Why Managing Compliance Risk Is Like Eating Spinach 

The overwhelming pace and complexity of healthcare regulatory change have become so routine that the constant grind now poses a distinct compliance risk to the organization it’s intended to protect. 

Yet, many hospitals still treat regulatory change as a routine monitoring activity, failing to adopt the systems thinking and discipline necessary to truly mitigate the risk.  

This article by a top healthcare compliance expert explains what it takes to make that transformation. (She also explains what spinach has in common with compliance risk assessment.) 

Beyond Spinach: A Systems Thinking View of Regulatory Change  

’Tis the season! Compliance risk assessment season, that is.  

Many healthcare organizations are in the middle of this annual “eat your spinach” preventative exercise, with compliance folks wandering the halls asking executives what keeps them up at night.  

This year, a CFO for one of my hospital clients raised a significant risk that is so ever-present it’s often treated as a constant rather than a risk. The pace and complexity of regulatory change in healthcare are so familiar that they’re easy to overlook as a distinct risk.  

Regulatory Change Complexity as Permanent Risk  

For those who do recognize and record risk, this one almost certainly hits near the top of the scoring index. Regulatory change in healthcare isn’t an occasional disruption. It’s a permanent condition of the operating environment.  

Despite recognizing it as a top risk year after year, many organizations still manage regulatory change as a monitoring activity rather than applying systems thinking. Updates are tracked. Summaries are circulated.  

But when change actually occurs, the organization is left to work out (often manually and inconsistently) what the change means and what to do next.  

Systems Thinking Brings Structure to Reducing Compliance Risk 

From a systems-thinking perspective, this is a structural failure, not an execution problem.  

A persistent, high-scoring risk should not rely on individual effort, institutional memory, or ad hoc judgment calls to be managed effectively. It should be supported by infrastructure that reliably converts inputs into outputs.  

In this case, the input is regulatory change. The needed outputs are: 

• Applicability analysis 
• Operational decisions 
• Documented rationale 
• Accountable follow-through 

Failing to Operationalize Compliance Leaves You Open to Risk 

That’s where many regulatory compliance programs feel the strain. The risk isn’t failing to notice regulatory change. The risk is failing to operationalize it in a consistent, defensible way, especially across multiple departments, leaders, and decision points.  

From Effort-Based Compliance to System-Based Compliance 

Coming out of risk assessment season, this creates an opportunity to ask a more fundamental question: Do we actually have a system for managing regulatory change, or do we just know it’s a problem?  

Seen this way, the value isn’t the technology itself. It’s the shift from effort-based compliance to system-based compliance. And with systems and technology, you can do all this in a way that is repeatable and reviewable.  

In short, “eating your spinach” and doing annual assessments is good discipline. Relying on systems is how you stay healthy the rest of the time.  

About the Author 

As principal for AlloImpact LLC, Lisa Estrada provides Strategic Interim Compliance Leadership to hospitals, health systems, health industry vendors, and other healthcare organizations when a leadership vacancy or transition creates an inflection point—turning the moment into an opportunity to pivot, strengthen, and systematize.  

Whether bridging a CCO gap, stabilizing during mergers or growth, responding to heightened regulatory scrutiny, or modernizing a program that’s outgrown its practices, she helps teams build frameworks and cultures that endure. 

Lisa’s work centers on building systems that make compliance durable. By designing and helping teams implement repeatable, resilient processes that scale and stand under scrutiny, Lisa helps organizations move beyond heroics, so compliance keeps working even when key people change. 

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The post From Manual to Scalable: How to Manage Healthcare Compliance Risk  first appeared on YouCompli.

In this article, Lisa Estrada shares her perspectives on why systems beat heroes in compliance and how AI can help accelerate systems thinking in fast-paced healthcare environments. 

Lisa is a seasoned compliance executive with more than 25 years in healthcare, including serving as Chief Compliance Officer for several large, national health systems. See more of her impressive credentials at the end of this blog. 

Systems Beat Heroes: The Quiet Advantage in Compliance 

Ever notice how organizations love a hero story? The person who swoops in, tackles the problem, and saves the day. For the individual, there’s the rush of feeling impactful and the shout-out at the team meeting. For the organization, the crisis is averted, allowing it to direct resources to other pressing challenges. That is, until the next crisis pops up. 

This hero-driven culture is the norm in the healthcare systems where I’ve worked. And as a compliance leader, I’ve fallen into the trap of believing that a key way to establish the value proposition for the compliance function is to show up as the hero, avert the crisis and bask in the glow of the company-wide shout out.  

The Alternative to Hero-driven Compliance Culture 

But is assimilating into the hero-driven culture the right strategy for a compliance program?  

I’ve had a chance recently to think about this question in a very personal way. Since leaving behind my life as a senior legal and compliance executive at large health care systems, I’ve started providing interim compliance leadership services to small health care organizations — standalone hospitals, small systems, and health tech start-ups.  

I’m often a one-woman show writing on a blank or nearly blank slate. And on a near-daily basis, I face a choice between swooping in, tackling a problem and saving the day or stepping back, thinking holistically and building systems that will minimize the need for heroes longer term.  

Given that my role as an interim is short-lived by design, the choice is obvious — build systems that will help the organization navigate through compliance challenges long after my engagement ends. Even so, it can be a challenge to quell my inner hero — to focus on the complex and time-consuming task of building systems while forgoing the quick gratification of popping out an answer or a quick fix. 

Experiencing this tension has really highlighted for me how building strong systems is the counterbalance to playing the hero. And that, ultimately, building an effective compliance program requires prioritizing systems over heroes.  

What Is “Systems Thinking” in Compliance? 

Systems thinking views compliance as an interconnected web of people, processes and technology. This approach builds resilient workflows that deliver consistent results, no matter who’s on point. 

Why Systems Beat Heroes 

• Consistency: A system runs the same way every time, reducing risk and variability. 
• Scalability: Growth doesn’t depend on hiring more “unicorns.” 
• Resilience: When someone leaves, the process doesn’t fall apart. 
• Defensibility: Audit trails and documentation demonstrate effectiveness. 

What Systems Can’t Do 

Systems can’t do everything; they don’t obviate the need for judgment. Instead, they help pinpoint exactly where judgment is needed. In other words, systems can take care of routine and predictable aspects of compliance work, allowing the compliance team to focus their expertise on those unique or complex scenarios that need thoughtful decision-making and judgment calls. 

Moving from Heroics and Reactivity to Systems Steadiness 

The shift from heroics to systems thinking requires a move away from reactivity. In a reactive mode, attention is naturally drawn to individual problems that are urgent, visible and immediately solvable. The focus on immediate fixes makes it harder to step back slow and zoom out enough to see the larger patterns at play. This is a perfect description for most (if not all) corporate environments I’ve experienced. 

Systems thinking, on the other hand, involves creating the space to recognize how the system as a whole shapes recurring issues. Instead of focusing narrowly on the problem, it involves zooming out and asking questions like: 

• What pressures, structures or gaps made this outcome likely? 
• What yellow or red flags are we missing until something breaks? 
• What incentives are unintentionally rewarding risky behavior? 

