Five tips to help providers comply with Stark

The Stark Law creates a whole set of antikickback rules that providers must understand and actively work to comply with. And with all its good intentions, the Stark Law is incredibly restrictive. In fact, even the U.S. Court of Appeals for the 4th Circuit noted that “even for the well-intentioned healthcare provider, the Stark law has become a booby trap rigged with strict liability and potentially ruinous exposure.”

The Centers for Medicare and Medicaid (CMS) and Congress have taken steps to clear up confusion and loosen the rules in some cases (See our article on exceptions for value-based care). Still, your Compliance team has a tremendous responsibility to make sure that policies match the rules and that providers understand and follow the policies.

Policies match the Stark rules

Changes to the Stark Law have been coming out practically since the law was enacted. The law, which aims to protect against kickbacks and self-referrals, has gotten complicated in the details. Congress issues amendments to help  the law catch up to changing business practices. Healthcare organizations may have written policies that facilitated compliance originally. However, those may be completely out-of-date if they weren’t keeping up with the changes in the law.

For example, CMS has introduced modifications that addressed challenges with value-based care and resolve issues restricting coordinated care and health data exchange. Another modification to the law was allowing healthcare providers to accept cybersecurity tech donations from stakeholders.

While the compliance officer enforces the policies, he or she doesn’t have to live them the way those in operations do. Getting input from key stakeholders such as providers, Risk Management, and others in the C-suite can help ensure that final policies are clear. This early feedback and engagement can also help identify how the policy or regulatory changes will affect the individuals who must operate under them. Lastly, they can help identify potential operational conflicts with new policies or regulatory changes.

(See how YouCompli delivers model policies and procedures that help your organization comply.)

Providers following the Stark policies

With compliant policies in place, it’s time to help providers understand how to follow them. This is where communicating what certain key terms in a policy or regulation means in the context of the provider’s particular work becomes critically important.

Compliance officers know that “the road to success is going to run through quality of care,” says Harry Nelson, health care attorney at Nelson Hardiman. “Compliance isn’t the internal police that slows things down, but a strategic part of growth.” When it comes to making sure providers understand how to follow policies, the compliance officer has to look at the language of the policy from the providers’ perspective, not that of the compliance officer.

Here are five steps to help providers understand and follow Stark-compliant policies:

  1. Engage your operational leaders. Make sure the president and CEO understand the nature and intent behind Stark limitations so they can help explain and reinforce them. Give situational examples they can relate to so they understand what the key terminology means.
  2. Invest in training and communication. One email won’t do it with changes to Stark-related policies. Engage providers in small groups, in writing, and in person to explain nuances and answer questions about tricky scenarios. Whenever possible, use real-world scenarios to help illustrate how the regulations and policies impact them. Education and training should also be routine and ongoing with key stakeholders.
  3. Get feedback. Regularly check in to gather feedback from your leaders. Find out if the implemented tools and procedures are working for them, as well as to identify challenges they face. This step will help you see areas where the  words on paper mean something the compliance officer had not thought of. Adapt procedures and tools if necessary.
  4. Encourage people to ask questions. Make sure providers and your operational leaders alike know they can use you as a sounding board for grey areas or possible violations. It’s much better if they proactively ask if a proposed arrangement is compliant. Otherwise, they may have to unwind a relationship if they find out it is not compliant.
  5. Promote awareness to prevent future mistakes. Once an error is made, chances are it will reoccur and lead to additional violations. As you are addressing errors, promote awareness to prevent future mistakes. For example, when you are communicating the fact that a mistake was made, go the extra step to what caused it. This will be an opportunity to find out where their confusion was and use that insight to update policies or training.

Stark compliance starts with knowing about changes to the regulations and continues with crafting policies that providers can understand and follow. Involving stakeholders in policy creation and training, and engaging tech systems to reinforce the lessons will support the long-term success of Stark-compliant policies.

Do you have the tools you need to recognize and manage regulatory change across your organization? Find out how YouCompli can help you manage and coordinate your response to regulatory change or schedule a demo.

