Focus on: Compliance

by • July 1, 2007 • UncategorizedComments Off on Focus on: Compliance1944

Part 1: Emergency Preparedness remains a focal point with the JCAHO

© The Medical-Legal News, 2007

• The Gist: Hospitals accredited by the Joint Commission must be responsive to the changes in the standards addressing patient safety. If a hospital is JCAHO accredited and were to be out of compliance with its guidelines, resulting in a patient safety issue, it could impact litigation.

By Angela L. Tobias RN, BSN, MSHSA, LNCC

The Joint Commission has revised its standards in emergency preparedness to help address patient safety issues during an emergency or community disaster, such as happened in New Orleans during Hurricane Katrina.

The Joint Commission recently revised Emergency Management Standards EC 4.10-EC 4.20.

These standards are applicable to critical access hospitals, hospitals and long-term care facilities.

In the June 2007 issue of Perspectives, revisions to the environment of care standards were outlined.

As stated, “While no organization can predict the nature of a future emergency, nor can it predict the date of its arrival, the organization can plan for managing six critical areas.”

The six areas addressed included communication, resources and assets, safety and security, staff responsibilities, utilities management and patient clinical and support activities. Each of these areas addresses the organization’s plans to provide for appropriate functioning when all other resources fail. As we all learned with hurricane Katrina, healthcare organizations can no longer count on community resources to keep them up and running during the time of disaster. The healthcare organization must be self-sufficient at least for a while until outside helpbecomes available:

• Adequate communication pathways must be in place in the event that community infrastructure is damaged;

• The organization must have a plan in place to maintain internal communication and communication to the outside community to ensure access to much needed supplies;

• The organization’s utilities must be able to provide uninterrupted power, ventilation, water and fuel;

• Security and organizational safety is a must also;

• Organizations have a responsibility to their patients and families to provide a safe and secure environment during disaster. Clinical needs of the patients are critical times of disaster; 

• The Joint commission requires that “organizations have reasonable plans in place to address the needs of patients during extreme conditions when the organization’s infrastructure and resources are taxed.”

The Joint Commission calls it an “All Hazards Approach” which supports a level of preparedness sufficient to address most any emergency.

When an organization has a grasp on the above-mentioned six critical areas, they are more than ready to handle most any emergency.

For more information concerning the Joint Commission’s revisions to the environment of care standards addressing emergency preparedness, see the June 2007 Edition of The Joint Commission Perspectives. •

Angela L. Tobias RN, BSN, MSHSA, LNCC is co-owner of Nightingale Consulting, LLC a legal nurse consulting firm located in Dalton, Ga. She has served as a hospital CEO and Corporate Compliance Officer,

Part 2: Seven elements of compliance — a roadmap to an effective program

• The Gist: Compliance programs are a good way to detour and detect fraud, waste and abuse. Not having a program could result in severe penalties for a healthcare organization found guilty of fraud and abuse. The organization could face expulsion from the Medicare and Medicaid programs. The OIG believes effective programs begin with a commitment to detouring fraud, waste and abuse and the implementation of seven basic elements.

By Angela L. Tobias RN, BSN, MSHSA, LNCC

How do you ensure your facility has an effective compliance program? It lies in the fulfillment of the Office of Inspector General’s program guidance — seven elements of compliance.

Compliance programs are made of components. Each must address the OIG’s seven elements to ensure effectiveness.

Program elements include:

• Written standard of conduct, as well as, written departmental and organizational policies and procedures that promote the organization’s commitment to compliance;

• Designation of a corporate compliance officer and corporate compliance committee responsible for program oversight;

• Development of regular effective hospital-wide communication and education regarding the compliance program;

• Maintenance of a process to receive complaints, and the adoption of procedures to protect the anonymity of complainants;

• Development of a system to respond to allegations of improper or illegal activities and enforcement of appropriate disciplinary action against employees who have violated compliance policies, applicable statutes, regulations or federal healthcare program requirements;

• Use of audits or reviews or other evaluation techniques to monitor compliance and assist in reduction of identified problem areas;

• Investigation and remediation of identified systemic problems and development of policies addressing the non-employment or retention of sanctioned individuals.

Compliance programs must develop written standards of conduct, as well as written policies addressing the above seven elements in order to promote ethical business conduct and a commitment to compliance. The standard of conduct demonstrates the ethical attitude of the organization.

In addition, compliance programs’ overall function must be to focus on a culture of prevention, detection and resolution of instances of conduct that do not conform to federal, state or local laws and federal, state and private payer healthcare program requirements as well as the hospital’s ethical and business policies.

Standards of conduct and compliance policies and procedures provide guidance to all employees, volunteers, medical staff and contractors regarding ethical business practice.

With standards of conduct that provide insight into the “right way of doing business,” and organizational policies addressing appropriate business practices, the organization can ensure its compliance program is effective.

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