Systems thinking can also mean building playbooks, decision rules and feedback loops for frequently arising compliance issues.  

How Can AI Help with Systems Thinking in Healthcare Compliance? 

In the real world, compliance leaders are often required to react to urgent issues. The question then becomes how best to toggle back and forth between reactivity and systems thinking. One tool for facilitating this balance is an AI assistant. I’ve found that AI can help create that crucial space to step back and see the system as a whole, while still allowing me to toggle back to reactivity when needed. 

In my work, I have come to rely heavily on AI as a thought partner – helping me to extract and organize my knowledge and experience into repeatable, shareable protocols customized to a particular organization’s needs.  

Three Examples of AI as Systems Thinking Partner 

Here are three specific examples of how I have used AI as a systems thinking partner for compliance programs: 

1. Structured Knowledge Extraction 

This works one of two ways for me. Sometimes I do a brain dump, sharing with my AI assistant my thoughts on  

• What I’m trying to achieve 
• What I’ve seen work or fail in the past 
• What challenges I anticipate 

Other times, I ask my AI assistant to interview me about the problem and possible solutions. Both paths yield a structured outline, allowing me to translate my judgment and approach into clear steps. 

2. Turning Steps into Repeatable Workflows  

Once my AI assistant has my knowledge in a structured form, the next steps are  

• Creating standardized workflows 
• Identifying decision points and criteria  
• Capturing it all in a playbook to hand off to others with plain language instructions, checklists and templates 

3. Continuous Improvement through Continuous Feedback 

Good systems are designed to improve over time. They are structured enough to create consistency and clarity, but flexible enough to absorb real-world experience from the people who use them.  

AI can support this by helping surface patterns, friction points, and recurring questions that emerge as the protocol is used day to day. This facilitates a continuous feedback loop in which protocols can be regularly refined to better reflect how work actually happens.  

The Takeaway: A Fresh Way of Viewing Compliance Effectiveness 

What I’m advocating for here is a different way of thinking about effectiveness in compliance. Being the person who can step in, solve the problem, and keep things moving can feel like success — and in the short term, it often is. But over time, that pattern can hide deeper system weaknesses and make organizations overly dependent on individual heroics. 

Systems thinking offers a quieter alternative. It invests in structures that make good outcomes more likely without constant intervention. When systems are doing their job, judgment doesn’t disappear — it gets used more intentionally in the situations that truly require it. 

I’ve learned that tools like AI can ease and accelerate this shift by helping translate experience and intuition into shared workflows that others can use and improve. The goal isn’t perfection or automation for its own sake, but durability: compliance programs that continue to function well even as people, priorities, and pressures change.

About the Author 

As principal for AlloImpact LLC, Lisa Estrada provides Strategic Interim Compliance Leadership to hospitals, health systems, health industry vendors, and other healthcare organizations when a leadership vacancy or transition creates an inflection point—turning the moment into an opportunity to pivot, strengthen, and systematize.  

Whether bridging a CCO gap, stabilizing during mergers or growth, responding to heightened regulatory scrutiny, or modernizing a program that’s outgrown its practices, she helps teams build frameworks and cultures that endure. 

Lisa’s work centers on building systems that make compliance durable. By designing and helping teams implement repeatable, resilient processes that scale and stand under scrutiny, Lisa helps organizations move beyond heroics, so compliance keeps working even when key people change. 

• One Compliance Pro’s Regulatory Change Management Process    by Amy Laufmann, MBA
• Five ways to show how healthcare Compliance delivers value by Jerry Shafran
• Revenue Cycle Management Compliance: Ensuring… by Maya Turner, CPMA, CPCO, CFPC, CPC, CPC-I, AAPC
• 12 key metrics for compliance officers looking to… by Kenneth Zeko, JD, CHC
• Transforming Compliance to a Department of Yes  by Lisa Herota, RHIA, CHC, CHPS, CCS Compliance & Privacy Officer
• Three Strategies to Align Compliance with Revenue Cycle  by CJ Wolf, MD
• How the Three Lines Model Strengthens Healthcare Compliance by Kenneth Zeko, JD, CHC
• Navigating Compliance Responsibility: A Foundation… by Amy Laufmann, MBA
• Mitigating Conflicts of Interest that Drive Profit… by Susan Thomas
• New Regulation– Now What? Step-by-Step Guide to… by Amy Laufmann, MBA

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The post How to Build a Holistic Approach to Healthcare Compliance with Systems  first appeared on YouCompli.

It’s the nature of our mission to stay on top of what’s happening in the world of healthcare compliance. And right now, that focus couldn’t be more important.  

These are unusual times, and Compliance is feeling the impact. The Medicare Fiscal Year 2026 Final Rules were expected to be late but came through on time. However, hospitals must still rush to analyze and respond with action plans in short order. CMS transmittals are also likely impacted by the government shutdown (more on that later). 

That leaves many hospital compliance teams unprepared and under-resourced to cope with fast-coming changes. The price of noncompliance, even under extenuating circumstances, is reimbursement risk. 

Two Areas Needing Compliance Attention: Final Rules and Transmittals 

• Final Rules – Legally binding federal regulations that establish new policies in particular areas of healthcare. 
• CMS Transmittals – Internal instructions for updating CMS operational manuals to reflect new or changed policies. 

Two Important CMS Timelines: Fiscal Year and Calendar Year 

The CMS guidance for healthcare comes with its own deadlines attached, and every year there are two important and separate timelines for fiscal year and calendar year Final Rules.  

In healthcare, fiscal year guidance typically has an October 1 effective date, and that Final Rule usually drops in August. This year, YouCompli analysts got through the fiscal year Final Rules incredibly quickly, because CMS cut a lot of the material in the preamble, and that allowed more efficient review and analysis. 

Effective Date of Calendar Year Final Rule Coming Up Fast 

As every seasoned compliance professional knows all too well, CMS puts out a handful of big, omnibus rules for different areas of health care on an annual basis. This time of the year brings us the final rules affecting outpatient costs and billing. These areas usually get addressed during the calendar year, and these calendar year communications started dropping this year on November 5. That gives an effective date of January 1 of the next year.  

It’s important to get these annual changes synthesized and implemented in a health care organization because they cover the entire year. Even when Rules drop at the usual time (and not during a government shutdown), the short time frame to the established effective date still puts pressure on providers to analyze and develop a compliance action plan. That’s where having a partner like YouCompli already breaking down these rules and translating them into actionable business requirements is essential.  

Transmittals Could Be Delayed and Affect Claims Processing 

On top of concerns about Final Rules delays, CMS transmittals ceased to come out on September 30. Transmittals are typically issued on a running basis as they come up. In a given month, you can have anywhere from 15 to 150 transmittals come out.  

A CMS transmittal is not the same as a Final Rule. They are two distinct types of guidance documents from the CMS. Transmittals are official documents to communicate new or changed policies, procedures, claims and other operational guidance to Medicare administrative contractors (MAC), regional offices, and healthcare providers. The communications update specific CMS program manuals, instructions, and other documentation to ensure consistent implementation of Medicare rules.  