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Six key steps to reduce the impact of telehealth audits

Telehealth is almost as old as the telephone itself. In 1879 – just three years after Bell patented the telephone – an article in Lancet described the concept and advocated its adoption. 

A law that’s even older can trigger many telehealth audits today. The 1863 False Claims Act (FCA) was enacted to keep profiteering contractors from defrauding the Union army. It can trigger serious problems for hospitals that don’t take proactive steps to make sure their telehealth practices are audit-proof.  

That’s because the 2010 Affordable Care Act updated the FCA to make healthcare providers liable for “retention of any overpayments” from Medicare and Medicaid. This even includes overpayments resulting from accident or error. Indexing penalties for inflation each year, a requirement added in 2015, increased hospital liabilities. This puts liabilities at three times the amount of the overpayment(s) plus $11,803 to $23,607 for each instance. (Some 29 states and the District of Columbia have additional False Claim laws.) 

These laws’ implications and requirements touch every part of the hospital. Keeping the whole organization in compliance means that all departments have to work together. 

New laws, new regs, new worries for telehealth 

Even before COVID, the government audited claims from what was then a smaller, rural telehealth system. Regulators found a trend of incorrect payments to doctors outside rural areas, who were therefore ineligible to receive them. 

Telehealth is on the latest Office of the Inspector General (OIG) work plan, too. The OIG will be addressing remote patient monitoring by telehealth as an area of concern. 

The public health emergency, with its series of 90-day waivers, made it possible for telehealth to grow so fast. Now, as the COVID emergency ebbs, Congress is considering making its current, expanded status permanent. (Two bills were introduced in May. One would enable audio-only telehealth services for Medicare enrollee. The other would expand telehealth for Medicaid and Children’s Health Insurance Programs.) 

That’s good. But with laws come regulations covering acceptable types, locations and forms of delivery of telehealth services. And with regulations come scrutiny and audits. That can create challenges, especially with the specter of FCA liability in the background. 

The best way to cope with audits is to prevent the need for them in the first place. Here are six steps to follow: 

  1. Know what you’re up against. Keep up to date with all the developing federal and state regulations, waivers, and other requirements. That in itself can take up most, if not all, of your personal and your compliance team’s time.  
     
    Related: Find out how a team of expert compliance professionals and a nationally respected law firm track and analyze the latest regulatory changes, keep you updated, and give you actionable ways to adapt your process.  
     
  1. Inventory your waivers. Which waivers do you rely on, in which departments and facilities? Do the providers and staff that they apply to know about them? And who makes sure the requirements are met and documents it? 
  1. Check your records. One of the biggest causes of noncompliance isn’t malice. It’s error. Did an accidental typo in Coding result in an incorrect claim? Does everyone in Billing know which states require what reimbursement levels for telehealth services? Are certain telehealth records missing? Who’s responsible for keeping the signed doctors’ orders and documents that establish medical necessity? Do patients and services meet billing guidelines? Do you have a telehealth compliance policy? Does it need changing? Start conducting spot-checks to find out. 

    Related: Find out about state requirements for telehealth billing.  
     
  2. Audit your process. Another big cause of noncompliance is miscommunication – particularly the assumption that someone else is taking care of something. So put together an internal audit team, with each department represented. That way, each can learn from the other. Hold an entrance conference to highlight what you learned from your spot checks, define the internal audit’s scope, set expectations, and assign specific tasks and timelines. 
  1. Fix whatever’s broken. Reconvene the internal audit team and communicate the findings. Together, use that input to find opportunities to correct or cure what’s wrong in your process. Then, create a Corrective Action Plan (CAP) that will include needed education, training, policy, and process changes. Monitor your CAP over time, to see how it’s working and to spot anything else that needs fixing. 
  1. Rebill and repay. If your internal audit and CAP were successful, you’ll have discovered missing or insufficient documentation. Report it. You may have also have found instances of incorrect payments. Rebill and repay. Yes, it will cost your hospital money. But not nearly as much as a full-blown government audit. A Department of Justice investigation could end up costing you time, legal fees, and FCA triple damages. 

