healthcare industry, things have gotten a lot better. So, you know applause on both ends, and I look forward to that even getting better than it is.   

CJ: Well, Isabelle, thank you so much. First of all, for your years of experience and then your willingness to share your expertise and perspectives. It's so valuable to me personally and I think to our listeners. So, thank you so much for joining us today.   

Isabelle: Thank you and you're welcome.   

CJ: Well, everybody, thank you for listening to another episode of Compliance Conversations. Again, we encourage you to subscribe so you don't miss future episodes, please share this amongst your friends and you can also comment and give us ideas if there are topics that you'd like to hear about, or if there are guests that you think we should be interviewing, please share that with us.  
Thanks, everybody. Have a great day.