10 Easy Steps to Compliance!
- Appoint a Compliance Officer
This first step is sometimes the hardest. Providers agonize over the expense, and board members often see compliance more as a necessary evil than anything else. It is up to key managers to generate the commitment among board members, establish the budget and parameters for the position and embark on the hiring process. Compliance needs will vary from organization to organization, and compliance usually - though not always - becomes more multifaceted and complex as providers become larger. One important part of this step is to ensure that the officer appointed is properly empowered to carry out his or her duties and has the full support of the board and key personnel.
- Assess the Current Status of Compliance in Your Organization
Your board, managers and key staff members need to know immediately what stage your organization is at when it comes to compliance. This is crucial, as it provides a snapshot of what risks - if any - your organization has taken in the past or is taking at present. An assessment will include an overview of what has been studied, what measures implemented, what risk remains and what steps are in place to ensure an ongoing monitoring and maintenance of the compliance program. Once this assessment has been undertaken, your organization is fully prepared to move to the next step.
- Obtain Board Approval & Participation
Boards of Directors are notoriously difficult to mobilize at the best of times and no less so when it comes to a project (like compliance) with which no tangible profit seems immediately forthcoming. However, its approval, full understanding and some degree of participation are vital to the implementation of the compliance program. A short presentation outlining the nature and substance of compliance programs and their benefits, what a realistic and ongoing cost to such a program would be and how they can reduce liability and potential scrutiny by regulatory authorities is normally sufficient to convince your board that a compliance program is the right direction in which to go.
- Involve Management & Key Staff
No matter what the size of your organization, implementing compliance is an involved and tricky process. It is not, contrary to popular belief, exceedingly expensive or hard to master intellectually, but it remains a challenge nonetheless. And it is a challenge that is best addressed by multiple individuals. Not only does this take the burden off the shoulders of one person only, but it helps keep and develop perspective on compliance as a whole. The appointed person should initiate programs and involve managers and key personnel as much as possible. Not only will this make compliance much easier to implement and monitor in the short term, but their involvement is the surest way to concretize a solid compliance program in the long run. This is any provider's best guarantee to avoid the kind of headaches that non-compliance almost invariably invites.
- Acquire Multi-Media Training Material
Developing a compliance program is made much simpler by effective training materials. Too much compliance literature is dry, academic, long-winded and formatted like textbooks. Today's busy professional does not have the time or inclination to digest vast amounts of material, however useful it might be. Material like that provided by Wholesale Knowledge, Medical Division addresses the need for a multi-media training environment in which compliance flourishes. Books, manuals, CD Roms, DVDs, VHS video, powerpoint presentations, FAQs, Q&A sessions are all viable and necessary teaching modes which are effective and which guarantee the best retention and participation on the part of your staff.
- Assess Budget
Like any program, compliance implementation will cost money. What is important to understand is that the costs involved do not have to be astronomical, even if you are a large provider. Establishing a realistic budget which has the approval and participation of the board and key managers is a necessary first-step. The budget includes time, training and research material and human resources, in addition to the need to be constantly vigilant on an ongoing basis. The compliance officer should observe however, for the participants and staff more broadly, that ongoing maintenance of a compliance program is well documented to be inexpensive - a "compliance autopilot", in other words, can be established and maintained with relative ease and at minimum cost.
- Decide on Implementation Phases
Putting together a compliance program, as we have established is not the daunting task that many people make it out to be. But it still requires careful planning and a keen eye for timing. The last thing a compliance professional wants to do, for example, is to disrupt the workings of his/her facility by trying to do too much too fast. On the other hand, if your organization has not made good faith efforts with compliance up to now, there is considerable urgency to get going soon! Implementation schedules and objectives must be agreed upon by all relevant parties and should be done logically, in a step by step fashion. Slow but steady implementation consists of training, documentation, reporting and maintenance phases and experts suggest roughly 2-3 months per phase. It is crucial to the Office of the Inspector General (OIG) and its outlines of "due diligence" that the proper time and energy is allocated to each phase.
- Establish Standards/Benchmarks Across the Healthcare Industry
Every healthcare provider wants to know where it stands relative to others. Comparisons on patient care quality, costs, profits, and reputation are common throughout the industry. The degree to which your organization is compliant is another important benchmark in the industry: who is being investigated? Why? What was the outcome? A compliance officer can easily find the many healthcare reporting organizations (eg, www.healthgrades.com) to allow for cross-comparison on the subjects of the speed of implementation, cost, effectiveness and timing of a compliance program. This is both useful and interesting as an exercise. Professsionals can find organizations of their own size and scope, and match their efforts up to an industry average, as an excellent way to ascertain where they stand!
- Establish Parameters for Constant Renewal of Program
As many experts on compliance have observed, it is one thing to create and implement a compliance program and another entirely to re-examine, constantly develop and maintain one once it has been created. Part of an officer's function is to ensure that his/her hard work doesn't "fade away" once the initial part is complete. Program renewal includes obvious things like monthly meetings to review progress and deadlines but also less obvious things such as subscriptions to industry newsletters to keep abreast of what's current. Your privacy, medical records, and administrative personnel should all be aware of the ongoing goals of the compliance program and it will also be the role of the compliance officer to ensure that the board discusses compliance efforts quarterly, at a minimum.
- Self-Evaluation & Internal Audits
The last step in effective compliance is to be able to evaluate one's self. There is an abundance of material available in the sector which allows providers to assess their program objectively and arrive at conclusions designed to aid in the compliance process. Self-evaluation audits include subjects the frequency of meetings, the nature of electronic records, progress on privacy and security methods and keeping current on billing and coding terms. It also includes testing of staff at regular (though not intrusive) intervals to ensure that the lessons garnered in the initial phases of compliance implementation are not slowly lost!