Patient demand for telehealth isn’t going away. Neither are the costs of noncompliance with telehealth regulations. As the public health emergency expires, fines from regulators and denial of claims from payers are sure to add up. The best way for your healthcare organization to solve these potentially massive financial problems is to work together to prevent them. Proactively partnering with colleagues in all relevant departments, your compliance team can lead the efforts to identify and fix issues before they become major problems. That way, you’ll be able to provide the telehealth services patients want in compliance with what the regulations demand. 

It’s a big effort to keep your compliance champions connected and communicating. See how YouCompli can help you manage the rollout of new regulations and verify best efforts to regulators and your board. YouCompli is the only healthcare compliance software combining actionable regulatory analysis with a simple SaaS workflow. 

Communicating Compliance Terms in Plain English…

communicate compliance terms in plain english

If you have ever been new to a particular field of the workforce, such as healthcare compliance, you know all too well that the language used by coworkers can sound foreign, like gibberish, or “alphabet soup.”  As we continue to work in the field though, we too, start speaking the language.  However, while that may be ok for conversing in the compliance department, it still be confusing if we are trying to communicate with, or to educate, other functional areas of the healthcare organization.  Without knowing the terminology, the message we are trying to convey is unlikely to be understood when received.

Alphabet Soup

Take a look at an example of terminology just starting with the letter “A” from the Office of the Inspector General Work Plan (reference below):

  • ADAP AIDS Drug Assistance Program (note this one includes an abbreviation in the definition);
  • AI/AN American Indians and Alaska Natives (I, for one, was unfamiliar with this abbreviation);
  • AIDS acquired immunodeficiency syndrome;
  • ALF assisted living facility;
  • ALJ administrative law judge;
  • AMD age‐related macular degeneration (while I have heard of macular degeneration, I did not know this was a standard abbreviation);
  • AMP average manufacturer price;
  • ASC ambulatory surgical center;
  • ASP average sales price; and
  • AWP average wholesale price.

Say I am talking to another seasoned compliance professional in front of a new employee.  Using the above “A” acronyms only, the conversation may sound something like this,

“Based on the billing audit, I see we are not receiving contracted AWP reimbursement under our AI/AN contract for ALF patients with AMD.”

As you can imagine, a new employee might be confused by the acronyms and terms communicated instead of using common business English.  Sometimes just saying the entire word instead of the abbreviation is a good place to start, so instead of saying AWP say average wholesale price.

Repetitive Communication

In order to improve communication between seasoned compliance professionals and other members of the organization, it is important to use repetitive teaching strategies.  In addition to saying the entire compliance term and the abbreviation, be repetitive and write out the compliance term in addition to the abbreviation in written communications.  That way staff become more familiar with compliance terminology and it becomes a part of their daily vocabulary.

Knowledge in Practice

When it comes to any industry, including healthcare, it is easy to throw around acronyms and jargon that is familiar and efficient.  However, it is important to be aware of who you are talking to, and therefore make sure they clearly understand whatever it is you are communicating.  Translate and reword industry terminology in emails, policies and teaching materials where necessary in order to improve communication and understanding.  Better compliance will ultimately be the result.

PRACTICE TIP:

  1. Regularly evaluate training and orientation materials to ensure industry specific terminology is defined and understandable.
  2. Utilize the youCompli system as a centralized hub for new and existing compliance processes and utilize the included model procedures throughout the various areas of your organization.

RESOURCES:

Health Care Compliance Association (HCCA) Compliance Dictionary found at https://www.hcca-info.org/publications/compliance-dictionary

Health and Human Services (HHS), Office of the Inspector General  (OIG), Work Plan Appendix B: Acronyms and Abbreviations found at   https://oig.hhs.gov/publications/workplan/2011/wp09-appx_b_acronyms.pdf

Denise Atwood, RN, JD, CPHRM

District Medical Group (DMG), Inc., Chief Risk Officer and Denise Atwood, PLLC

Disclaimer: The opinions expressed in this article or blog are the author’s and do not represent the opinions of DMG.

Denise Atwood, RN, JD, CPHRM has over 30 years of healthcare experience in compliance, risk management, quality, and clinical areas. She is also a published author and educator on risk, compliance, medical-legal and ethics issues. She is currently the Chief Risk Officer and Associate General Counsel at a nonprofit, multispecialty provider group in Phoenix, Arizona and Vice President of the company’s self-insurance captive.  

