Compliance 101: A Guide to Building Effective Compliance Programs

Compliance 101: A Guide to Building Effective Compliance Programs Lori A. Brown, Seton Hall University Nikita Williams, TCS Education System Christopher Myers, Holland & Knight

Program Speakers Lori A. Brown, Esq. Director of Compliance & Risk Management Seton Hall University South Orange, NJ Nikita Williams, Esq. Director of Regulatory Affairs & Compliance Office of Compliance and Legal Affairs TCS Education System Moderator Christopher Myers, Esq. Partner, Holland & Knight Chair, Compliance Services Team

Overview I. Compliance Background II. Elements of an Effective Compliance Program – Session will cover FSG compliance program elements – Suggestions for small institutions and those with limited resources III. Tool Kit – Handout CD ROM with practical compliance tools IV. Reference Materials – Will provide citations to additional sources of assistance

I. Compliance Background

What is Compliance? Compliance is a comprehensive program that helps institutions and their employees conduct operations and activities ethically; with the highest level of integrity, and in compliance with legal and regulatory requirements.

Why Have Organizational Compliance and ERM programs? Compliance Programs – Fiduciary Responsibility – Federal Financial Reporting and Internal Control Standards – Legal and Regulatory requirements and organizational policies Enterprise Risk Management Programs – Standard & Poor’s- Credit Ratings

Business Reasons For Developing Compliance Programs Foster a culture of ethics and compliance that is central to all of the institution’s operations and activities. Understand the nature of risks and potential exposures. Identify and manage risks that impact the institution’s reputation. Integrate the compliance program into ERM Framework

Why Are Compliance Programs Important? BOARD OF TRUSTEES/REGENTS Seeking enhanced visibility into the risks of the institution Promoting greater accountability for risk management ACCREDITORS & AUDITORS HIGHER ED ANALYSTS INSTITUTION Instituting ERM ratings criteria for public debt issuers Seeking assurance on stewardship of donated funds DONORS

Factors Affecting Organizational Context for Compliance Board and Audit Committee o Independent and engaged? Management’s Philosophy and Operating Style o Communicates by word and action there is support for compliance and commitment to ethics o Code of Conduct o HR Practices and Policies: Recruitment and hiring; orientation; evaluation, promotion and compensation; disciplinary actions Organizational Structure o Centralized vs. Decentralized o Assignment of Authority and Responsibility Risk Culture (Appetite and Tolerance)

Smaller Organizations [M]ay meet the requirements of this guideline with less formality and fewer resources than would be expected of large organizations. In appropriate circumstances, reliance on existing resources and simple systems can demonstrate a degree of commitment that, for a large organization, would only be demonstrated through more formally planned and implemented systems. Federal Sentencing Guidelines Manual Effective Compliance Programs Guidelines Commentary

Smaller Organizations, Cont’d [M]ay meet the requirements of this guideline [by] . . . modeling its own compliance and ethics program on existing, well-regarded compliance and ethics programs and best practices of other similar organizations. Federal Sentencing Guidelines Manual Effective Compliance Programs Guidelines Commentary

Practical Tools and References to Supplement Your Program --Compliance Background

Associations with Reference Materials – NACUA: http://www.nacua.org/ – Society for Corporate Compliance and Ethics http://www.corporatecompliance.org – Association of Corporate Counsel: http://www.acc.com/ – ECOA : http://www.theecoa.org – NACUBO: http://www.nacubo.org/ Publications – Ethikos Magazine: http://www.singerpubs.com/ethikos/ – Ethisphere Magazine: http://ethisphere.com/? gclid CMbC7siNtZ0CFdVL5QodnytqiQ

II. Elements of an Effective Compliance Program

To have an effective compliance program, an organization must establish and maintain an organizational culture that “encourages ethical conduct and a commitment to compliance with the law.” U.S. Federal Sentencing Guidelines §8B2.1(a)(2)

Eight Elements of an Effective Compliance Program: 1. High level company personnel who exercise effective oversight and have direct reporting authority to the governing body or appropriate subgroup (e.g. Audit Committee); 2. Written policies and procedures; 3. Training and education 4. Lines of communication

