Designing Compliance Excellence: Perspectives on People Strategy

Assembling the ideal compliance team is no small task – and that’s why it can be such a puzzle. We invited Sarah Couture, a former nurse turned compliance executive, to share her insights on structuring effective compliance teams.

Tune in to our new episode, “The Art of Building a Successful Compliance People Strategy,” as we discuss:

    • Important considerations for building a strong compliance team
    • Why compliance liaisons can boost your program’s effectiveness
    • Real-life examples of compliance staffing done right (and not so right)
    • Strategies for compliance officers to approach succession planning and mentorship


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Sarah currently serves as a Senior Managing Director at Ankura, and she is also a faculty member for the Health Care Compliance Association (HCCA). She started her career as a nurse and made the transition to compliance when she saw an opportunity to support and strengthen health care compliance. If you’d like to hear more from Sarah, you can sign up for her upcoming HCCA webinar!



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The Art of Building a Successful Compliance People Strategy - Podcast

Episode Transcript

CJ Wolf: Welcome everybody to another episode of Compliance Conversations. I am CJ Wolf with Healthicity and it's great to have everyone here listening, and I have such a wonderful guest today. Sarah Couture. Welcome, Sarah! 

Sarah Couture: Thank you, CJ! I'm glad to be here.  

CJ: I'm so grateful to have met you in prior compliance conferences and learn a little bit about your background and I'm excited about today's topic too. We're going to talk today about compliance program kind of people strategy, which is a really cool topic and Sarah has some great insights on it. But before we get there, Sarah, we love to have our guests just tell us a little bit about themselves. We all kind of end up in compliance from all these varied paths and no one kind of grows up thinking; "I'm going to be a compliance professional!" And so, anything you want to share about kind of your background or your current position, or what you're doing, we'd love to hear a little bit about you.  

Sarah: Thanks, CJ! Yeah, I did not grow up thinking I want to be a compliance professional. In fact, I'm a nurse by background. And honestly, in the majority of my nursing jobs, I'd never heard of compliance, which you know, what does that say for the job that the compliance program was doing communicating about compliance?  

CJ: Right!  

Sarah: But I've been a nurse for the last 22 years, the first ten or so of those, I was in clinical positions in faith-based free clinics as well as in Pediatrics and at outpatient and inpatient pediatrics. And then I accidentally stumbled into compliance. One of the board members of the free clinic that I was working with was a Chief Compliance officer in an academic medical center. So, had my foray there, working in the academic medical center for a couple of years, and then our family relocated, and that was at a time where we couldn't work remotely, right? That wasn't a thing prior to COVID.  

CJ: Right!  

Sarah: So, in 2015 I started in consulting when our family relocated to a spot where there was a compliance position. So, I've been in the same position since 2015. It was first with Aegis Compliance & Ethics, and then we were acquired by Ankura in 2017.  

I'm a senior managing director and I lead our compliance sector. So, really anything we do in the provider compliance space, I help lead that strategy and in marketing and conversations, I'm privileged to get to work with a lot of great, great people at Ankura as well as with clients in physician practice groups, hospitals, health systems, academic medical centers, and labs. Really anyone who's providing any sort of healthcare would be kind of our client base.  

And I'm also faculty for the Healthcare Compliance Association Research Academy and also the Compliance Essentials Workshop, which is the new-ish virtual workshop, and we do it each quarter that was birthed out of COVID, but has really continued to stay an important part of HCCA's teaching mission.  

CJ: Yeah, that's so great! And I think we met years ago we were both sitting for one of the various certifications.  

Sarah: Yes, we were in line, CJ, waiting to take the CHRC, both hoping we would pass since we knew it was hard and I think we both passed on the first try.  

CJ: We did and so, that's for those of you who don't know, that's the research compliance. I know Sarah has some good experience there and I have some experience, you know, from the academic medical side too. And so, it's great to have you. Thank you for introducing yourself and thanks for being here today.  

You know, we want to talk a little bit about the compliance people strategy and I'm sure you know, you working with all your clients across the country, you see a lot of variety and how compliance programs are kind of designed where people have weaknesses and gaps where they're strong. And so, I think you're the perfect guest for this topic.  