MACs Also Risk Claims Backlog with Transmittal Delays 

Another job of a transmittal is to direct the MACs on what to do in processing claims. These third-party contractors are hired by CMS to administer claims, and they can get backlogged on their instructions and claims processing when transmittals run late.  

Any claims processing delays impact providers, so it’s important to keep an eye on when these transmittal communications come out, especially if it drags out for weeks. If MACs struggle with claims processing because they can’t keep up with the updates, providers lose money. 

Whether it be through time-related loss, because then they have to reissue claims with fixes and things of that nature, delays directly impact revenues. That’s not good at a time when health systems are already under the gun. 

Solution: Proactive Compliance to Know, Act and Verify 

If you’re a YouCompli customer, you wouldn’t have to scramble to prepare for last-minute changes, because we would handle it.  

If communications are ever delayed, creating a time crunch, let us act as your analysist team, grabbing communications as soon as they come out, and breaking it down for you. We capture the necessary data and deliver it, along with easily understandable business requirements.  

You’ll know what you need to do to comply, so when the next Final Rule or transmittal hits your inbox, you’re ready to run with updating procedures, training and other requirements.  

We suggest getting on board with us now, so when that time comes, you’re not struggling with these risks and delays.  

About the Author 

Nate Ward, J.D. is the Manager of Compliance and Content Development at YouCompli Software. He comes from a deep background in healthcare compliance and the legal field. Nate leads a team of experts who read regulations, analyze how they apply, and recommend action plans for healthcare compliance.   

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27 Ungated Resources for Compliance Leaders and Teams 

Compliance professionals sometimes feel undervalued in comparison to other functions in their organization. They think leaders and colleagues don’t really understand what they do.  

These resources will help. Packed with ideas, tips and recommendations, these pieces were written by professionals with many years of compliance experience. 

You can quickly skim for articles that relate to your needs and interests. Bookmark this page as a reference for future questions or projects.

Visit Now

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The post How to Prepare for New CMS Final Rules and Transmittals  first appeared on YouCompli.

In every organization there is a moment where the quality department becomes either the trusted operational partner or the operational roadblock. The difference tween the two comes from how you communicate, assign responsibility and how you follow through. This blog explains how to adopt the OG style for more effective quality programs in healthcare. 

Comparing Two Styles of Quality Performance 

There are two guys – let’s call them Young Buck and OG. The Young Buck is probably 30, limitless energy, the one-man wrecking machine. You know that guy. Full of passion or some other nonsense. All gas and no brakes. Runs through the facility on a crusade to save the world. All alone. Takes on all the tasks but somehow, really accomplishes nothing except annoying everyone else on the team with his constant question of “Need anything?” 

OG is a bit different. Older. Works like he is 30 with the wisdom that comes from being 20 years older. Shaved head, salt-and-pepper beard. Dresses as he wants because he has the street cred and knowledge to back it up, so no one cares. Works as an individual contributor but has a connection to everyone on the leadership team. Can tell you about all their strengths. Kills every audit, understands the entire operation. Has paid his dues, knows who he is and does not chase anyone’s validation except his own. 

Operational Partner or Quality Roadblock? 

The OG knows a thing or two about operational improvements that matter. He goes beyond simple efficiency improvements such as how units are staffed or cost-cutting initiatives like slashing overtime because the team is over hours.  

The OG embraces the philosophy that all aspects of the organization work harmoniously to deliver maximum value to customers, while minimizing waste and variation in processes (Six Sigma, 2025). It’s simple execution like this, isn’t it?  

• The organization develops systems that promote problem-solving at all levels. 
• Best practices are the norm not the exception  
• Cultivate culture where improvement is habitual, not exceptional.  
• Discipline and consistency are staples that override passion and enthusiasm. 

The operational roadblock is not always the guy who says no, at least not in this scenario. What we are describing is far too common. This roadblock doesn’t know what he doesn’t know and is too focused on short-term results (his own) than on long-term gains (the team’s). He’s in favor of acting but instead of evolving his processes thoughtfully, he wants to make significant changes to the way an organization operates. What this does is create bottlenecks, upset the status quo and build employee resistance. 

OG or bottleneck? Take your choice:  

• Long-term investment or short-term expense?  
• Streamlined processes or maximized rework? 
• Improved quality control or weakened inventory management?  

Us, too. The difference is how you communicate, how you assign responsibility and how you follow through. 

Three Ways to Partner like a Pro 

Want to be more like the OG? Here are some tips for more effective quality operations: 

1 – Communication: Be clear. Be direct. Know what you want to say before you actually say it. Think it out and then say it. Don’t be monologuing at people like Carson on The Tonight Show. You don’t need people to necessarily like you. It helps but it helps more if they respect you. The only way to get that is to tell them what needs to be said, say it and then follow up when needed. 

2 – Responsibility: Assign tasks to people for things they can be responsible for and actually succeed in. Read that again. It is selected delegation. Holding people responsible for things that they cannot perform is a recipe for disaster. In cliched terms, hold your people accountable. 

3 – Follow Through: So simple it only takes one sentence. Do what you say you are going to do, how you said you’d do it, when you said, over and over again. Period. That’s it. All you need to do. 

OG Your Way to Effective Quality and Compliance 

You don’t need to “young buck” your way through quality and compliance. The only way to be the OG is to become respected, highly regarded, skilled and authentic in what you do. Your team and organization will thank you. 

Ready to Learn More? 

We’ve got more resources on quality and compliance in healthcare. Have a look at these three selections: 

White Paper: How Compliance Drives Healthcare Quality and Safety 

Effective compliance management directly supports quality care, operational efficiency, and financial stability. Read the white paper for practical ways to leverage compliance as a strategic asset, transforming regulatory obligations into opportunities for excellence in patient care and organizational success. 

Blog: Four Ways to Integrate Compliance with Safety/Quality Efforts 

How can your compliance program answer the OIG’s call and include patient safety and quality in your oversight efforts? This blog explores four practices to integrate safety/quality concerns into compliance practices. 

Blog: Building a Quality Education Program That’s Good Enough 

It’s essential that you build a quality education program that works. Doing that right means covering the basics well, not adding fancy bells and whistles. This blog explains what will lead to training sustainability for you and the organization.   

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Andrea has taught first grade in Willoughby, Ohio for 27 years in the same classroom that she attended school as a child. She earned a Bachelor of Science in elementary education with a minor in language arts from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

John builds and fixes quality departments, while currently thriving as the Administrator & Director of Quality, Risk Management and Compliance at River Vista, a behavioral hospital in Columbus, Ohio.

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The Q-Kids – John R Nocero and Andrea L Bordonaro – are experts at everything quality, regulatory, education training and compliance and love sharing their knowledge on YouCompli.

Follow them on LinkedIn – for more quality content or send them a message – they’d love to hear from you.

