Compliance Archives

As a healthcare compliance officer, I have to ensure our governing board is not only informed about compliance matters but also actively engaged — even when it competes with other priorities for attention. Through years of experience, I’ve learned that successful board engagement isn’t just about what we report – it’s about how we present compliance information in a way that resonates with board members and drives meaningful action.

Board members carry significant responsibility for compliance oversight, but especially in federally-qualified health centers, many come from diverse backgrounds outside healthcare. Without clear, structured, and compelling presentations, compliance updates can become routine check-ins rather than meaningful discussions.

The effectiveness of a compliance program depends on how well compliance officers communicate essential risks, policies, and mitigation strategies to our boards. In this article, I’ll share strategies for delivering impactful reports, and explore how to present compliance information in ways that resonate with board members.

Understanding the Board’s Role in Compliance

Healthcare governing boards have fiduciary duties that include overseeing risk management, ensuring adherence to federal and state regulations, and upholding ethical standards. Regulations from agencies like the Office of Inspector General (OIG) and the Health Resources and Services Administration (HRSA) outline specific expectations. Effective board involvement requires active engagement, not just presence.

The three fundamental fiduciary duties of non-profit and profit board members are the Duty of Care, Duty of Loyalty, and Duty of Obedience. Board members must provide appropriate oversight by reviewing key reports, ensuring organizational policies are in place, and monitoring compliance with applicable regulations.

Here’s a look at how these duties relate to the board’s compliance obligation.

Duty of Care

Make informed decisions by thoroughly reviewing compliance reports and data
Actively participate in board discussions about compliance risks
Maintain a high-level understanding of how the regulatory landscape affects the organization
Request additional information when needed to make sound compliance decisions

Duty of Obedience

Put the organization’s compliance interests ahead of personal or professional interests
Maintain confidentiality of sensitive compliance information
Disclose any potential conflicts that could affect compliance oversight
Support necessary compliance measures even when they impact other priorities

Duty of Loyalty

Ensure the organization operates within applicable healthcare laws and regulations
Verify policies align with regulatory requirements and organizational mission
Monitor compliance program effectiveness through regular reporting
Support implementation of corrective actions when needed

Beyond these explicit duties, board members must understand the crucial distinction between strategic oversight and operational execution. While day-to-day compliance operations fall to management, the board’s role centers on strategic direction and risk assessment. This requires meaningful participation in discussions, thoughtful questioning of compliance reports, and maintaining a high-level understanding of the regulatory landscape.

I’ve witnessed how organizations that fail to engage their board properly risk regulatory fines, reputational damage, and operational inefficiencies. Conversely, those with engaged boards experience proactive compliance measures, mitigating risks before they escalate.

Best Practices for Engaging Your Board in Compliance

Leading compliance for multiple healthcare organizations, I’ve learned that effective board reporting means having critical data that drives meaningful dialogue, action and engagement. Compliance officers serve as the critical bridge to effective board oversight, translating regulatory information into strategic insights the board can act upon.

Only 14.6% of board members are healthcare professionals, which highlights the need for compliance officers to dissect and contextualize key data in a digestible format. Instead of assuming familiarity with technical details, I focus on dissecting and contextualizing key data, ensuring the board understands both the implications and strategic relevance.

While most organizations’ bylaws dictate specific board meeting frequencies, there is significant value in increasing the cadence of compliance-related discussions. Whether through monthly check-ins or impromptu meetings when issues arise, more frequent engagement strengthens board alignment and responsiveness, especially in a rapidly evolving regulatory environment. This is particularly important given that 61% of healthcare boards do not have a continuing education requirement for their members. Without regular touch points, board members may struggle to stay current on complex compliance landscapes and evolving regulatory expectations, leading to gaps in oversight. Consistent engagement not only reinforces accountability but also ensures the board remains equipped to make informed decisions, even as regulations shift.

Selective reporting is equally important. While we track numerous compliance metrics, I focus board reports on critical issues that require strategic oversight — such as significant program updates, emerging risks, and culture indicators. Overloading board members with excessive details can hinder engagement and obscure key messages.

Using Dashboards to Make Compliance Data Accessible

Data visualization has changed how we communicate compliance to boards. Dashboards allow us to present complex data in a way that’s easy to digest, helping board members quickly grasp key trends and risks. Effective dashboards don’t just display numbers — they tell a story. By organizing data visually, we make it easier for board members to see how our compliance efforts impact the organization.

This is incredibly challenging without electronic data in one tool, available in real time. In fact, when I shared this information on a MedTrainer webinar, 51% of poll respondents said it is very difficult, even overwhelming, to access needed compliance data. With the right system in place, it’s easy to collect and analyze your data, so you can provide a well-designed dashboard, or board report, that prompts more meaningful discussions and better decision-making.

A well-designed compliance dashboard provides an overview of incident reports and emerging risks. It helps board members understand the status at a glance. But it’s important to go beyond the numbers. I always include context that explains why certain metrics matter, showing the board how the data ties into the bigger picture.

Download the presentation template and dashboard I use to report on HIPAA events, investigation timelines, and regulatory incidents.

How to Make Compliance Work for Your Board

For compliance professionals looking to improve board engagement, the key lies in refining how we communicate compliance issues. Whether through structured reporting, interactive discussions, or real-time data visualization, there are numerous ways to make compliance more meaningful for board members.

In my webinar Making Compliance Meaningful for Your Governing Board, I had the opportunity to discuss board engagement with one of my board members, Patti Hartsfield. Patti shared practical strategies for balancing strategic oversight with operational details. In the conversation, we explore how to demonstrate the true impact of compliance, what to prioritize in quarterly dashboards, and how to keep your board aligned with organizational goals.

When it comes to compliance reporting, it’s not just about what you present but how you present it. Fostering that understanding is key to turning compliance into a powerful tool for your organization’s success.

Report to your governing board with confidence using this template and presentation designed by a compliance professional.