Performance Health Partners
An effective healthcare compliance program serves as the backbone of an organization’s effort to remain within the boundaries of federal and state regulations and is continuously being improved upon. Beyond meeting basic regulatory requirements, it creates an organizational culture that prioritizes transparency, accountability, and safety.This blog post examines the seven key elements of an effective healthcare compliance program, as first outlined in 1976 and recently updated in 2023 by the Office of Inspector General (OIG).
1. Comprehensive Written Policies and Procedures
At the core of any healthcare compliance program are comprehensive, clearly articulated written policies and procedures. These documents guide the entire organization, clearly setting out the expectations for compliance with legal regulations, ethical standards, and operational protocols. An effective compliance program will cover areas such as patient privacy (HIPAA), billing, coding, and fraud prevention comprehensively.
These policies must be regularly updated to reflect changes in compliance regulations and industry best practices. Every employee, regardless of their role, should have access to these guidelines and be able to find them easily. Digital compliance programs are useful for housing these documents, providing easy access and version control, and ensuring all staff always have access to the most current information.
2. Strong Leadership
A successful healthcare compliance program starts at the top with strong leadership. It’s essential to appoint a dedicated compliance officer and create a compliance committee. In smaller organizations, an office manager may assume the role of compliance point of contact.
The compliance officer is tasked with overseeing the program, acting as the point person for compliance issues, and ensuring that regulations are being followed throughout the organization. To bolster this effect, a multidisciplinary compliance committee ensures that all departments and stakeholders are represented, integrating healthcare compliance into every aspect of the organization’s operations, from clinical practices to administrative tasks.
However, the distribution of these responsibilities can be challenging.
Research indicates that one third of healthcare compliance professionals reported increases in their responsibilities over the last year.
This escalation in workload often correlates with the main obstacles to addressing healthcare compliance risks identified in Thomson Reuters’ “2023 Risk & Compliance Survey Report”: a lack of knowledgeable personnel, inadequate resources, and poor organizational culture.
These issues not only strain the compliance infrastructure, but also highlight the critical need for robust support systems and adequate resources to sustain effective compliance practices and prevent the overburdening of key personnel.
This underscores the critical role of leadership to set an example for the entire organization by consistently promoting the value and importance of compliance, embedding it within the very foundation of the organization, and taking action to provide staff with the proper resources they need to succeed. When staff see that leadership holds compliance in very high regard, they will also be encouraged to do the same.
3. Effective Training and Education Programs
In 2023, 42% of compliance and risk professionals identified training employees on policies as one of their top policy management challenges.
This statistic highlights the complexity of healthcare regulations and the necessity for employees to be well-equipped with the necessary resources, knowledge, and skills to navigate them effectively.
Therefore, it’s crucial to dedicate more time and resources toward a robust training program, ensuring that the importance of compliance in healthcare is consistently emphasized.
This training should:
- Be mandatory for all staff members
- Cover key areas like HIPAA, billing, and fraud prevention
- Include the names and contact information of the organization’s compliance officer, so employees can reach out should they have questions or concerns
- Utilize videos or slide presentations to simplify training for large groups of staff
- Incorporate tests to gauge and verify employees’ understanding and retention of the training material
- Be ongoing and incorporate updates as regulations evolve through annual training sessions, keeping all staff in the loop
4. Clear Communication Channels
Open, clear communication channels are critical for ensuring that employees feel safe reporting compliance concerns or discussing their organization’s compliance program in general.
These channels could include:
- Hotlines
- A website
- An email address
- A mailbox where staff can submit compliance issues or ask questions
However, communication shouldn’t be one-sided; the compliance officer and other leadership must do their part to keep the entire organization informed about updates to policies and procedures, regulatory changes, and best practices. Compliance committees should also schedule routine check-ins with other departments to ensure that compliance efforts are being effectively communicated and understood across the board.
