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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.

mailto:[email protected]

mailto:[email protected]

mailto:[email protected]

mailto:[email protected]

Journal of Health Care Compliance — November–December 202028

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.

Journal of Health Care Compliance — November–December 2020 29

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 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.).

Journal of Health Care Compliance — November–December 202030

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

Journal of Health Care Compliance — November–December 2020 31

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

Journal of Health Care Compliance — November–December 202032

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.

www

healthypeople.gov/2020/topics-objectives/topic/socia

healthypeople.gov/2020/topics-objectives/topic/socia

l-determinants-of-health#one

https://solutions.complianceline.com/2020-compliance-benchmark-report

https://solutions.complianceline.com/2020-compliance-benchmark-report

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