Eight Elements of an Effective Compliance Program, Cont’d 5. Standards enforced through well-publicized disciplinary guidelines 6. Internal compliance monitoring 7. Response to detected offenses (including remediation of harm caused by criminal conduct) and corrective action plans (including assessment and modification of the compliance and ethics program); and 8. Periodic Risk Assessments

Practical Tools and References to Supplement Your Program --Elements of an Effective Compliance Program

Toolkit: – Federal Sentencing Guidelines for Organizations – Federal Sentencing Guidelines Manual – Federal Sentencing Guidelines Advisory Committee Report – 2010 FSG Amendments HHS Office of Inspector General References: http://oig.hhs.gov/fraud/complianceguidance.asp

Suggested Readings on Ethics Paine, Lynn Sharpe: Managing for Organizational Integrity, Harvard Business Review (March-April 1994) Weaver, Trevino, Compliance and Values Oriented Ethics Programs: Influences on Employees’ Attitudes and Behavior, Business Ethics Quarterly (April 1999) Joseph, Integrating Ethics and Compliance Programs: Next Steps for Successful Implementation and Change, Ethics Resource Center (2001) Ethics Resource Center, Leading Corporate Integrity: Defining the Role of the Chief Ethics & Compliance Officer (CECO), (2008) Tyler, Dienhart, Thomas, The Ethical Commitment to Compliance: Building Value-based Cultures That Encourage Ethical Conduct and a Commitment to Compliance, California Management Review (February 2008) Roach, Davis, Establishing a Culture of Ethics and Integrity in Government, Ethikos (September-October 2007)(Toolkit)

High Level Personnel

Day to Day Responsibility – May be a Chief Compliance Officer (GC, IA, or Independent) and /or Compliance Committee; – Must have overall responsibility for day to day operations of the compliance program; – Must have prompt access to the Board to report instances of criminal conduct; – Must report annually to the Board on compliance and ethics program; – Must have access to effective high level management and executive oversight

The Organization’s Governing Body Should: Be knowledgeable about the program; Exercise effective and ongoing oversight; Promote the program. (See, e.g., In re: Caremark and Stone v. Ritter.)

Smaller Organizations “Examples of the informality and use of fewer resources with which a small organization may meet the requirements of this guideline include using available personnel, rather than employing separate staff, to carry out the compliance and ethics program.” Federal Sentencing Guidelines Manual Effective Compliance Programs Guidelines Commentary

Developing the Team/Structure Risk Reports Board of Trustees President/Sr Leadership Internal Audit Risk Management Committee Provost Risk Reports Finance/ Legal/ HR Select Deans Ext Affairs Risk Mgr ? Compliance ERM functional representation, risk management activity support and shared services College A College B College C Dept A Dept B Risk information and root data, issues management Dept C

Practical Tools and References to Supplement Your Program --High Level Personnel

Tool Kit: Chief Compliance Officer Job Description Office of Compliance Mission Statement Compliance Officers Working Group Charter Compliance Steering Committee Charter Audit and Compliance Committee Charter; Audit and Compliance Committee Calendar Sample SOX gap analysis form. Reference Materials: Ethics Resource Center, Leading Corporate Integrity: Defining the Role of the Chief Ethics and Compliance Officer, http://www.ethics.org/ (Great free download)

Periodic Risk Assessments

Periodic Risk Assessments Efficiency: risk assessments allow you to maximize the utility of scarce resources by directing them to the most significant compliance issues faced by your institution. “Buy-in” and Ownership: when individuals who have day to day administrative responsibilities participate in identifying compliance risks and developing mitigation plans they are more likely to actively participate in the compliance process. Coordination: most compliance risks have potential significance across multiple functions, so risk management encourages coordination and consensus building, particularly in organizations with distributed/decentralized management.

Periodic Risk Assessments, Cont’d Keep the risk management process simple. – Build into existing business processes – Complex processes feel like red tape Start small and build over time. – Don’t overload administrators with too many projects – Additional projects and processes can be added over time “Don’t let the perfect be the enemy of the goo

Periodic Risk Assessments Conducting a Compliance Risk Analysis

Compliance Risk Analysis 1. Organizational Context: What are your organization’s objectives, structure and operations? 2. Risk Identification: What are the possible risk events your organization faces? 3. Risk Assessment: o o What is the likelihood of the risk event happening? What is the potential impact of the risk event? 4. Risk Evaluation- Having assessed the risks: o o What is your organizations “appetite” for risk? What are the most important risks to address?

