This document discusses the anatomy and essential parts of an ethics and compliance program. It describes ethics and compliance as the head, brain, heart, lungs, muscles, blood, and skeletal structure of an organization. It emphasizes the importance of executive leadership, education and training, policies and procedures, and management oversight ("walking around") in creating a living culture of ethical compliance. The document also discusses metrics and goals for evaluating and continually improving an ethics program.

1. Anatomy of a
Body of Ethics
Compliance and
Requirements

2. Ethics is part of Compliance and
Compliance is Part of ERM

3. The Heart of Ethics and
Compliance
Creating a “living”
culture of ethical
compliance in
which doing the
right thing, the
right way, all the
time, everywhere,
is the norm and in
which we take
tests to monitor
our ethics health.

4. Essential Parts of A Body of
Ethics and Compliance
 Head (Executive Leadership)
 Brain, Heart, and Lungs (The
sustaining mechanisms,
confidential disclosure; non-
retaliation)
 Muscles and Blood (education
and training)
 Skeletal Structure (the
regulatory, compliance,
monitoring and auditing
components; prevention and
detection; policies, procedures,
practices)
 Feet (“Management by Walking
Around”)

5. “Living” Means Different Things In
Different Contexts
"Look! It's moving. It's alive. It's alive... It's
alive, it's moving, it's alive, it's alive, it's alive,
it's alive, IT'S ALIVE!"
Dr. Henry Frankenstein, Frankenstein (1931)

6. Ethics and Compliance:
The Story of Four People
• This is the story of four people.
Everybody, Somebody, Anybody, and
Nobody. There was an important job to be
done and Everybody was sure that
Somebody would do it. Anybody could
have done it but Nobody did it. Somebody
got angry because it was Everybody's job.
Everybody thought that Somebody would
do it. But Nobody asked Anybody. It ended
up that the job wasn't done and
Everybody blamed Somebody, when
actually Nobody asked Anybody.

7. Leadership In Ethics
Compliance
• “Leadership begins when you decide to shape your
environment rather than letting it shape you.”—Earl
G. Graves, Sr., Black Enterprise, August, 2010.
• “To Lead Is To Measurably Help Others To
Succeed”
• “Managing winds up being the allocation of
resources against tasks. Leadership focuses on
people. My Definition of a leader is someone who
helps people succeed.”
• “You must be the change you wish to see in the
world.”--Gandhi
The Rules of Business: 55 Essential Ideas to Help Smart People and Organizations Perform At Their Best,
at 1 and Tom Peters, The Little BIG Things: 163 Ways To Pursue Excellence, at 146.

8. Eight Characteristics Of A “Living” Ethics and
Compliance Program
• Is part of the institutional culture of values based integrity.
• Is celebrated by examples.
• Is interactively engaging, enlightening, educational, edifying,
enjoyable, and empowering.
• Is enforced, is marked by transparency and disclosure.,
and is grounded in what is right, fair, and good.
• Is thoroughly documented
• Is visible (e.g. on websites, annual reports, etc.) and
celebrated.
• Principles are promoted, Goals are S.M.A.R.T, roles are clear,
expectations are set, and there is both responsibility and
accountability.
• Leading and lagging metrics are identified, monitored, and
preventive action is taken. New measures, such as converting
percentage of ethics and compliance DNKs to NIKs, are
considered.

9. Organizational Culture And
Ethics
Charles Harrington, Chairman and CEO, Parsons
“A major league baseball team is playing its last regular season game
of the year: win this game and they advance to the play-offs; lose,
and they watch the play-offs on TV. In the bottom of the 9th, one of its
star players steps to the plate, the score tied, a man on first, no outs.
The right thing for him to do is to lay down a sacrifice bunt to move
the runner into scoring position. This player happens to have an
incentive clause in his contract, however, that would be triggered if he
gets one more hit for the season, and that incentive clause would
bring him a big bonus and a contract extension. The player lays down
the sacrifice bunt, and his team goes on to win the game and
advance to the post season. After the game, a reporter who was
aware of what was at stake for that star player in his last at-bat asked
the team’s manager how he convinced the player “to do what was
right.” The manager replied, “We try to create an atmosphere here
where the question doesn’t even arise.”

10. Two Truths Common to Sports, Medicine,
Ethics and Compliance
• If you monitor and
measure what’s
important, you can
manage improvement.
• “You can observe a lot
just by watching.”
—Yogi Berra, former New
York Yankees catcher
and sage
• .
10

11. Some Characteristics of A “Dead”
Ethics and Compliance Program
• It is not visible.
• Principles are not promoted.
• Goals are not S.M.A.R.T.
• Roles are unclear.
• Expectations are set and communicated.
• There is no responsibility.
• There is no accountability.
• It is perceived as being “impossible” to live
with.
• It is perceived as being impossible to manage.

