Blog Post

Evidencing a Culture of Compliance

Richard P. Kusserow | May 2021

Key Points:

  • DOJ Guidelines stress importance of evidencing a culture of compliance.
  • Survey finds only 30% of organizations have independent supporting evidence.

The 2020 Department of Justice (DOJ) Evaluation of Corporate Compliance Programs raises many questions related to the ability of organizations to demonstrate a culture of compliance. This guidance for DOJ prosecutors stresses that “beyond compliance structures, policies, and procedures, it is important for an organization to create and foster a culture of ethics and compliance with the law at all levels of the company.” (Emphasis added.) Prosecutors are advised that “the effectiveness of a compliance program requires a high-level commitment by company leadership to implement a culture of compliance from the middle and the top.” 

The challenge for compliance officers is to develop and implement credible evidence of a culture of compliance that addresses questions inferred from the DOJ guidance, such as the following:

  • What policies and procedures have been implemented that incorporate a culture of compliance in day-to-day operations? 
  • What evidence is there that the board of directors and executive leadership are committed to implementing a culture of compliance? 
  • How has a culture of ethics and compliance been promoted at all levels?

While DOJ prosecutors may consider these types of questions when determining whether an organization under scrutiny has an effective compliance program, they are not likely to view attestations or internally generated documents as credible. Also, questions about organizational culture hinge on outcomes, not process outputs. Training programs, public statements, and policy documents alone would not be satisfactory evidence of a culture of compliance.  

In response to requests from respondents to the 2020 Healthcare Compliance Benchmark National Survey, which is administered by SAI Global and Strategic Management Services, a question about how organizations demonstrate a culture of compliance was added to the 2021 survey. The responses to this question indicate that most organizations are not adequately prepared to provide independent credible evidence. Nearly 60 percent of respondents indicated they would rely upon the results of internal monitoring and auditing efforts, while only 30 percent indicated that they have an independent mechanism to provide such evidence (such as the results of an independent compliance program effectiveness evaluation or an independently administered compliance culture survey). The remaining 13 percent of respondents reported they would not be able to produce any such evidence.

To learn more about the results of the 12th annual Healthcare Compliance Benchmark National Survey, join SAI Global and Strategic Management Services for a webinar on Thursday, May 13th at 2:00 pm ET. Please register here.

For more information on this topic or the Healthcare Compliance Benchmark National Survey, contact Richard Kusserow at [email protected].

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 3,000 health care organizations and entities in developing, implementing and assessing compliance programs.

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