So maybe we just jump in kind of at a general level and you can kind of just. Maybe share your thoughts from a general philosophy standpoint on compliance program people and staffing strategy, if you have some thoughts there.  

Sarah: Yeah, for sure. I tend to approach compliance programs in a lot of ways from the people's perspective. Maybe that's driven by my personality. Maybe that's because of the nursing background, but I really feel like in so many ways, the success of a compliance program can really thrive or fail on the people. You probably have an example, CJ, where you have seen that.  

So, I do think it's really important for leaders who are identifying the Chief Compliance Officer and the Chief Compliance Officer working to build a team, to not take that lightly. It's very important to think about the kind of people, and their backgrounds that we're hiring as well as once we have them hired, how do we structure them? How do we keep them on the front edge of their game?  

I really think the first key, CJ, is to make sure you have diversity in your group, and I mean that from a lot of different ways, right? Diversity of professional backgrounds, you and I come from different angles and that's important. You mentioned how none of us grew up thinking we want to be a compliance officer. And I think because of that, we all have different professional backgrounds. We are auditors, we are attorneys, we are clinicians, and we come from an operations background. We come from a research background. We come from an HIM background. And that really has contributed to the beauty of our profession, and I really think that right there is the number one staffing strategy that I would recommend, making sure that the people we bring on our team bring that diversity of their expertise, diversity of experiences.  

Also, certainly diversity of personality. We don't all, right? We don't want to have a bunch of cookie-cutter people, because we're interacting with so many different stakeholders, so many different risk areas. It's really important just to have a really nice blend of people.  

CJ: I can't agree more with that. I was working with a client myself in the New York City area and we were helping them kind of craft a compliance program people strategy kind of like you're talking about and we were looking exactly what you said, diversity background.  

So, you know, they were a hospital system, they had nursing homes, they had clinics. And so, it's like we want people, you want somebody with maybe some big background in maybe privacy and data security. You want somebody maybe with some background in revenue cycle billing coding compliance. Somebody with kind of a legal background, maybe somebody with data analytic experience. And so, I think you're spot on is kind of that diversity of skill set is a really important factor.  

Sarah: And CJ, as you were talking, you can almost say you need a staff according to your risk assessment, right?  

CJ: Right!  

Sarah: I mean, everything comes back to the compliance risk assessment, but even in our staffing, because we have such a diverse set of risks, we've got to have diverse expertise at the table. If we, you know, if we can, now we're a one or two-person compliance program. We're going to be working with a diverse group of operational partners to help us do what we need to do. 

CJ: Then you put the diversity like on the compliance committee or something, right? Like if you're for a one or two-person shop you're like; "Let's get some people with expertise in these different areas, finance and maybe IT and research," all these different things.  

Sarah: And I think once you have, in my mind, it's about bringing in the right people with that diversity of skills and goals, personalities, and backgrounds to essentially meet your diverse risk profile.  

And then I think the second part of strategy is how do you organize them? As you can imagine, you know, we do a lot of compliance program effectiveness assessments. So, it's a good idea every two or three years to bring in someone from the outside, so you get an objective perspective on; "We think we're effective. Are we as effective as we think we are? Where are our blind spots that we're not seeing so we can address them to continue pursuing effectiveness?"  

So, we see, you know, obviously I've lots of lots of great examples, lots of interesting stories from doing that for so many years with dozens and dozens of healthcare organizations, but I don't know that I would say there's a right or wrong way on this one, CJ, when it comes to how to organize your staff, I have seen compliance programs organize their staff according to the seven elements. So, they may have people that do policies, people that do education, people that do auditing, people that do investigations. And that I think works very well if you have a large compliance program and a large organization, I've seen others that organized by risk area. So, a 340B person, a research person, an ambulatory person, a hospital person, a physician practice person.  

So, again, I don't know if there's a right or wrong way on that one. I think it really needs to be; "What's going to be the best approach in your organization with the people you have?"  

CJ: Yeah! And that kind of brings out the creative juices of the compliance leadership too. It's like you get to create, that's to me because I've been in that role before and it's kind of fun to put together, a team over a period of time that complements the needs, the culture of the organization, and all that, it's so fun.  

Sarah: Absolutely! I mean a compliance program needs to be tailored to the size, complexity, and risk profile of the organization. So, we need to do that with our staffing strategy as well, needs to be tailored.  