Compliance Risk Analysis, Cont’d 5. Risk Treatment: What steps must be taken to mitigate the risks Identified? 6. Monitoring, Review and Corrective Action, o Are internal controls working effectively to mitigate risk? o Is there any corrective action needed? 7. Communication: Throughout the Organization

Risk Identification Process Flow Analysis o Regulatory analysis o Responsible Officers Event Inventories o Organizational History o External Context (Stakeholder expectations) o Events Common to Industry Interviews, Questionnaires, Surveys Facilitated Workshops Leading events and escalation triggers

Risk Assessment Inherent Risk o o o o o Strategic Operational Financial Compliance Reputational Residual Risk o Risk after accounting for current internal controls

Risk Evaluation Having assessed the risks: o What is your organizations “appetite” for risk? o What are the most important risks to address?

Risk Response Avoidance Reduction/Mitigation (Internal Controls) Sharing (e.g. Insurance) Acceptance o Crisis Management Plans o Business Continuity Plans o Other Operational Plans o Development of new policies/procedures

Internal Controls Organizational/Process Controls (i.e. separation of duties) Documentation - written policies and procedures Training Audit Reports Security and Integrity

Practical Tools to Support Your Program --Risk Management

Tactical Process Overview Risk Assessment Risk Identification Risk Analysis Risk Evaluation Risk Treatment Risk Communication, Monitoring & Review

Risk Identification Initial interview/survey with Risk Owner o Risk Assessment Survey (i.e. Survey Monkey) What issues/areas of concern that keep them up at night? What is the probability of occurrence? Risk owner impression of impact level Create a risk registry Person Interviewed Risk Owner Department Area of Concern Issues Affect On Other Departments Probability of Occurrence H 70% M 30-70% L 30% Impact

Risk Analysis/Evaluation For the high probability and high impact risks, do a detailed analysis on the impact or consequences of the risks. o o o o o o o Legal/Compliance Health & Safety Reputation Operational Social/Behavioral Physical Environment Financial Rate the impact of each risk using a defined scale.

Distill Registry to Top 5 Risks Identify Top 5 Risks Type of Assess Evaluat Mitigate / Risk (Severity e/ (Internal (i.e. and Priorito Control) Strategic, Probabilit rize Operationa y) l, Financial, Complianc e, Reputation al) Monito r and Update the Plan

Sample Risk Project Form Each risk owner creates a project plan with timelines for mitigating risks. Risk owner provides semi-annual progress updates on risk mitigation projects. Communicate progress to the Audit Committee of the Board of Trustees. 1. General Project Information Project Title: Project Sponsor/Department: Project Summary: 2. Project Update Current Status List completed action items and project successes thus far. Remaining Tasks List the remaining tasks/action items which are needed for the successful completion of the project.

Compliance Communications

Compliance Communications More Elements: Written Policies and Procedures Training and Education Lines of Communication o Hotlines and Whistleblowers Standards enforced through well-publicized disciplinary guidelines o Codes of Conduct

Written Policies and Procedures Explain legal requirements so that employees understand their obligations and how to conform their behavior to meet them; Encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation, and Should be made easily available (e.g. policy webpage)

Training and Education Reasonable and practical steps must be taken to disseminate information about the organization’s compliance program and its policies and processes. Training should be provided to the governing body, high level executives, employees and, where appropriate, the organization’s agents. (May be required by law, e.g. Medicaid, Human Subjects Research).

Smaller Organizations “Examples of the informality and use of fewer resources with which a small organization may meet the requirements of this guideline include . . . training employees through informal staff meetings.” Federal Sentencing Guidelines Manual Effective Compliance Programs Guidelines Commentary

Lines of Communication The FSG state that to enhance the effectiveness of the compliance program, the program must establish lines of communication whereby: – Employees and agents may seek guidance and report concerns, including the opportunity to report anonymously – There are assurances that there will be no retaliation for good faith reporting; – Sometimes required by statute, e.g. Medicare/Medicaid.

