7 Key Elements of a Strong Healthcare Compliance Program

Are you ready for audits by the Office for Civil Rights (OCR) under the U.S. Department of Health and Human Services (HHS)? By 2015, approximately 400 healthcare providers were expected to face these audits.

If your compliance program isn’t fully updated or you haven’t been preparing, don’t panic.

A TechTarget report highlights the main HIPAA violations OCR focuses on, including:

• Not conducting risk assessments for data breaches.
• Ignoring security threats to Protected Health Information (PHI).
• Providing inadequate staff training on protecting PHI.

Hospital compliance officers should understand and implement the seven key elements of a strong compliance program to address these issues and stay prepared.

1: Written Policies to Guide Compliance

Your compliance program should include well-written policies such as:

• A Corporate Compliance Program
• A Code of Conduct or Ethical Conduct
• Training, Acknowledgment, and Corrective Action Plans
• A Disaster Recovery Plan

These policies should apply to everyone in the organization, including employees, volunteers, staff, and hospital management. When creating policies and procedures, remember to align them with your organization’s mission, values, and core principles. Also, ensure they follow all relevant laws and regulations. It’s important to create these policies before an incident happens, not afterward.

Involve hospital staff and management in the process. Ask for their feedback on changes to policies and how they should be applied. This helps build a culture of compliance and ensures everyone is on board. Regularly review and update these policies to keep them current with new regulations and your organization’s evolving needs.

2: A Corporate Compliance Officer and Committees

Choose someone to lead the compliance program as the Corporate Compliance Officer. Then, decide who will be part of the compliance committees. Clearly define each member’s individual responsibilities and how they will work together as a group.

Plan how often the committees will meet, what topics they will cover, and how they will share their discussions and decisions. Outline the communication methods they’ll use and how they will collaborate to achieve the program’s goals. This ensures everyone stays on the same page and works toward compliance success.

3: Effective Education and Training

If your staff doesn’t know about the compliance program, it won’t work. Effective policy and procedure management requires three things: education, access, and enforcement.

Ask yourself:

• Who will train new employees, and when?
• Will employees get printed materials or access policies online?
• Who should they go to with questions?
• Will they need to confirm they’ve read and understood the policies?
• Will there be refresher training and follow-up tests?
• Who will ensure employees are properly trained and have acknowledged the policies?

To make sure tasks don’t fall through the cracks, you’ll need a reliable management system. This system should handle large amounts of documents, distribute policies to the right employees, and send automatic notifications when updates are available. Employees should be able to quickly find policies, confirm they’ve read them, and complete any necessary tests. This ensures everyone stays informed and prepared.

4. ​Keep Communication Open

A culture of openness is important for your company. Employees should feel safe reporting compliance concerns without fear of punishment. If staff are unsure about a policy or procedure or think there might be a compliance issue, they should feel comfortable asking questions.

Your policies and procedures should clearly explain how employees can communicate concerns and who they should contact. These communication channels should be easy for everyone to access, ensuring employees know where to turn for help.

5: Share Disciplinary Guidelines

Plan how you’ll enforce your compliance program. Begin by deciding how to train employees and share policies and procedures. A policy management system can help by sending automatic notifications when new policies are published. Employees can then confirm they’ve received and understood them.

Next, decide what actions to take if someone doesn’t follow the compliance program. Clear guidelines will ensure everyone knows what’s expected and the consequences of not following the rules.

6: Auditing and Monitoring

Just like getting a yearly check-up from a doctor, it's important to regularly review your compliance program to make sure it’s working well and stays relevant. Decide how often your organization will be audited and create a plan to address any issues found during the audit.

Use an automated system to stay on track. This system should remind you when policies need to be updated, renewed, or retired. Make sure your compliance committees and the compliance officer have access to the system so they can easily view the documents they need to manage compliance effectively.

7. ​Corrective Action Plans

In step #5, we talked about educating employees, enforcing policies, and addressing violations. A strong compliance program also includes plans for dealing with violations and improving training to prevent future issues.

Corrective action plans should explain how to:

• Identify and confirm compliance violations.
• Decide who needs to be notified.
• Take appropriate disciplinary actions.

The goal is to fix the problem and find ways to improve your program so the same issue doesn’t happen again.

All seven elements of a compliance program come from detailed written policies and procedures. These documents should be well-organized and reviewed regularly to help your compliance team manage the program effectively.