I'm with you, CJ, I think it is fun. Honestly, the fact that in compliance, we healthcare compliance, we have the seven elements and we have generally a similar risk profile across organizations. But the way that compliance programs get to be built, we get to paint in beautiful colors to make something work specifically for that organization for the full, for their culture, for what works for their context, for their patients. And I'm with you, I think that's really the most exciting part of our profession.  

CJ: Yeah, like for example, just to kind of bring that home. So, I worked at a large Cancer Center, huge research profile, right? And a huge portfolio for research and so and they were preeminent researchers in the cancer field. And so, research compliance was huge, and then in another very large healthcare organization I worked in, that had like 80,000 employees, they were a community-based not-for-profit kind of system. Yes, they did some research and yes, we had research compliance, but it wasn't, you know, 50% of their portfolio, right? And so, it's just a slight tweak or a slight different spin, depending on the focus areas of the mission of the organization.  

Sarah: Absolutely! Another, I think, staffing strategy that I don't see get a ton of traction, but if it's okay, CJ, I'm going to go ahead and plug an HCCA webinar on September 7 that I'm doing with one of my industry friends named Joe Zelinsky, who's in the skilled nursing space. We just wrote an article in the March 2023 Compliance Today on using compliance liaisons and as you're probably aware, it's a requirement in the skilled nursing space for if you have five or more facilities. Really, it's such a great solution for organizations that have multiple locations, how do you wrap your mind around, really getting the tentacles of the compliance program out into the field and empowering and partnering with operational partners. 

So, I think that's an exciting one, CJ, that a lot of folks maybe haven't tapped into or thought about. So that webinar on 9/7 we're going to look at what the skilled nursing requirement is, but really the application and we're going to make the application that it's a great way to ensure compliance program effectiveness and really increase your reach and your touch to your locations.  

CJ: Yeah, that's perfect. I'm glad you raised that and people can watch that and listen to that as well. So, let me ask you kind of moving along a little bit. How have you seen compliance programs get this whole people strategy wrong and how have you seen them excel? if there are some differences.  

Sarah: Yeah, absolutely. Like we were talking about doing compliance program effectiveness assessments. I get to see a lot of ways that people put things together really well or ways that could be tweaked so that they could be more effective. I think the biggest, I don't know. I mean getting, saying, getting it wrong maybe is strong, but I think one of the big challenges that I see is when a compliance program doesn't have that diversity, so I'll give you a couple of examples.  

And interestingly, the three examples that I'm thinking of, the Chief Compliance Officer was one profession and then staffed the whole roster with the same background so.  

CJ: Ah! Yep, Yep!  

Sarah: Let's say you're a JD, you hire eight JDs and like, it just didn't work. I mean, they got some things done, but they were not touching the rest areas that they needed to. They didn't have the buy-in and some of the areas, like it was just very flat, just one-dimensional.  

CJ: Right!  

Sarah: I've seen the same thing where the Chief Compliance Officer was an RHIA, 80% of the staff are RHIAs. Again, same thing it's just not meeting the risk need. It's not tied to the risk assessment. There's not enough diversity of backgrounds and expertise.  

I've seen the same thing, but in this organization, the Chief Compliance Officer had an internal audit background. Let me tell you they did a lot of auditing! But some of the other elements were lacking and they were not in all the risk areas because there were just a lot of auditors.  

Again, I'm not dissing auditors or lawyers or RHAs, right? Like if you as an MD or me as an RN did the same thing where we just stacked the deck with people just like us, we would have the same criticism.  

CJ: Exactly!  

Sarah: So, I really think that's the best way to get it wrong quickly.  

CJ: Yeah, I agree. And kind of like how we began, you know, people have different strengths and you know, I was in one organization where we had to your point about the element design, somebody who was just over education. So, they had a background in designing good training and you know they might not be a subject matter expert in every compliance topic, but they're experts in designing effective training.  

And so, you know, you work as a team, like it who you know, no one ever really works in a silo anymore, at least they shouldn't be. And so, you're pulling on different people's strengths as you're developing training for example, but like you said same thing for policies and same things for investigations in this other organization I worked at, we had one person, this was a large compliance program, but we had one full-time person who all she did was investigations of you know really sensitive nature. Because she had a background in investigating and there's a real skill set there, in learning how to ask questions, how to not put people off, how to find the right information.  