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• One Compliance Pro’s Regulatory Change Management Process    by Amy Laufmann, MBA
• Five ways to show how healthcare Compliance delivers value by Jerry Shafran
• Revenue Cycle Management Compliance: Ensuring… by Maya Turner, CPMA, CPCO, CFPC, CPC, CPC-I, AAPC
• 12 key metrics for compliance officers looking to… by Kenneth Zeko, JD, CHC
• Transforming Compliance to a Department of Yes  by Lisa Herota, RHIA, CHC, CHPS, CCS Compliance & Privacy Officer
• Three Strategies to Align Compliance with Revenue Cycle  by CJ Wolf, MD
• How the Three Lines Model Strengthens Healthcare Compliance by Kenneth Zeko, JD, CHC
• Navigating Compliance Responsibility: A Foundation… by Amy Laufmann, MBA
• Mitigating Conflicts of Interest that Drive Profit… by Susan Thomas
• New Regulation– Now What? Step-by-Step Guide to… by Amy Laufmann, MBA

The post Healthcare Quality Leadership: How to Be an Operational Partner, Not a Roadblock first appeared on YouCompli.

Peripheral vascular disease (PVD) reimbursement is fraught with potential compliance pitfalls. With increased scrutiny and worrisome statistics about improper payments, healthcare providers must identify and mitigate any PVD compliance risks that could jeopardize their operations.  

This expert-written blog addresses the pressing concern of compliance risks in PVD reimbursement. It provides insights into regulatory trends, recent investigations and best practices.  

Equip yourself with the knowledge to navigate this complex environment and safeguard your organization’s reputation and financial sustainability. Learn effective strategies to mitigate compliance risks in peripheral vascular reimbursement by focusing on medical necessity and adherence to guidelines. 

What’s your compliance risk when it comes to reimbursement for specific medical procedures like peripheral vascular interventions (PVD)? 

Hospitals, health systems and medical practices providing peripheral vascular procedures should be aware of recent scrutiny of these services by government enforcement agencies. 

What Therapies Target Peripheral Vascular Disease? 

Peripheral vascular disease can result in the narrowing or blockage of arteries in the periphery, such as the lower extremities. There are many different therapies to address PVD, including the typical first-line treatment of lifestyle changes and medications.  Lifestyle changes include quitting smoking, eating a healthy diet low in saturated fats, regular exercise and weight management. Some PVD medications include the statin class of drugs, antiplatelet agents, ACE inhibitors and others.   

If lifestyle changes and medications don’t work, and certain clinical criteria are met, patients can undergo peripheral vascular procedures. These are minimally invasive procedures intended to improve blood flow through the arteries. Angioplasties, atherectomies and placement of stents are types of peripheral vascular procedures. 

OIG Looks at Compliance Risk in PVD Reimbursement  

Enforcement agencies are concerned with the increasing volume of these procedures. The problem relates to suspicions that some clinicians perform these procedures when they’re not medically necessary. 

The HHS OIG has added two different projects to their work plan related to peripheral vascular procedures. The first is “Utilization of Peripheral Vascular Procedures and CMS’s Related Program Integrity Efforts.” They report that in one calendar year, Medicare paid more than $600 million for atherectomies and angioplasties in peripheral arteries with and without a stent.   

Editor’s Note: The Work Plan is a guide to OIG priorities around oversight and compliance. By reviewing the Work Plan, health systems can identify potential compliance risks and proactively take action to mitigate them. 

Fraud Concerns Over Vascular Reimbursement Volume 

The OIG also states that both CMS and whistleblower fraud investigations have identified these surgeries as vulnerable to improper payments. This particular project is designed to determine trends in Medicare fee-for-service for surgeries in peripheral arteries over several years and identify paid claims that exhibit questionable characteristics.  

The OIG will also describe program integrity activities that CMS and its contractors have taken to combat fraud, waste and abuse specific to procedures in peripheral arteries. The report is expected to be issued in 2026. 

Understanding Medicare Compliance for Vascular Interventions 

The second work plan project is named “Medicare Payments for Lower Extremity Peripheral Vascular Procedures.” The OIG reports that peripheral vascular procedures in an office setting have increased among the Medicare population over the past decade.  

In fact, OIG says for calendar years 2022 and 2023, Medicare paid approximately $1.16 billion for lower extremity peripheral vascular procedures in office settings. Their concern is that these procedures are generally recommended only after patients have exhausted medical and exercise therapy and have lifestyle-limiting symptoms.  

The OIG plans to analyze Medicare fee-for-service for peripheral vascular procedures for questionable characteristics. They would also like to assess whether these procedures complied with CMS requirements and met applicable treatment guidelines. This report is expected to be released in 2025 under report number W-00-24-35914. 

Whistleblower Fraud Investigations Find Compliance Issues 

The OIG reported that there have been some whistleblower fraud investigations concerning these procedures. One case recently occurred in Florida where the whistleblower was a physician who claimed a vascular center and its providers were performing and billing for medically unnecessary peripheral vascular procedures.   

The government intervened in the case and alleged the providers submitted false claims to Medicare for percutaneous transluminal angioplasties that were not reasonably or medically necessary because they were performed without appropriate diagnostic imaging or clinical justification.   

The case was resolved when the medical providers agreed to pay $810,301, of which $337,625 was restitution. The defendants also agreed to pay $85,000 for the whistleblower’s reasonable expenses, including attorneys’ fees and costs. 

Report: Faster Treatment, Higher Costs with Office Procedures 

The Journal of Vascular Surgery published a report in June 2024 that concluded Medicare patients with peripheral artery disease are treated more quickly but undergo higher cost interventions in office-based laboratories compared to outpatient hospital settings. 

The authors used publicly available Medicare fee-for-service claims data spanning a five-year period that identified all patients undergoing certain peripheral procedures for certain conditions. They then evaluated the associations of patient and procedure characteristics with the site of service. 

Steps for Compliance in Peripheral Vascular Reimbursement 

So, what’s a compliance officer to do?  The first step is to determine the level of involvement the organization has in these particular procedures.  

If found to be significant, it’s probably wise to evaluate the clinical guidelines and policies in place for use of peripheral vascular procedures. Most organizations have a medical director or department chair who could guide a review to determine if procedures are medically necessary.  

Seek Out External Resources about PVD Compliance 

Alternatively, seeking external expertise is also an option. Though professional societies’ clinical practice guidelines are not the “end-all,” it might be useful to reference such guidelines as a starting point.  

These might include: 

• Society of Vascular Surgery

• American College of Cardiology/American Heart Association Joint Committe

• Society of Interventional Radiology

Best Practices for Peripheral Vascular Procedure Compliance  

Most compliance programs only perform medical coding reviews of the procedure documentation, but the OIG suggests including medical necessity audits as well. In their General Compliance Program Guidance (GCPG) document, they state, “Medicare requires, as a condition of payment, that items and services be medically reasonable and necessary.  

“Therefore, entities should ensure that any claims reviews and audits include a review of the medical necessity of the item or service by an appropriately credentialed clinician. Entities that do not include clinical review of medical necessity in their claims audits may fail to identify important compliance concerns relating to medical necessity.” 

Given this, compliance professionals shouldn’t ignore the question of medical necessity for peripheral artery procedures. Scrutiny of these services continues to be a priority for the OIG and their work plan as well as the Department of Justice, as evidenced by cases that result either from data analytics or whistleblowers. 