12. Some Rules To Remember
RULE: The Ethics Compliance Program is
the result of a team effort.
• Together
• Everyone
• Achieves
• More

13. Some Rules To Remember
RULE: In ethics, preventing a violation from
occurring is preferable to remedying a
violation after it has occurred.
From The Hippocratic
Oath, Modern Version:
“I will prevent disease
Whenever I can, for
Prevention is preferable
to cure.

14. Some Rules To Remember
Regardless of what
you job is or what
you wear while
working, in ethics and
compliance everyone
has a secret identity
and can become a
super hero or shero
by exercising two
super powers:
(1)The power of
voice to say “No”;
and
(2) The power of
choice.
ADM FLLA
VOICE CHOICE

15. ETHICS AND COMPLIANCE
MANAGEMENT
• The Challenge of
Time
• The Challenge of
Hear No, See No,
Speak No

16. ETIOLOGY OF ETHICS AND
COMPLIANCE DISEASE
• “The word ‘etiology’ is mainly used in medicine,
where it is the science that deals with the
causes or origin of disease, the factors which
produce or predispose toward a certain disease
or disorder.
• Today in medicine one hears (or reads) that "the
etiology is unknown." Translation -- we don't
know the cause.
• Aetiology is the preferred spelling in some
countries, including the UK, whereas ‘etiology’
without an ‘a’ has taken over in the US. The
word comes from the Greek ‘aitia’, cause +
‘logos’, discourse.”
http://www.medterms.com/script/main/art.asp?articlekey=3334

17. Four Reasons “Why some people
tolerate wrongdoing even when they
recognize it.”
• “Ignorance of the protections that exist for those
who report wrongdoing.” William F. Owen, Jr. MD, President, UMDNJ
• “Indifference to the positive changes that occur
when ethical behavior is the standard.” William F. Owen, Jr.
MD, President, UMDNJ
• “Inertia”, e.g. complacency to wrongdoing to the
extent that inactivity has become the norm.” William F.
Owen, Jr. MD, President, UMDNJ
• “Insignificance”, “I’m so far down in the
organization, what I do or do not do can not make
a difference to anyone or anything.

18. A Treatment Plan For Ethics And
Compliance Disease
Five Stages Disease Symptoms
Disease
Presenting
Problem As
Disease Treatment
Plan and
Objective
Precondition Ignorance
"No one every told
me" Education
1st Stage
Indifference/
Insignificance
"It makes no
difference what I
do."
2nd Stage Inertia
"See no, speak no,
hear no". TBD
3rd Stage Irresponsibility
"Somebody else is
responsible for
ethics, not me." TBD
End Stage Intransigence
"I don't care, will
not change, and
will not comply" Removal

19. The Challenge of Time
• When confronted with allegations of
unethical or illegal conduct by a
company, agency, department, or its
employees or agents, employers are
legally obligated to promptly
investigate those allegations.

20. The Challenge of Hear No, See No, and Speak No
• It is sometimes the case that when I introduce myself as an Ethics
Compliance Officer, the reaction I get is captured in the preceding slide.
People have a tendency to want to say to you, “I didn’t see anything, I didn’t
hear anything, and I am not going to say anything.” But the reaction of the
humans shown in that slide is as unintelligent as the reaction of the
monkeys.
• The only difference is that when it comes to Ethics Compliance matters, the
Hear No, See No, and Speak No will not save an individual or the agency
or enterprise for which he or she works. Persons have a duty to cooperate
with the Ethics Compliance Officer when the Ethics Compliance Officer is
conducting an investigation. A person who refuses to cooperate is subject
to disciplinary action.
• And perhaps most dangerous of all, should a workplace situation get into
litigation, some of the key questions are going to be who knew what, when,
and what did they see, say, or hear. And if an employee is called to the
witness stand, his/her hands will not be over his/her mouth, ears, or eyes.
One of those hands will be raised in the air, the other will be over a holy
book, and both ears will be hearing the words “Do you solemnly swear to
tell the truth, the whole truth, and nothing but the truth!”

