HopeWest

Stephanie Fakier

Compliance Governance Steward

Stephanie Fakier is a compliance leader with over 10 years of experience in healthcare regulatory adherence, privacy and accreditation. She develops policies and procedures that balance operational efficiency with compliance, fostering collaboration across legal, clinical and operational teams to mitigate risk and promote ethical practices.

Making Compliance a Continuous Discipline

Over the past five to ten years, I have seen healthcare compliance shift from a reactive, event-driven function to a proactive and continuous discipline. Compliance teams no longer begin preparations after receiving an audit notice. They now maintain a state of ongoing audit readiness through routine monitoring, current documentation and collaboration with operational and clinical team members.

The emergence of artificial intelligence has further accelerated this evolution by improving the speed and efficiency with which organizations can organize, review and produce supporting documentation. However, these tools must be implemented with appropriate oversight to ensure accuracy, privacy, security and regulatory alignment.

Building a Culture of Shared Accountability

Effective collaboration starts with giving compliance a meaningful voice at the decision-making table. Leaders must consistently demonstrate that compliance is a shared organizational commitment, not simply the responsibility of the compliance team.

Executive support and early involvement help create a practical, effective compliance program that is woven into the organization’s culture and day-to-day operations. The compliance leader has direct access to the CEO and an independent reporting relationship with the board of directors, in line with guidance from the U.S. Department of Health and Human Services Office of Inspector General on effective healthcare compliance programs.

Compliance professionals should build trust by educating clinical and operational team members. The team should convey that compliance is a strategic partner, not just an enforcement function. Collaboration is especially important when regulatory requirements are ambiguous or subject to interpretation. In those situations, open dialogue among compliance, clinical, legal and operational leaders enables the organization to evaluate competing considerations, make informed decisions and mitigate risk proactively without creating unnecessary barriers to patient care.

Balancing AI Innovation with Patient Privacy

Artificial intelligence is the most significant emerging compliance and privacy risk in healthcare because its capabilities are advancing faster than many organizations’ governance frameworks. Although improving patient care should remain the primary objective, AI systems can expose patient information to new risks through the aggregation, analysis and reuse of large data sets.

Effective oversight requires a multidisciplinary approach involving compliance, privacy, information security, clinical leadership, legal counsel and other key stakeholders. One particular concern is the potential re-identification of data previously considered de-identified when AI systems combine it with other available data points. This risk really drives the need for rigorous data-governance standards, access controls, vendor oversight, ongoing monitoring and clearly defined accountability.

“Leaders must consistently demonstrate that compliance is a shared organizational commitment, not simply the responsibility of the compliance team.”

Informed consent presents an additional challenge. From an ethical standpoint and also in alignment with some state regulations, healthcare organizations must communicate not only that AI is being used, but also how it may influence clinical decisions, how patient information will be processed, and what limitations or risks may be involved. This can be difficult when clinicians and other teams do not fully understand the technology themselves.

Compliance leaders can help by working with technical and clinical experts to translate complex system functions into clear guidance, educate the workforce and establish appropriate consent and disclosure practices. This will ensure that patients receive understandable information. A strong governance program should enable innovation while preserving transparency, patient autonomy, privacy and trust.

Aligning Compliance with Patient Care

Compliance leaders can strengthen accountability by partnering with clinical and operational teams to ensure that policies and procedures support both regulatory requirements and efficient patient care. This requires observing workflows in practice—not simply reviewing them on paper—to identify gaps between written policy and day-to-day operations.

Outdated, overly complex, or impractical requirements can create unnecessary administrative burdens, disrupt care pathways and reduce patient access. When those barriers are identified, compliance should help the responsible teams update their processes while ensuring that operational leaders retain ownership of their policies and procedures. Compliance professionals should also clearly communicate that their role is to provide guidance, education and practical support. This collaborative approach promotes accountability while helping teams manage risk without compromising care delivery.

Advice for Healthcare Compliance Professionals

Begin by taking ownership of your professional development and establishing yourself as a reliable compliance resource. Stay current by regularly reviewing OIG alerts and bulletins, CMS guidance and other relevant regulatory updates. Seek opportunities to participate in your organization’s compliance or risk committee; if you have a strong technology background, consider contributing to an AI strategy or governance committee as well.

Courses, webinars and professional publications can help strengthen your technical knowledge. To become a well-rounded compliance professional, learn the fundamentals of your organization’s clinical specialties, operations, quality programs and business practices. Finally, join professional associations, build relationships across healthcare, compliance and quality. I think you should also pursue relevant certifications as your experience grows. Together, these steps can create a strong foundation for a long-term career and future leadership opportunities in healthcare compliance.