Confident Compliance Starts Now 

YouCompli customers are confident in their approach to compliance challenges like managing PVD reimbursement. Learn more about the unique combination of expert human analysis and digital compliance management tools. 

CJ Wolf, MD, M.Ed. is a healthcare compliance professional with over 22 years of experience in healthcare economics, revenue cycle, coding, billing, and healthcare compliance. He has worked for Intermountain Healthcare, the University of Texas MD Anderson Cancer Center, the University of Texas System, an international medical device company and a healthcare compliance software start up. Currently, Dr. Wolf teaches and provides private healthcare compliance and coding consulting services as well as training.   

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• One Compliance Pro’s Regulatory Change Management Process    by Amy Laufmann, MBA
• Five ways to show how healthcare Compliance delivers value by Jerry Shafran
• Revenue Cycle Management Compliance: Ensuring… by Maya Turner, CPMA, CPCO, CFPC, CPC, CPC-I, AAPC
• 12 key metrics for compliance officers looking to… by Kenneth Zeko, JD, CHC
• Transforming Compliance to a Department of Yes  by Lisa Herota, RHIA, CHC, CHPS, CCS Compliance & Privacy Officer
• Three Strategies to Align Compliance with Revenue Cycle  by CJ Wolf, MD
• How the Three Lines Model Strengthens Healthcare Compliance by Kenneth Zeko, JD, CHC
• Navigating Compliance Responsibility: A Foundation… by Amy Laufmann, MBA
• Mitigating Conflicts of Interest that Drive Profit… by Susan Thomas
• New Regulation– Now What? Step-by-Step Guide to… by Amy Laufmann, MBA

The post How to Avoid Compliance Risk in Peripheral Vascular Reimbursement   first appeared on YouCompli.

On a daily basis, compliance officers are asked to find solutions to a variety of operational requirements. For example, consider a regulatory change requiring the organization to adjust an operational process in order to bill for a particular service. In this case, the solution must be compliant and operational-friendly, but who’s responsible for making that happen? 

While supporting operations in finding compliant solutions is part of our role, becoming the de facto fixer of what constitutes “operationally friendly” is beyond our scope. That piece must be owned by operations.  

The challenge then becomes how to get operational leaders to take ownership for resolving their own compliance challenges. 

Five Strategies to Help Operational Leaders Take Responsibility 

These five strategies will help your operational leaders take responsibility for their particular compliance issues, while preserving your role as a trusted advisor. 

#1 Use a “Coach” Mindset, Not a “Gotcha” One 

If you want your leaders to take more ownership of their own compliance challenges, then position yourself as a coach who helps them think through problems and find solutions—not as a person who catches mistakes. 

To pull this off, you need to be intentional about the types of questions you ask. More specifically, you want to ask curiosity-based questions, not judgmental ones. Here are some examples of guiding questions you can ask as you’re helping them find a solution:  

• What challenges are you facing right now? 
• Is there a part of this new regulatory change that feels uncertain to you? 
• What steps do you think you need to take to address this issue? 
• What’s one small step you could take today to move forward? 
• What options or solutions have you considered? 

Know When to Step In and When Not To 

Having a coach mindset also means knowing when to step in—and when not to. For example, your role is to escalate compliance risk when appropriate (e.g. a deadline looks like it’s going to get missed), but it’s not to do the operational work for them (e.g., following up with a subject matter expert for their input).  

If a leader doesn’t take action despite your support, then resist the urge to fix it yourself. Instead, document it and elevate appropriately within your organizational structure to bring about resolution. 

Having a coach mindset encourages operational leaders to own their compliance challenges because when leaders feel heard and supported, they’re more motivated and invested in their work to find a solution. Also, by supporting those closest to the work in addressing issues, it leads to more practical (and often) faster solutions. 

#2 Frame Risk as Operational Risk, Not a Compliance Burden 

In my experience, operational leaders are more likely to engage when compliance is framed in business terms and not compliance jargon. For example, instead of reading or citing regulations, explain the operational impact of the requirement to them. Talk about things like billing delays, lost revenue, patient safety, or reputational damage.  

Additional topics to consider when framing risk as operational risk include: 

• Patient care 
• Staffing 
• Operational costs 
• Budget variances 
• Workflow 

Framing risk as operational and not as a compliance burden helps promote ownership in solving compliance challenges for a couple of reasons. First, this approach speaks their language. When you frame risk in terms that operations understand, they’re more likely to grasp the urgency and relevance of the ask.  

Second, it makes the problem theirs—not yours. If the risk is shown to impact their budget, performance metrics, or reputation, they’re more likely to feel responsible for addressing it.  

Finally, presenting risk in this way increases engagement and accountability. When compliance risks are reframed as disruptions to their performance goals—employees naturally step into problem-solving mode and take accountability.   

 
#3 Stay Curious, Not Critical 

In my experience, the most effective way to approach communications with operational leaders when it comes to compliance is one rooted in a curious mindset, not a judgmental one.  

For example, let’s assume a leader did not follow through on something they said they would do. A judgmental way to respond would be: “You said you would do this, but clearly that meant nothing.” On the other hand, if you said, “Tell me what challenges you’re facing in moving this forward?” that comes across less adversarial, and more likely to produce a collaborative discussion.   

To help compare and contrast the two approaches, consider these additional examples: 

Taking a curiosity-based approach helps support leaders in solving their own compliance challenges because it builds psychological safety by inviting open dialogue and new perspectives. In my experience, operational leaders are more likely to think creatively when they don’t feel scrutinized.  

#4 Make It Easy for Leaders to Act 

Like compliance officers, operational leaders face constant pressure, decision fatigue, and competing priorities—all of which leads to cognitive overload. Relatedly, if the problem-solving process feels overly complex or burdensome, leaders are likely to disengage or defer responsibility.  

To that end, making compliance easier for your leaders doesn’t mean dumbing it down—it means removing friction. (YouCompli Software is designed for this.) 

When you need support, free up mental bandwidth demands by simplifying the work. Clearly communicating expectations or removing unnecessary steps frees up their mental bandwidth. In my experience, when leaders feel less overwhelmed, they are more likely to engage with issues and take initiative.  

So how can you make the work easier for them? Here are some examples that may help: 

• Explain compliance language in terms they can understand. 
• Take the initiative to set up and facilitate root cause analysis discussions. 
• Coordinate and facilitate stakeholder calls to discuss solutions. 
• If they’re feeling stuck, suggest a series of smaller goals to achieve the work. 
• Provide templates, decision trees, checklists, or other tools to make compliance easier. 
• Offer potential solutions (but as pointed out above, don’t take on the work involved.) 

Making the work easier for your operational leaders encourages them to solve their own compliance challenges because it makes the process more approachable and less threatening. That, in turn, increases their willingness to participate and take ownership. When leaders feel less overwhelmed, they are more likely to engage with issues and take initiative.  

#5 Recognize and Reward Ownership 

Finally, another way to foster operational ownership is to call out your leaders (publicly or privately)—in a good way of course—when they take the initiative to solve their own compliance issues.  