21. A Common Reason That Goals Aren’tA Common Reason That Goals Aren’t
Accomplished Is That They Are Not ClearlyAccomplished Is That They Are Not Clearly
Defined. If Employees Don’t Understand TheirDefined. If Employees Don’t Understand Their
Company’s Ethics Goals and Its Game Plan,Company’s Ethics Goals and Its Game Plan,
These Goals Won’t Be Achieved. Plenty ofThese Goals Won’t Be Achieved. Plenty of
Organizations Fail for That Very Reason.Organizations Fail for That Very Reason.
Football Doesn’t Make This Mistake. Its GoalsFootball Doesn’t Make This Mistake. Its Goals
Are Always Clearly Defined. At the End of theAre Always Clearly Defined. At the End of the
Field It’s a Goal Line. Why Do We Call It aField It’s a Goal Line. Why Do We Call It a
Goal Line? Because Eleven People on theGoal Line? Because Eleven People on the
Offensive Team Huddle for a Single Purpose—Offensive Team Huddle for a Single Purpose—
to Move the Ball Across It. Everyone Has ato Move the Ball Across It. Everyone Has a
Specific Task to Do—the Quarterback, the WideSpecific Task to Do—the Quarterback, the Wide
Receiver, Each Lineman, Every Player KnowsReceiver, Each Lineman, Every Player Knows
Exactly What His Assignment Is. Even theExactly What His Assignment Is. Even the
Defensive Team Has Its Goals Too---to PreventDefensive Team Has Its Goals Too---to Prevent
the Offensive Team From Achieving Its Goal.”the Offensive Team From Achieving Its Goal.”
Jim Tunney, National Football League RefereeJim Tunney, National Football League Referee
THE GOALS OF ETHICS AND COMPLIANCE MUST
BE AS CLEAR TO US IN OUR FIELDS AS THE GOALS
IN FOOTBALL ARE TO THE PLAYERS

22. What is Ethics And
Compliance?
• To some, it may seem
like an exercise
between beings from
different worlds
searching for a common
language by which they
can communicate.
• To some it is simply a
close encounter of the
wrong kind.
• To others it is a
commitment culture, to
do the right thing,
everywhere, and all the
time.

23. Ethics and Compliance Are Like Elements in Star
Trek: Logical. A journey and a destination.
Fascinating. And Resistance is Futile.

24. A Negative View Sees Ethics
As:
• Rule infraction
focused, grounded
in a punishment
mentality.
• Just a “do not do”
List

25. A Positive View Sees Ethics
and Compliance As:
• Presenting opportunities for excellence.
• Aligning with and being part of a culture of
integrity, and a holistic shared value
system.
• Being Compatible with professional
responsibilities.

26. “See no, Speak no, Hear no” Fear and Uncertainty
 Fear of retaliation
 Fear of getting
someone into trouble.
 Fear of legal action
 Fear of appearing weak
or over-reactive
 Uncertainty/Unsure of
what to do
 Uncertainty regarding
policies/protocols
What are Six Leading Barriers to Reporting
Ethics Violations?
26

27. Building Blocks For A Sustainable
Ethics Compliance Process
1. Define risks
2. Prevent compliance
lapses/failures.
3. Detect Non-
compliance
4. Respond to
Allegations and
Violations
5. Evaluate results and
Continually Improve.

29. Zero Tolerance
• Is a “declaration of
our values…our own
unwillingness to
accept perceived
wrongdoing and to
look away.” (William F. Owens,
Jr. Md, President, UMDNJ)
• The organization will
not tolerate unethical
conduct and will
impose penalties
appropriate to the
nature and severity of
the violation.

30. Ethics: Looking Around and
Ahead
• What is hurting us today? One possible
metric: ethics and compliance data such
as hotline calls.
• What might hurt us in the future? Identify
trends in law, regulation, culture that
affects ethics and compliance. (AMA
study)

31. Just As Press Ganey Uses Indicators to
Measure Performance, Use Key Performance
Indicators to Measure and Monitor Ethics
Compliance
• “What gets
measured gets
done.”
• Measure what
matters.
Types of Metrics
include
• Activities Metrics
• Process Metrics
• Outcome Metrics

32. Ethics Compliance: You Have To
Set Goals and Objectives
• “If you don’t know where you are
going in business…,
• … “any road will get you there” (Old
New England proverb)
• …“you’ll end up someplace else”
(Casey Stengel),
• … “you’re lost” (Yogi Berra)

33. Ethics Compliance:
The Gazelle and The Lion
• “Every morning in Africa, a gazelle wakes
up. It knows it must run faster than the
fastest lion or it will be killed. Every
morning a lion wakes up. It knows it must
outrun the slowest gazelle or it will starve
to death. It doesn’t matter whether you are
a lion or a gazelle. When the sun comes
up, [when it comes to Ethics Compliance]
you’d better be running.”
Kenneth Chenault, Chairman and CEO American Express Co, in Take A Lesson, at 8. Caroline V. Clarke, editor

34. Compliance Training is Essential
to Walk the Walk of Ethics

35. 35
Looking Out and Around
Ethics and Compliance:
• What’s going on
today.( dashboards
showing “real time”
ethics and compliance
data; helpline calls;
cases under
investigation)
• What’s ahead.
(Timely Corporate
Integrity Agreement
reporting; trends in
law, healthcare, etc.)

36. The Chief Ethics and Compliance
Officer
• Questioner-in-Chief.
• Works to prevent define, prevent,
detect, respond to, evaluate the
causes of ethics and compliance
lapses/failures.