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Best Practices for an Effective Compliance Program in a Healthcare Facility Blog Feature
Jan Laws

By: Jan Laws on October 26th, 2018

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Best Practices for an Effective Compliance Program in a Healthcare Facility

Provider Credentialing | Nurse Credentialing | Healthcare Provider Credentialing

Hospitals are increasingly challenged by healthcare compliance laws and changing regulatory standards.

Healthcare institutions need to continually evaluate their hospital’s compliance training, technology adoption, and delivery of care while simultaneously balancing staff shortages, privacy and security concerns, and their ability to meet accreditation standards.

In short, these issues can put a hospital’s compliance at risk.

Below, we’ll review several strategies and best practices to keep your healthcare organization compliant, including:

  • Implementing policies and procedures to support accreditation standards
  • Managing healthcare providers amid changing legislation
  • Addressing credentialing issues resulting from technology innovations
  • Recognizing that staffing challenges increase the need for compliance

Implementing Policies and Procedures to Support Changing Accreditation Standards

The Joint Commission (TJC) recently introduced new methods for implementing and reporting surveys of hospitals. These include new frameworks for reporting back to the accredited hospitals.

Introduced in 2016, the Survey Analysis for Evaluating Risk (SAFER) changed several times, and was only finalized in January of 2018. The changes were based on hospital feedback that reflected the need for a clearer and more user-friendly format.

The SAFER matrix for scoring risk is only a facet of the TJC’s larger “Project REFRESH” initiative, designed to improve functions of the pre-survey, onsite survey and post-survey process.  

Even though change toward a better process is good, it does lead to uncertainty in the established processes for surveys performed by accrediting bodies.

In addition to TJC accreditation, hospital bylaws and policies and procedures must inevitably evolve, and with this evolution comes a refactoring of workflows, task management, and general uncertainty.

Delegated credentialing is an example of such a change that may influence changes in hospital bylaws.

  • Delegated agreements benefit hospital systems by enrolling physicians more quickly with payer organizations. In turn, those payer organizations benefit from the credentialing efforts of the hospital system.
  • Accreditation requirements of the managed care organization are in place to set the standard delegated agreements.
  • Hospital systems' bylaws do not often account for accreditation requirements, so healthcare organizations must review their governance and compliance standards.

Despite this uncertainty, one of the ways to reduce accreditation risk is to ensure your policies and procedures are consistent and up to date.  By ensuring that provider credentialing and privileging  processes are transparent and readily available to authorized personnel, you reduce the risk of a survey writeup or compliance standards violation.

Learn More About Physician Credentialing

Managing Healthcare Providers amid Changing Legislation

The Medicare Access and CHIP Re-authorization Act (MACRA) and changes to the Affordable Care Act (ACA) and Quality Payment Programs (QPP) are all having impacts on compliance in healthcare.  

The quality metrics and issue baseline measurements that healthcare organizations must track, store and report against are not only affecting physician group practices, but also hospitals and managed care organizations.

An estimated 538,000 physicians are employed by hospitals either directly or through contractual arrangements with group practices. Specifically, hospitals employ 70% of physicians affected by MACRA.  

Depending on the agreements in place with their physicians, hospitals may have to absorb the administration and related expenses of complying with a QPP mandated by MACRA.

Regulations are complex, but compliance shouldn’t be. Provider management software is critical to securely registering, authorizing, and providing privileges to the thousands of providers that may exist in your single or multi-network healthcare system.  

Privacy and security are paramount to protecting patient safety and data security. Meanwhile, ensuring that the right providers have authorization is critical to meeting healthcare compliance laws.

Addressing Credentialing Issues Resulting from Technology Innovations

Automation, AI, machine learning, blockchain and other technologies are working their way into healthcare. Hospital networks will face growing regulatory hurdles to ensure that patient safety, and their information, is securely maintained.

In the meantime, the introduction of telemedicine has huge cost saving potential, as much as a 25 percent savings per case, while improving access to care for thousands of patients.  However, regulations and best practices have had a hard time catching up with the telemedicine trend.

Originally, the providing site was responsible for the credentialing and approval process for the healthcare practitioner providing telemedicine services. But the patient's facility and/or the state where the patient resides may have different bylaws or regulations that would otherwise identify the practitioner as ineligible to practice, or at least non-compliant.

As of 2010, it is now recommended that a telemedicine practitioner be privileged at both the providing site and originating site.  Several potential compliance issues are raised by telemedicine providers including credentialing in a timely fashion, privileging, competency assessment, information-gathering, adherence to an organization’s bylaws and more.  

Provider credentialing software will be increasingly needed as patient, provider, and network become more distant from one another.

Recognize that Staffing Challenges Increase the need for Compliance

A survey by HCPro conducted in 2014 showed that:

  • Over 45 percent of medical staff  professionals held no certification for their position
  • Almost 30 percent of respondents employed only one full-time medical staff professional
  • Over 35 percent of respondents indicated they had worked in their position for 10 or more years
  • A third of these positions held an older, disappearing workforce

These numbers speak to the fact that more work is being done by a small number of individuals, many of whom do not hold a formal certification in their area of expertise.

In addition, HR departments will be challenged to replace these open positions let alone fill additional staff openings created due to increased demand.

More work by fewer certified employees introduces risk and potential hospital compliance issues. Labor shortage will be another aspect of healthcare that puts pressure on the adoption of labor saving technologies.  

Finally, it will be imperative that healthcare institutions upgrade their compliance programs to address gaps in certification, experience, and expertise.

Compliance will continue to be a top priority for healthcare institutions for 2018 and beyond.

Strategies to ensure your compliance program remains in top shape:

  • Reducing risks that affect patients, staff, and providers
  • Addressing accreditation issues within your healthcare organizations
  • Streamlining processes and procedures
  • Implementing provider management systems that improve credentialing while reducing costs
  • Educating staff on compliance changes

Effective credentialing is critical to ensuring that your healthcare facility remains compliant, and passes and audit with flying colors. Download our Physician Credentialing Checklist to get a quick-reference guide to conducting your credentialing process.  

download the physician credentialing checklist


About Jan Laws

Jan Laws is a member of the Product Management team at symplr. She holds both CPMSM and CPCS certification distinctions through NAMSS. Prior to joining CACTUS/symplr, Jan served for more than 20 years in the Medical Staff Services field. Her experience includes roles in centralized verification organizations’ operations, medical staff management in both system and single hospital organizations, and provider credentialing. Jan eagerly shares her expertise through learning experiences that enhance the positive collaboration between symplr teams and our clients. In addition to her expertise in medical staff services, Jan is a licensed professional counselor who operates a successful private practice.

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