For example, let’s assume an audit was conducted in a clinical department related to medical necessity documentation. As part of a corrective action plan, monitoring is needed to ensure the documentation is in the patient’s medical record. If the department director proactively develops a tool for monitoring and vets it with you, then in response, you might say:  

“I really appreciate how you took ownership to proactively develop this tool. That kind of initiative supports us in maintaining a strong culture of compliance in the organization.” 

If leaders only get attention when their problems are escalated to you, they learn to seek approval through dependence. Recognizing effective problem-solving flips the script. It signals that ownership and resolution—not escalation—are what gets rewarded. 

Here are some ways you can recognize and reward your leaders:  

• An unexpected handwritten thank you note directly to the leader, or better yet, the leader’s supervisor  
• One-on-one verbal recognition 
• A note sent from the Chief Compliance Officer (if that’s not you) to the leader 
• Public recognition in a department or team meeting 
• Nomination for a leadership award 
• Feature in a compliance or organizational newsletter 

Recognizing and rewarding great work is helpful for motivating leaders to solve their own compliance challenges. It creates a positive feedback loop where those behaviors become self-reinforcing and then contagious to others on the team. 

Compliance work is complex, and compliance work requires human interaction. That is especially true when it comes to getting your operational leaders to find solutions to their own compliance challenges.  

By following the strategies outlined above, you empower operational leaders to manage their own compliance risks. Just keep in mind that it is a process that takes time, but in the long run, an empowering leadership style will improve buy-in to your program and create a more cohesive culture of compliance.

Download a free PDF Tip Sheet Version of this blog below.

Jay is a compliance professional and consultant in Colorado. He is a healthcare lawyer with significant industry knowledge of the U.S. healthcare market. Over the past 20 years, he has worked for large for-profit and non-profit health systems and small physician-owned entities. In tackling the countless regulatory and operational issues for these diverse organization types, he has developed a deep understanding of the business of healthcare and the regulations governing the industry. 

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27 Ungated Resources for Compliance Leaders and Teams 

Compliance professionals sometimes feel undervalued in comparison to other functions in their organization. They think leaders and colleagues don’t really understand what they do.  

These resources will help. Packed with ideas, tips and recommendations, these pieces were written by professionals with many years of compliance experience. 

You can quickly skim for articles that relate to your needs and interests. Bookmark this page as a reference for future questions or projects.

Visit Now

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• One Compliance Pro’s Regulatory Change Management Process    by Amy Laufmann, MBA
• Five ways to show how healthcare Compliance delivers value by Jerry Shafran
• Revenue Cycle Management Compliance: Ensuring… by Maya Turner, CPMA, CPCO, CFPC, CPC, CPC-I, AAPC
• 12 key metrics for compliance officers looking to… by Kenneth Zeko, JD, CHC
• Transforming Compliance to a Department of Yes  by Lisa Herota, RHIA, CHC, CHPS, CCS Compliance & Privacy Officer
• Three Strategies to Align Compliance with Revenue Cycle  by CJ Wolf, MD
• How the Three Lines Model Strengthens Healthcare Compliance by Kenneth Zeko, JD, CHC
• Navigating Compliance Responsibility: A Foundation… by Amy Laufmann, MBA
• Mitigating Conflicts of Interest that Drive Profit… by Susan Thomas
• New Regulation– Now What? Step-by-Step Guide to… by Amy Laufmann, MBA

The post 5 Strategies for Compliance Accountability Across the Organization  first appeared on YouCompli.

Aligning healthcare regulatory compliance with revenue cycle management is critical to mitigating risks and preserving business integrity. This blog explores three effective strategies to foster collaboration between compliance teams and revenue cycle management.  

Some of the most significant compliance risks faced by healthcare organizations today are found in the revenue cycle. The HHS OIG has stated, “One of the best ways to identify fraud and abuse risks is to follow the money.” 

For many healthcare organizations, this means having a good working relationship with the entity’s revenue cycle team.  

The revenue cycle is the process that starts with a patient’s initial appointment and ends with full payment for services. It encompasses all the administrative and clinical functions that contribute to collecting patient service revenue.  For healthcare organizations that provide services to patients, the revenue cycle is the organization’s financial lifeblood. 

3 Ways Compliance Can Stay Connected with RCM 

If compliance has a good working relationship with revenue cycle management, the two functions can enjoy a fruitful outcome.  

Compliance professionals should consider the following three ways to interact with the revenue cycle team. 

1. Regular Collaboration 

We know from OIG guidance documents that, to be effective, the compliance officer should maintain a degree of separation from the entity’s delivery of healthcare items, services, and related operations.  

Even though this means the compliance officer should not be responsible, either directly or indirectly, for the delivery of healthcare items and services or billing, coding, or claim submission, it does not mean the compliance officer should not be well-versed in these functions through regular communication and collaboration. 

Take Advantage of Compliance Committee Connections 

Regularly collaborating with the revenue cycle team will inform compliance professionals of the specific risks and potential compliance red flags the revenue cycle may be facing.  Many organizations ensure this collaboration by having revenue cycle leadership serve on the organization’s compliance committee.  

In fact, the OIG states the compliance committee “…should be comprised of the relevant leaders of both operational and supporting departments, which could include Billing and Coding, Clinical and Medical, Finance, Internal Audit, IT, HIM, Human Resources, Legal, Quality, Risk Management, Sales and Marketing, and other operational managers.”  Most of the departments suggested by the OIG play a role in the revenue cycle. 

In addition to revenue cycle personnel participating in the compliance committee, collaboration between compliance and revenue cycle can occur on a weekly basis through meetings and sharing of revenue cycle data such as denial rates, reports from electronic claims editors, communications from third party payors and any internal coding and billing monitoring the revenue cycle is performing. 

2. Proactive Claims Auditing  

The OIG tells healthcare providers that they “…should take proactive measures to ensure compliance with program rules, including regular reviews to keep billing and coding practices up to date as well as regular internal billing and coding audits.” 

In organizations that submit claims for services, a sizable number of resources should be dedicated to ensuring the claims they are submitting for reimbursement meet all program requirements.  

The revenue cycle team should have monitoring efforts in place for correct coding and billing.  Also, compliance departments should ensure that independent claims audits are also occurring regularly. 

Assisting Revenue with 60-Day Repayment Rule Requirements  

Even if an entity makes innocent billing mistakes, they have an obligation to repay the money to government third-party payers such as Medicare and Medicaid. The Affordable Care Act included a requirement that entities must report and repay overpayments by the later of: “(A) the date which is 60 days after the date on which the overpayment was identified; or (B) the date any corresponding cost report is due, if applicable.”  Sometimes this is referred to as the 60-day repayment rule. 

If a revenue cycle team’s internal monitoring identifies overpayments, it is critical for compliance departments to know the date of discovery, so the organization does not run afoul of the 60-day repayment rule. If the entity does not monitor the repayment requirements, they could be subject to liability under the Federal False Claims Act. 