The option to include anonymous reporting or anonymous channels of communication can also be useful to encourage employee engagement without the fear of blame or retribution. Some staff may feel uneasy or apprehensive about submitting compliance reports when they know it can be traced back to them. Anonymous communication channels foster a culture of honesty and improvement, rather than fear or punishment.
5. Consistent Enforcement of Standards
Every healthcare compliance program must include a disciplinary policy that outlines the consequences for noncompliance. This policy ensures that violations are addressed fairly and uniformly across the organization, reinforcing that any compliance breach, whether intentional or accidental, carries consequences. This approach is critical in discouraging unethical behavior that could result in higher costs, legal action, or patient harm, while simultaneously fostering a culture of integrity and fairness within the organization.
In fact, as part of 2024’s new regulatory and enforcement initiatives, there are now higher penalties for HIPAA violations. However, whether the consequences are punitive or non-punitive may depend on the organization and the intent behind the noncompliance.
These rules must be strictly enforced. Disciplinary guidelines should be well-publicized and easily accessible so that all staff are made aware of their organization’s compliance plan and the effects of noncompliance.
On the other hand, incentives can be used to encourage compliance in healthcare by providing staff with rewards or public recognition. Some instances where employees may be incentivized and rewarded include:
- Going above and beyond the individual’s job description to perform compliance activities
- Engaging in activities that reduce compliance risk or enhance compliant outcomes
- Meeting organizational compliance goals
Not only do incentives reward exceptional compliance efforts, but they also develop a positive association with the organization’s healthcare compliance program and overall culture.
6. Ongoing Monitoring and Auditing
Effective monitoring and auditing are vital for identifying weaknesses in compliance efforts and ensuring that the organization is adhering to policies and regulations. Routine internal audits help to spot potential issues before they become costly or damaging legal problems. Monitoring activities can include billing audits, HIPAA compliance checks, and employee adherence to standard protocols.
In addition, organizations should take a proactive approach by utilizing data analytics tools to detect trends or anomalies that indicate noncompliance. For example, data-driven auditing practices can help to identify unusual billing patterns, deviations from clinical standards, or improper access to patient data.
Healthcare compliance programs should ideally utilize technology to ensure that all actions associated with a safety incident are recorded, providing a comprehensive history essential for audits. In fact, approximately 65% of corporate risk and compliance professionals said using technology to streamline and automate manual processes would help reduce the complexity and cost of risk and compliance.
This highlights the impact that healthcare compliance programs have not only on efficiently monitoring and auditing but improving and streamlining compliance efforts as a whole.
7. Prompt and Decisive Response to Offenses
Even with the best preventive measures, regulatory violations may still occur. When they do, an organization must have a clear process for investigating the issue and taking corrective action. This includes identifying the root cause of the problem, whether it’s a systemic issue or an individual violation, and implementing measures to prevent future occurrences.
Records of any investigations into noncompliance incidents should have a comprehensive record containing all information associated with the process, regardless of the severity of the incident. According to the OIG, such records should include:
- Documentation of the alleged violation
- A description of the investigative process
- Copies of interview notes and key documents
- A log of the witnesses interviewed, and the documents reviewed
- The results of the investigation
- Any disciplinary action taken, or corrective action implemented
Corrective action might include policy revisions, retraining, or even disciplinary measures where necessary.
An effective compliance plan views each incident as a learning opportunity, using it to strengthen the organization’s overall approach to compliance.
Final Thoughts
Establishing a well-structured healthcare compliance program is critical for successfully managing the ever-changing and evolving regulatory demands within the healthcare industry. By prioritizing the seven key elements listed in this blog post, organizations can establish a compliance program that will meet their goals.
Not only do these elements create a solid foundation for healthcare compliance and reduce the risk of legal issues, but they also promote higher standards of patient care and help to foster an ethical culture of integrity and continuous improvement within the healthcare organization.
By keeping up-to-date with new regulations and refining these elements accordingly, healthcare organizations can ensure their compliance efforts remain effective and responsive to the changing regulatory landscape.