With vaccine rates up and COVID infection rates down, healthcare organizations are anticipating the end of the federal public health emergency (PHE) sometime soon and the regulatory change management that comes with it.
In the year and a half since the pandemic began, many highly regulated activities have, understandably, gone minimally watched, and policies and procedures have loosened somewhat to allow for work from home or telehealth. All in the interest of keeping patients and staff safe. (Note I said minimally watched, not unwatched. Even at the height of infections last summer, enforcement actions were still occurring.)
With the likely return to greater oversight and enforcement, many are wondering what policies and procedures need to be updated or converted to reflect the new normal. The need for effective tools to manage regulatory change has never been greater.
A culture of control and managing regulatory change
In the best, most highly functioning hospital system, there is certainly a culture of control when it comes to policies and procedures. There is also a dynamic compliance capability that spans departments and has access to very current updates about the regulations that matter. Leaders are freed up to manage their teams and minimize rogue policies and procedures because they aren’t working through regulatory minutia.
More than 600 regulatory sources have something to say about how US healthcare organizations care for patients and manage their business. They are constantly evaluating practices and updating regulations. An effective policy and procedure system has to keep up with these updates and push them to the people whose work is affected.
Sometimes it’s a big change – one where you’d have an extensive change management and communication plan in place to help people understand the regulations and how the hospital has changed systems and practices to respond. The regulations that came out of HIPAA are a good example of this. Those changes were major undertakings and everyone was paying attention to see what they would need to do differently.
But sometimes – often – the changes are small and easy to miss. I’m thinking of timelines for submitting forms or ensuring a billing code was changed properly. With changes like these, people aren’t on the lookout for them, and they need help changing their habits and practices.
What is a regulatory change management process?
Managing and responding to regulatory change is a significant effort for healthcare institutions. The first step is for the department to be aware of these changes and to have a clear way to assess whether the regulation applies. Many healthcare organizations handle this at the department level, with leaders monitoring relevant listservs, and then reading and interpreting new regulations and changes. Others monitor relevant agencies through YouCompli. The Compliance team receives notifications about regulatory changes from the agencies they care about and then collaborates with affected departments to update policies and procedures.
Once the organization knows about the regulation, someone needs to decide whether it applies to their organization. Some do this by having a department head or compliance analyst read and interpret the reg to determine its relevance. Some look to outside counsel to understand the implications of new or changed regulations. YouCompli customers use the decision criteria we provide. Our Expert Compliance Professionals have already read the reg and identified key questions to ascertain relevance, and we’ve verified the work through expert healthcare counsel. YouCompli users walk through the questions and use those to decide whether the regulation applies to them.
With changes that require action, the organization manages the update, often with the Compliance team providing resources to department heads who need to update policies and procedures. This can involve a time-intensive search for sample clauses or language. YouCompli provides law firm validated model policies and procedures to speed this drafting process.
From there, it’s on the department heads to educate their teams to manage the change and help the institution verify compliance. Coaching the team is arguably the most important element of a leader’s role. It can also be the most compressed step because these leaders are spending too much time interpreting regulations. With YouCompli, these leaders can take the busy work out of demonstrating compliance and communicating back to hospital leadership. This support frees them up to work with their teams and provide excellent patient care that complies with regulatory requirements – no matter how often they change.
No policy, procedure or system will eliminate bad actors or human error. But disciplined systems and practice can drastically improve employee habits, awareness and compliance. Being able to demonstrate best efforts at compliance is incredibly helpful in case of an audit or other questions from regulators.
There’s no need to create a regulatory change management system from scratch. YouCompli has already done the heavy lifting to free your leaders to manage their teams and care for patients.
Are you looking for ways to reduce the time providers and leaders spend reading regs and worrying about changes? Take a look at YouCompli, the only healthcare compliance software combining actionable, regulatory analysis with a simple SaaS workflow.
Jerry Shafran is the founder of YouCompli.