3. Training and Education Geared to Job Roles 

Coding and billing rules are regularly updated and can change frequently, and it’s often difficult for busy clinicians to stay on top of the changing regulations. Compliance and revenue cycle teams should work together to ensure those involved in revenue cycle functions are educated on the most current rules. 

The OIG recommends targeting training depending on an individual’s role. Thus, those involved in revenue cycle operations need to provide training and education specific to the nuances of the revenue cycle. The training sessions should cover any compliance risks specific to the learners’ roles and responsibilities.  

Depending on the learners’ roles, these may include: 

• Billing 
• Coding 
• Documentation 
• Medical necessity 
• Beneficiary inducements 
• Gifts 
• Interactions with physicians  
• Other sources or recipients of referrals of federal healthcare program business 

Three Ways to Show You Follow the Money

If healthcare organizations are going to address their biggest compliance risks, they must include the revenue cycle. Compliance professionals can lead in addressing revenue cycle risks by: 

• Driving effective collaboration between compliance and revenue cycle teams 
• Verifying that proper auditing and monitoring of claims are occurring  
• Ensuring those involved in revenue cycle receive targeted training based on their specific role.  

Doing these three things helps show your compliance program is indeed “following the money” as suggested by enforcement agencies such as the OIG. 

About Solutions for Compliance Management and Operations 

Need help keeping track of everything going on in regulatory management? When multiple people and departments are involved, the last thing stretched compliance teams need is more manual work.  

YouCompli compliance solutions keep cross-functional engagement organized, verified and on schedule.  

• Identify and assign specific individuals responsible for completing regulatory requirements. 
• Track progress and on-time completion of all regulatory requirements. 
• Verify that regulatory requirements have been acted upon within the organization. 
• Gauge and quantify potential areas of risk related to incomplete regulatory requirement assignments. 

Detailed reports equip compliance teams with oversight information they need to effectively communicate, act on, monitor, and focus organizational compliance efforts. 

Combine YouCompli solutions with the three best practices in this blog to build productive connections with Revenue and other departments.  

More Resources About Revenue Cycle Management and Compliance 

If you’re interested in learning more about the Revenue angle of healthcare compliance, here are a few additional resources: 

White Paper: Exploring the Four Hot Spots Of the Healthcare Revenue Cycle 

Case Study: Getting It Right: Minimizing Self-identified Overpayments & Maximizing Accurate Billing 

Tips and Tactics: Revenue Cycle Management Compliance: Ensuring Financial Health in Healthcare 

CJ Wolf, MD, M.Ed. is a healthcare compliance professional with over 22 years of experience in healthcare economics, revenue cycle, coding, billing, and healthcare compliance. He has worked for Intermountain Healthcare, the University of Texas MD Anderson Cancer Center, the University of Texas System, an international medical device company and a healthcare compliance software start up. Currently, Dr. Wolf teaches and provides private healthcare compliance and coding consulting services as well as training.   

Download our Latest Whitepaper

Sign-up for our Weekly Newsletter

Qualified compliance professionals do the heavy lifting for you, simplifying regulatory change management  

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27 Ungated Resources for Compliance Leaders and Teams 

Compliance professionals sometimes feel undervalued in comparison to other functions in their organization. They think leaders and colleagues don’t really understand what they do.  

These resources will help. Packed with ideas, tips and recommendations, these pieces were written by professionals with many years of compliance experience. 

You can quickly skim for articles that relate to your needs and interests. Bookmark this page as a reference for future questions or projects.

Visit Now

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The post Three Strategies to Align Compliance with Revenue Cycle  first appeared on YouCompli.

Assertive Communication Skills for Compliance Officers | 8 Steps 

A career in healthcare compliance can be both exciting and overwhelming. You’re tasked with ensuring regulations are followed; risks are managed, and ethical standards are upheld—all while working with clinical and administrative leaders who may have vastly different priorities. 

When it comes to the compliance program, effective communication is essential for building strong relationships, resolving conflicts and gaining buy-in. One of the most valuable interpersonal tools to help you achieve these goals is assertive communication. It allows you to express your thoughts, needs and boundaries in a clear and respectful manner.  

But here’s the challenge—it’s easy to confuse being assertive with being aggressive.  

Understanding the difference between these styles can help you avoid unnecessary conflict and communicate more effectively when it comes to compliance-related needs.  

In this article, I cover: 

• Key differences between the two communication styles 
• How assertive communication benefits the compliance program 
• Strategies to help you master this skillset 

What Is Assertive Communication? 

Assertiveness is a positive form of communication that uses a balanced approach. You express your opinion about something that you want (which is placing value in yourself), while respecting the opinions of the other people involved (which is placing value in others). 

For example, let’s assume your audit plan includes a review of medical necessity documentation for your cardiac rehab program. Let’s further assume the program’s director insists her unit doesn’t need to complete the audit, nor does she have available staff to complete the work.  

Assertive communication might look like you saying:  

“I understand your team is extremely busy right now. However, cardiac rehab billing has been the subject of a number of government settlements lately, and we want to make sure our practices can withstand a government investigation or audit. What if we work together to find the least disruptive approach for your team to complete the work?” 

This response is assertive because it acknowledges the program director’s concerns while communicating a compliance need.  

An assertive approach has several benefits:  

• First, it shows respect for yourself, which can help build confidence and self-esteem as you are expressing your needs in a positive manner.  
• Second, it’s an effective way to resolve conflict because you place equal value on everyone’s opinions.  
• Finally, it strengthens the relationship because you demonstrate respect for others.  

What Is Aggressive Communication? 

Aggressiveness is a negative form of communication. When you communicate aggressively, you offset the above-noted balance by sending a message to others that your opinion has a higher value than their opinion. It tends to be forceful, disrespectful, and often disregards the needs or perspectives of others.  

Let’s circle back to the scenario involving the cardiac rehab audit for a moment. The following might look like aggressive communication when responding back to the program director:  

“This is completely unacceptable. If your team doesn’t care about complying with the regulations, I’ll escalate this to your supervisor and let them know you’re putting the organization at risk.” 

Yikes.  

Such a response is aggressive because it uses blame, sarcasm, threats and an authoritarian tone.  

An aggressive approach can create several risks for the compliance program.  

• While it may produce short-term results, it damages trust and long-term relationships, reducing your chances of buy-in.  
• Taking such an approach demonstrates an intent to shut down dialogue at a time when you need it most for your compliance program activities.  
• It creates an environment where operational leaders feel reluctant to seek your advice. This can result in little messes becoming big ones because leaders are not reaching out to you proactively.  

Key Differences between Aggressive and Assertive Communication 

Generally speaking, assertive communication focuses on standing up for yourself. Aggressive communication focuses on attacking others. To help distinguish the difference, consider the following comparison and ask yourself—which feels more respectful?  

3 Ways Assertive Communication Drives Compliance Success 

Healthcare compliance officers often deal with sensitive topics like billing errors, patient privacy breaches or improper medical record documentation, all of which, by their very nature, can be emotionally charged situations. This makes good communication more important than ever. 

Assertive communication helps when it comes to carrying out sensitive compliance work for three main reasons.  