Sarah: Well, CJ, you know, not to go too far down that rabbit trail, but I think that's a great example of the importance of hiring people with the right skill set for something that's like very, very important. If you look at both the OIG HCCA compliance program, effectiveness guidance as well as the ever-evolving DOJ evaluation of corporate compliance programs. They both look at the qualifications of the investigator and how well the investigation was done and I see a lot of compliance programs where maybe they don't have the ability to hire a full-time investigator. Okay, great. But make sure that people doing it have had the training bring in training, send them to a training, because it's not something you want to get wrong.  

CJ: Exactly! This is so fascinating. We are going to take a quick break, though, and then we'll come back and talk some more about kind of this compliance people strategy. So be back in a moment everyone.  

Welcome back, everybody! We are talking about compliance people strategy and our guest Sarah, if we could maybe now talk a little bit about benchmarking and tools. And I've used the HCCA compliance staffing and budget benchmark surveys and those results a lot. How have you used it or how have you seen other people use that kind of data to help with the people strategy?  

Sarah: First thing, I'm just so thankful that HCCA does that budget and benchmarking survey, as you know, CJ, we do not have enough benchmarking from a healthcare compliance perspective, so kudos to HCCA, thank you for what you're doing!  

I did look to make sure I had the most recent version date. For those of you who haven't seen it, there is a new 2023 budget and benchmarking survey put out by HCCA. They actually published it in January. And there's nowhere else where you can really get, as you know, CJ, but maybe your listeners do not, HCCA categorizes according to employee count as well as total revenue. So, it helps you gauge your own compliance program size and budget based on how many employees are in the organization and total revenues. So, very helpful for those organizations who are like; "Gosh, I just feel like we may not have enough staff." It's a good kind of gut check, CJ.  

CJ: Exactly!  

Sarah: And also because it's a benchmark and it's objective, it's really helpful to present to your leadership and your board and say; "you know, Department of Justice understands, like those who are the regulators know these benchmarks exist. We are woefully short here." Like it may help someone make the case for getting more staffing or getting more budget. 

CJ: Exactly!  

Sarah: Yep, you know one limitation, which I'm sure you've experienced in your consulting and in-house work, it doesn't have any other specifics to the organization, right? So, it doesn't take into account like; "How the organization is organized?" It doesn't take into account really what space they are in, It's just healthcare. So, what kind of organization is it? What are their risks?  

So just like where we started, where everything comes back to the risk assessment, really think the most effective way to use the staffing and budget benchmarks is to tie those to your risk assessment. And really think about; "All right, based on our size, looking at peers, this is where we land," but you may need more or less people or more or less budget than what that looks like based on your risk profile at your organization. 

CJ: So again, one client I worked with, they were a safety net hospital system. And so, they wanted when I was using this benchmarking data, you know they wanted to know; "Well, how many of these are safety net hospitals?" You know, cause safety net hospitals traditionally don't have funding, they're always, you know, clamoring for donations, and this and that. So, they're a little less stable type of financial environment sometimes. So, to your point about missing some of that kind of drill-down data, but you know that the data that we have it's good.  

One other thing I would say too is our sponsor for the podcast Healthicity, they do a survey every year and it's growing and growing every year. We're in the midst of doing it right now. And so those of you that are interested, that survey focuses on kind of two pieces; compliance professionals, and I think last year we had close to a thousand respondents, and then also; Auditing and specifically kind of coding and billing. And so those are the two main arms. So, people can also look for that in the upcoming months.  

But I'm with you, those benchmarking criteria are so important, especially because the boards ask for that when they're approving budgets. And like you said though, it's a good gut check, it's not an exact science, but if you're like on the lowest end of that, that spectrum, right? And for your size and revenue, you know, let's say the lower 25% have you know 4 FTEs and you have one, and that's the lower 25% and the upper 25%, right might have 15. You know you're kind of off.  

Sarah: Right! Yeah, absolutely. It's almost like a gut check. Yeah, I agree.  

CJ: Well, awesome. So, let's talk a little bit about people's investment, right? You mentioned a little bit about that at the very beginning. What should people's investment look like in a compliance program?  