Publicized Standards and Discipline The Code of Ethical Conduct is the centerpiece of an effective compliance program Topics and Organization: – Leadership Statement – Inspirational provisions such as mission statement, guiding ethical principles, values statement – Explains who is covered – Standards of conduct – Discipline and enforcement – Reporting (obligations), whistleblower, nonretaliation

Publicized Standards and Discipline, Cont’d Code of Ethical Conduct Style: – Audience/Culture – Q and As and Resources – Acknowledgment of Receipt? – Publicly available?

Practical Tools to Support Your Program --Compliance Communication

Tool Kit Communication Plan Policy on University Policy Development Compliance Complaint Policy References Policies: http://www.acupa.org/resources.html Training: A good website for film clips, cartoons and good training ideas, as well as regular compliance updates: http://www.compliancebuilding.com/ Codes of Conduct: Ethisphere Magazine for Codes of Ethical Conduct http://ethisphere.com/?gclid CMbC7siNtZ0CFdVL5QodnytqiQ

Monitoring & Review

Monitoring & Review The organization shall take reasonable steps, including monitoring and auditing, to: – Ensure that the organization’s compliance and ethics program is followed; – Periodically evaluate the effectiveness of the organization’s compliance program.

Monitoring & Review Routine monitoring of actual performance vs. expected performance Review and periodic investigation of the current situation Internal monitoring and assurance processes should be ongoing

Monitoring & Review What should be monitored? o The risks and context– are things changing? o Effectiveness / appropriateness of the strategies and management systems o Risk Management plan and system as a whole Types of Monitoring o Line management reviews of risks and their treatments o Internal auditing o External auditing

Smaller Organizations “Examples of the informality and use of fewer resources with which a small organization may meet the requirements of this guideline include . . . monitoring through regular ‘walk-arounds’ or continuous observation while managing the organization.” Federal Sentencing Guidelines Manual Effective Compliance Programs Guidelines Commentary

Response to Monitoring After monitoring and auditing of the compliance program, the organization shall take reasonable steps to: – Respond appropriately to any violations of the law or policies to prevent future misconduct; – Modify and improve the organization’s compliance and ethics program. – Make restitution when appropriate if criminal conduct is found

Compliance Monitoring References: COSO Monitoring http://www.coso.org/documents/ COSO Guidance On Monitorg Intro online1.pdinf

How Smaller Institutions Can Build Effective Compliance Programs

How Smaller Institutions Can Build Effective Compliance Programs You must have buy in from the top Establish Compliance/ERM as a component of institutional strategic plan Vetted and accepted by Board of Regents/Trustees and Executive Cabinet Establish risk ownership and management of risk

Develop a Compliance Program Model REGULATORY STANDARDS: o Federal Sentencing Guidelines - Section 8B2.1(b) (7)(A) GUIDELINES & BEST PRACTICES: o Committee of Sponsoring Organizations of the Treadway Commission’s (COSO) ERM Framework o Standard & Poor's (S&P) ERM Ratings Criteria for Non-Financial Organizations o ISO31000 EMERGING REGULATIONS & GUIDELINES: o Accreditation requirements

Seton Hall University’s Proposed ERM And Compliance Model SETON HALL’S ERM AND COMPLIANCE MODEL FIVE STEP PROCESS FOR ERM Identify 1. 2. Assess Evaluate 3. 4. Mitigate Monitor 5. FIVE DIVISIONAL AREAS Finance & Technology Student Affairs Academic Affairs General Counsel University Advancement FIVE TYPES OF RISKS Strategic Operational Financial Compliance Reputational 1

Develop An Institutional Compliance Calendar Create universal template Divisions input statutes and regulatory compliance University wide inventory of dates for compliance

Seton Hall University Compliance Calendar Template Division of Student Affairs Enterprise Risk Management Plan Compliance Calendar GOVERNING AUTHORITY: REGULATION/LAW/STATUTE: DEPARTMENT: DIRECTOR: DATE: ACTION STEPS TO COMPLIANCE Steps/Description Responsibility Completio n Date

TCS Education System Compliance Calendar Template Standard Requirement Responsible Office Deadline Status FIRST QUARTER Higher Ed Corporate & Business Operations Tax Employment Financial/Audit Information Privacy & Security Other

Questions?