1. It nurtures your professional relationships.  

Assertive individuals communicate openly (i.e., sharing the good and bad news), which leads to trust and mutual respect while preventing resentment and misunderstandings. Open communication also fosters collaboration, productivity and teamwork. These traits are important when it comes to things like finding a compliant solution to a business proposal or carrying out corrective action plans. 

2. It improves self-confidence and decision-making.  

When individuals advocate for their needs and opinions, they feel more empowered. This confidence leads to better decision-making and problem-solving skills. Assertive communicators are willing to ask questions, clarify expectations, and negotiate effectively. This benefits work such as investigations, internal consulting and auditing.  

3. It encourages respect and professionalism.  

Assertive communication promotes a culture of mutual respect. When you communicate in a way that sets clear expectations and provides constructive feedback, you create an environment where ideas are valued.  

When it comes to things like implementing a new operational process to meet a requirement, or handling a government payer refund, compliance officers must communicate expectations, provide guidance and handle conflicts professionally. These are characteristics of an assertive style that will improve your results. 

Jay is a compliance professional and consultant in Colorado. He is a healthcare lawyer with significant industry knowledge of the U.S. healthcare market. Over the past 20 years, he has worked for large for-profit and non-profit health systems and small physician-owned entities. In tackling the countless regulatory and operational issues for these diverse organization types, he has developed a deep understanding of the business of healthcare and the regulations governing the industry. 

Take Free RL3M Assessment (Regulatory Lifecycle Management Maturity Model)

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Download our Latest Whitepaper

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Qualified compliance professionals do the heavy lifting for you, simplifying regulatory change management  

The post Aggressive vs Assertive Communication: What New Healthcare Compliance Officers Need to Know  first appeared on YouCompli.

Traditionally, many healthcare compliance programs have left the work of patient safety and quality to other departments. However, according to the Health and Human Services (HHS) Office of Inspector General (OIG), “Entities should incorporate patient safety/quality oversight into their compliance programs.”   

OIG’s recent emphasis on patient safety and quality is not necessarily a call for compliance programs to take over these efforts. Rather, it’s a reminder that a compliance program should be designed to address the significant risks health care organizations face, which includes patient safety and quality of care.  

How to Incorporate Quality and Safety into Compliance Practices 

How can your compliance program answer the OIG’s call and include patient safety and quality in your oversight efforts? This blog explores four practices to integrate safety/quality concerns into compliance practices. 

1. Build a Strong Compliance Committee 

2. Provide Safe Reporting for Safety/Quality Concerns 

3. Get Your Governing Board Involved with Quality of Care 

4. Nurture Relationships with Quality and Safety Leaders 

Four Ways to Drive Greater Connection Between Compliance and Safety/Quality 

1. Build a Strong Compliance Committee 

Most mature compliance programs have a compliance committee in some form or fashion. To build stronger safety and quality representation, include individuals responsible for quality assurance and patient safety as members of the committee. 

A strong compliance committee should ensure that appropriate auditing and monitoring of patient safety and quality take place on a regular basis. The OIG goes as far as suggesting that “Compliance committees of entities directly furnishing patient care, particularly entities such as hospitals, long-term care facilities, and other entities providing residential care, should also assess staffing for nursing, therapy, and other clinical services to ensure that the entity has the appropriate quantity, quality, and composition of care providers.” 

2. Provide Safe Reporting for Safety and Quality Concerns 

Compliance programs establish lines of communication for reporting concerns, and anyone aware of patient safety or quality concerns must know how to report such incidents or issues. They must also have confidence they won’t face retaliation.  

Awareness of incidents involving safety or quality is often the first step in developing a correction plan, so it’s essential that those who report know how their information is protected. 

Steps have been taken at the federal level to encourage reporting and analysis of medical errors. The Patient Safety Act and Rule provide federal privilege and confidentiality protections for patient safety information called the Patient Safety Work Product (PSWP). PSWP includes data, reports, records, analyses and written or oral statements related to patient safety events.  

More about the types of protections at the federal level can be found here: https://www.hhs.gov/hipaa/for-professionals/patient-safety/index.html  

 

3. Get Your Governing Board Involved with Quality of Care 

Governing boards of healthcare entities have ultimate accountability for ensuring quality of care, and their involvement can also ultimately benefit compliance outcomes.  

There are many resources available to educate your board on their responsibilities related to quality. These include: 

• “Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors”
• “Driving for Quality in Acute Care: A Board of Directors Dashboard”
• “Driving for Quality in Long-Term Care: A Board of Directors Dashboard” 

Read and share these with board members to help them stay informed more easily.  

4. Nurture Relationships with Quality and Safety Leaders 

Compliance departments aren’t expected to take over the detailed, day-to-day management of quality and patient safety programs. However, it’s essential that compliance leaders develop productive working relationships with leaders and in-house experts within the organization’s quality and patient safety programs. 

One way to develop productive working relationships is to better understand what quality and safety leaders do. A good resource for learning more about the standards, goals and language often used by quality and safety leaders is the Institute for Healthcare Improvement or IHI (https://www.ihi.org/).  

This organization offers both introductory, intermediate and advance learning opportunities for those who want to become better-versed in quality and patient safety topics. The IHI Open School (https://www.ihi.org/education/ihi-open-school) is a great place to start. And for those looking for more formal recognition, the IHI offers certifications, such as the Certified Professional in Patient Safety (CPPS). 

Compliance, Quality and Safety — Together for Common Good 

The call for compliance programs to become more involved in an organization’s patient safety and quality efforts is getting louder from agencies such as the OIG. It’s also smart business practice.  

In summary, this blog has covered four ways to begin the process: 

• Considerations for your compliance committee 
• Ensuring confidentiality of incident reports 
• Involving the governing board  
• Broaden understanding of what safety/quality leaders do 

With these practices in your toolkit, you’ll be on the path to a stronger, more effective compliance program.  

And to help with overall regulatory analysis and operations, learn more about how YouCompli compliance software can support your mission. The tools include capabilities to easily map and track responsibilities across functions.  

CJ Wolf, MD, M.Ed. is a healthcare compliance professional with over 22 years of experience in healthcare economics, revenue cycle, coding, billing, and healthcare compliance. He has worked for Intermountain Healthcare, the University of Texas MD Anderson Cancer Center, the University of Texas System, an international medical device company and a healthcare compliance software start up. Currently, Dr. Wolf teaches and provides private healthcare compliance and coding consulting services as well as training.   

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27 Ungated Resources for Compliance Leaders and Teams 

Compliance professionals sometimes feel undervalued in comparison to other functions in their organization. They think leaders and colleagues don’t really understand what they do.  

These resources will help. Packed with ideas, tips and recommendations, these pieces were written by professionals with many years of compliance experience. 

You can quickly skim for articles that relate to your needs and interests. Bookmark this page as a reference for future questions or projects.

Visit Now

---

Download our Latest Whitepaper

Sign-up for our Weekly Newsletter

Qualified compliance professionals do the heavy lifting for you, simplifying regulatory change management  

The post Four Ways to Integrate Compliance with Safety/Quality Efforts  first appeared on YouCompli.