Implementing policies and procedures - Health Care Compliance ...
Implementing policies and procedures - Health Care Compliance ...
Implementing policies and procedures - Health Care Compliance ...
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
April 200522COMPLIANCEFOCUSGROUPHCCA/AHIA■ Underst<strong>and</strong> laws <strong>and</strong> regulations■ Obtain <strong>and</strong>/or establish <strong>policies</strong> forspecific issues <strong>and</strong> areasdures most relevant to your organization2. Identifying the various types of compliance<strong>policies</strong> <strong>and</strong> <strong>procedures</strong><strong>Implementing</strong>a core set ofcompliance <strong>policies</strong> <strong>and</strong> <strong>procedures</strong>By R<strong>and</strong>all BrownEditor's note: This is the sixth article in aseries offered by The HCCA/AHIAAuditing & Monitoring Focus Groupregarding seven components to exp<strong>and</strong>on the roles of compliance <strong>and</strong> internalaudit functions, provide detailed "how tosteps", <strong>and</strong> discuss the essential coordinationlinks between compliance, internalaudit, legal, <strong>and</strong> management that arenecessary for each component. The finalarticle will address compliance education/awareness tools <strong>and</strong> techniques. Theauthor's contact information may befound at the end of this article.A focus group of <strong>Health</strong> <strong>Care</strong><strong>Compliance</strong> Association (HCCA) <strong>and</strong>Association of <strong>Health</strong>care InternalAuditors (AHIA) members has beenmeeting the past nine months toexplore opportunities to better define<strong>and</strong> explain auditing <strong>and</strong> monitoring,clarify the roles of compliance, <strong>and</strong>internal audit functions as they addressissues within their health care organizations,<strong>and</strong> develop guidance <strong>and</strong> referencematerials on key aspects of healthcare auditing <strong>and</strong> monitoring processes.The Seven Component Frameworkdeveloped by the HCCA/AHIA focusgroup for compliance auditing <strong>and</strong>monitoring is comprised of the followingactivities:■ Perform a risk assessment <strong>and</strong> determinethe level of risk■ Educate on the <strong>policies</strong> <strong>and</strong> <strong>procedures</strong><strong>and</strong> communicate awareness■ Monitor compliance with laws, regulations,<strong>and</strong> <strong>policies</strong>■ Audit the highest risk areas■ Re-educate staff on regulations <strong>and</strong>issues identified in the auditThis article provides guidance on implementinga core set of compliance <strong>policies</strong><strong>and</strong> <strong>procedures</strong>.The requirement to establish written<strong>policies</strong> <strong>and</strong> <strong>procedures</strong> is listed as thefirst element of the seven elements ofan effective compliance program identifiedby the U.S. Department of <strong>Health</strong><strong>and</strong> Human Services Office of InspectorGeneral (OIG). This fact demonstratesthe importance of health care organizationshaving written compliance <strong>policies</strong><strong>and</strong> <strong>procedures</strong> to serve as a guide forestablishing <strong>and</strong> maintaining an effectivecompliance program.The <strong>policies</strong> <strong>and</strong> <strong>procedures</strong> developedby an organization should address itsprincipal risks, clarify the purpose of thecompliance program, establish internalst<strong>and</strong>ards for compliance with laws <strong>and</strong>regulations, aid in the communication oforganizational values <strong>and</strong> expectationsregarding employee behavior, <strong>and</strong> facilitateemployees' underst<strong>and</strong>ing of theconsequences of non-compliance, forboth the organization <strong>and</strong> the individual. 1This article focuses on the followingsteps necessary to implement a core setof compliance <strong>policies</strong> <strong>and</strong> <strong>procedures</strong>:1. Determining those <strong>policies</strong> <strong>and</strong> proce-3. Establishing the role of the<strong>Compliance</strong> Officer related to theImplementation of compliance <strong>policies</strong><strong>and</strong> <strong>procedures</strong>4. <strong>Implementing</strong> a process for ongoingcommunication <strong>and</strong> updating of compliance<strong>policies</strong> <strong>and</strong> <strong>procedures</strong>Determining those <strong>policies</strong> <strong>and</strong> <strong>procedures</strong>most relevant to your organizationIn preparing to develop your organization'scompliance <strong>policies</strong> <strong>and</strong> <strong>procedures</strong>,it is important to establish someground rules to aid in consistent <strong>and</strong>effective communication of those <strong>policies</strong><strong>and</strong> <strong>procedures</strong>.We suggest:■ First, establish a st<strong>and</strong>ard format inwhich all <strong>policies</strong> <strong>and</strong> <strong>procedures</strong>will be written. Having a st<strong>and</strong>ardwill provide consistency in how the<strong>policies</strong> <strong>and</strong> <strong>procedures</strong> look <strong>and</strong>allow employees to readily recognizethem as relevant to compliance.■ Second, it is important to establish acontrolled revision process for all<strong>policies</strong> <strong>and</strong> <strong>procedures</strong>, includingmaintaining a history of changesmade over time. A crucial part of thisrevision process is to ensure the <strong>policies</strong><strong>and</strong> <strong>procedures</strong> are reviewed<strong>and</strong> approved by all relevant partiesbefore being communicated to theentire organization.■ Third, ensure the <strong>policies</strong> <strong>and</strong> <strong>procedures</strong>are readily available toemployees, management, <strong>and</strong> theBoard for quick reference/clarification.Having these <strong>policies</strong> <strong>and</strong> <strong>procedures</strong>in a location <strong>and</strong> format that<strong>Health</strong> <strong>Care</strong> <strong>Compliance</strong> Association • 888-580-8373 • www.hcca-info.org