Sarah: So obviously it's very pragmatic and it's common sense, right? We want to invest in our people so they can be excellent. But I also want to point out, again I always go back to government guidance, when we're talking about what a compliance program should be and how do we know if it's effective starting with those foundational documents, but both OIG and DOJ talk about that, are we investing in our people? Because it sends a message so much about what we do in our compliance programs, sends a message about our organization's commitments that compliance.  

So, if there's zero budget for our people to get certifications, to get continuing education, to go to conferences, to stay on that front end. Think about the message that sends about the importance of compliance. Go ahead ...  

CJ: Go ahead, finish your thought.  

Sarah: Sure! So, I think you know right there from a compliance program effectiveness perspective prioritize that because it sends a message. And then from the pragmatic side, we want our people to stay on the cutting edge. I mean, as we both know, CJ, the regulatory landscape sometimes changes every day. Sometimes there are slower months than others. But we need people to stay on the front edge.  

Some of your listeners may also attend the Ankura Compliance Round-up. We've been doing it every month for like 15 years. So, I'm happy, and maybe CJ, when we send out the notes, happy to share the link to that. It's a free one-hour webinar we do once a month and we called the Round-up because we round up everything that happened over the last month that we feel like is important from enforcement actions to CMS updates to OIG work plan updates.  

So, finding ways to stay current, you know tons of listservs from all of these government agencies, they can send you to your inbox the information that you need to know each day, obviously you know some vendors put out things like we do. HCCA puts out publications. So, you had a plan to stay in front of the curve. And I think with that plan, document it. Everything needs to be documented, so you have an SOP for this and that and your compliance program. Document your staff investment plan. This is what we do to stay on the front edge. This is how we require certifications. We require continuing education etcetera. Write it down and then document completion because that evidences that commitment over time.  

CJ: And you know, I think a perfect example of what you said, is some regs are stable, right? Like Anti-kickback statute really hasn't changed that much over the years, but you know a couple of years ago OIG highlighted speaker programs, right? and they're concerned about physicians and clinicians doing speaker programs for industry, pharma, and med tech.  

So, those types of things, to your point of staying, you know, people investment of keeping them on top of their game. Another example is obviously COVID, right? When COVID was rolling out, I had a compliance colleague who was pretty forward-looking and said; "You know, they're starting to loosen the regs a little bit and give some leeway, but that's letting the horses out of the barn! Those horses are going to have to be gathered in someday," and we all know that in May the PHE ended. And so, what regs are back to normal? We know, like, for example, telehealth had some things pulled back, but Congress passed some laws that allowed for some relaxation and some new pathways for telehealth. But that is I think, an example of, your point of investing in people and making sure people are aware of what has changed, what's the current thing. And I love your roundup idea because I'm sure you probably talked about those types of you know real-time types of changes in priorities.  

Sarah: Absolutely! We spent a good amount of time on ramping up on the PhD flexibilities and then ramping back, right?  

CJ: Exactly! 

Sarah: Yes, exactly. We had a whole, I mean our July edition, it was an extended amount of time on telehealth and you know have those flexibilities like you mentioned, many of them have been extended through December of 24 but many of those flexibilities around you know other items ended May 11th. So yes, gosh, COVID is the best example ever of you've got to stay on the front end and have your eyes open. And again, that ties back to your risk assessment, right? Because your risks are ever-changing based on the regulatory landscape ever-changing.  

CJ: One thing we do, I kind of try to summarize the OIG work plan additions every month and Healthicity puts out a little E-brief just kind of summarize those. And then the other thing I would point out is I think you were probably there in Anaheim in April with HCCA's compliance institute. And the Inspector General, Christie Grimm, spoke about two very important priorities for OIG, one being nursing homes moving forward, and the second being Medicare Advantage, and HCC and risk adjustment coding. And so, it's just kind of you know that's been around for a while, but now they're ramping up on the scrutiny of those areas. So, it's kind of like you said, staying in the know that's a good investment in people.  

Sarah: Absolutely! 

CJ: We are getting a little bit close to our end here, but I want to ask one more question and then maybe we can also if you have any parting thoughts, how should compliance officers approach mentoring and succession plan? Such important topics for people strategy.  

Sarah: CJ, when I think about it, neither of us nor really anybody listening to this podcast would be where we were, where we are if others hadn't poured into us. And maybe that wasn't even intentional, right? If I look back on my 22-year career here as a 44-year-old since nursing school, the people who have had an influence on me, whether they meant to right or not, some very much did they were very intentional, others just the way that they led the way that they spoke, the way that they strategized and carried themselves, I learned from that. And they were investing in me by their example. So, how can we not do the same, right?  

CJ: Right!  

Sarah: The people that we work with, whether that is someone that is in our organization, whether that is a client, or whether that's just someone in our network, I think we all have an obligation to essentially carry it forward. People have invested in us, let's do the same for them. And you know, sometimes I think that people don't think they have a whole lot to offer. But if you, if they've ever talked to someone who's 20 years behind them. Very obvious, right? 

CJ: Yeah! It's so spot-on like I remember my first, you know, I came from a clinical background. Like I left the physician world, like who does that, who goes to medical school and then leaves? But I had this mentor who taught me, beginning my career was in coding and billing and teaching physicians about those types of fun rules that they just love to hear about, but that person mentored me and then I got to the point where I kind of had kind of mastered a lot of that body of knowledge and I wanted the next thing and there was somebody there to help me and then kind of mid-career, I was like; I would hire people, and you kind of mentioned this at the beginning about personalities, I can almost train people in any subject matter, but I can't train their certain personality and ethics, you know, that's something mom and dad should have done since the time you born. 

And so, it's like I would often hire people off of personality. Of course, if they have the experience as well, awesome! But if not, I almost favored that personality, and then I could train them in the technicalities of it, and so that mentoring piece, I think kind of fits into that as well.  

Sarah: And I think something to think about, you know, for those who may be interested in mentoring, I think there are, it's almost like a spectrum, right? Where there's like the very intentional mentoring relationship and these are the parameters that we're going to put about around it. And this is how often we're going to meet, for how long, and we're going to talk about the other end of the spectrum is I view, you know, the person doesn't really know they're mentoring me. It's just the way that they act and then everything in between.  

I feel like most of my mentoring relationships are probably somewhere in between where it's someone that I know and you know and I've asked, "Hey, this is something I need help it with. Can you thought partner with me? Do you mind if I reach out to you about X? This is something I'm struggling with."  

So somewhere in between where it's kind of organic, but you know you're asking for it as well. So, I think people need to kind of figure out where on that spectrum they're comfortable and then figure out how can we give back. You know, CJ as we know well, the first generation of healthcare compliance professionals have either retired or they're close to retiring.  

CJ: Exactly! 

Sarah: It's a whole new day there, you know, you mentioned we all come from a different background where we landed in compliance, but now there are 18-year-olds who want to go into compliance and there are compliance bachelor's programs and masters programs like that's a thing. So, tremendous opportunity for us to invest in others and I think it's really for the good of our profession. Our profession will evolve, continue to evolve, but let's do that hand in hand with others.  

CJ: Yeah, spot on. Well, Sarah, we could, we could talk all day. I feel like I could talk to you all day, you've got so much knowledge and so much experience. Thank you so much for sharing! Do you have any last-minute thoughts? And if not, that's fine but kind of give you the last word here. If you have any.  

Sarah: No, just really appreciate the opportunity, CJ. I'll hope that we can join again some other time on another topic, but you know compliance people strategy like you said in the beginning, it's not something we talk about all the time. It's really important, it's foundational. If you can get these things right, you're well on your way to having the right kind of compliance program. So again, just thanks for the opportunity, enjoyed the conversation.  

CJ: Thank you so much, Sarah! And I think you're right. It's like if you get these things right, a lot of your life goes easier in your profession. If you get them wrong, a lot of things are more challenging, but they're just a little bit more subtle. And if we're intentional about it, I think there'll be benefits.  

Sarah: Yep, absolutely!  

CJ: Thank you so much, Sarah! And thank you to all of our listeners. If you enjoy these podcasts, please subscribe and share with friends and colleagues. And we are always open to hearing about the topics you'd like to hear more about. Also, if you have speakers or potential guests that you think would make good guests on certain topics, please let us know, we'd like to make these podcasts better for everyone. And thank you all so much for listening! Until next time, have a great day!


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