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Collaboration Between Compliance and Risk: What is Permissible?

Compliance departments, generally speaking, guide staff and boards of directors to comply with the requirements, laws and regulations that govern the organization’s business. They also monitor for compliance via internal audits.  Risk departments, on the other hand, address ways to mitigate risk to an organization through such activities as the evaluation and purchase of insurance policies.  Given the broad nature of the scope of these two departments within the organization, when is compliance and risk collaboration permissible?

Possible collaborations

  1. Strategic planning: Collaboration here should include not only compliance and risk but the entire organization and the board of directors, if applicable.
  2. Disaster response and business continuity: As with strategic planning, disaster response and business continuity planning should also involve input and collaboration from all departments in the organization.
  3. General security and privacy : Here the compliance/privacy officer, information technology/security officer, and risk management director should all be included in the planning.
  4. Known security threat and/or breach incident: Compliance, information technology (IT), and risk management would all participate in mitigating a security threat or breach incident on the organization. Each would provide input and guidance on their respective areas of knowledge.
  5. Risk assessments, gap analysis and mitigation plans: Again, the development of these plans should include leaders from the entire organization; moreover, compliance and risk would specifically collaborate on the assessment, analysis and mitigation activities.
  6. General policy development: Compliance and risk staff can collaborate and provide feedback and input for all organization policies.
  7. Record and document retention schedule: Here compliance and risk can collaborate with legal counsel to ensure record and document retention policies comply with state and federal laws.
  8. Staff education: This is an area where compliance and risk can collaborate to provide training, whether it is done in person, virtually, by email or via online course.

Collaborations to vet and evaluate permissibility

  1. Security breach: As noted above, compliance, IT, and risk will work together once a security breach has been identified. It is important to ensure compliance addresses HIPAA related information and potential reporting requirements; IT evaluates the technical aspects of the breach; and risk focuses on reporting to the insurance carrier and mitigation strategies in conjunction with compliance and IT. These collaborative activities will usually take place under a breach coach or law firm to protect the confidential nature of the breach.
  2. Shared work areas: Depending on the confidential nature of discussions, say a lawsuit against the organization, it may or may not be appropriate for compliance staff to be privy to such information. So shared work areas should be closely evaluated.
  3. Shared staff: As with shared work areas, if a staff member such as a registered nurse (RN) is shared between the compliance and risk department, both leaders and the RN must remain in the scope of the job role in which they are working at the time.
  4. Reporting to the board: Typically, compliance reports to the organization’s leader (such as a CEO) but also has direct or dotted line reporting to the board of directors. Make sure any collaborations with other departments do not create potential conflicts of interest with reporting up this chain of command.
  5. Committee membership: As with the analysis discussed above, make sure to vet compliance staff member membership on the risk committee and vice versa to avoid any actual or potential conflicts of interest.

Goal

All organizations should work to develop a culture where permissible collaborations between compliance and risk occur. They should also make certain that staff feel comfortable calling the compliance or risk department with potential concerns while ensuring the staff not crossing any lines when it comes to compliance or risk department confidential matters or conflicts of interest.

PRACTICE TIP:

  1. Evaluate opportunities for the compliance department to collaborate with the risk management team, as noted above.
  2. Access youCompli to find resources which address required document and record retention requirements.

Denise Atwood, RN, JD, CPHRM

District Medical Group (DMG), Inc., Chief Risk Officer and Denise Atwood, PLLC

Disclaimer: The opinions expressed in this article or blog are the author’s and do not represent the opinions of DMG.

Denise Atwood, RN, JD, CPHRM has over 30 years of healthcare experience in compliance, risk management, quality, and clinical areas. She is also a published author and educator on risk, compliance, medical-legal and ethics issues. She is currently the Chief Risk Officer and Associate General Counsel at a nonprofit, multispecialty provider group in Phoenix, Arizona and Vice President of the company’s self-insurance captive.  

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Manage your healthcare regulatory change process effectively and efficiently

YouCompli enables the compliance officers to assign ownership and oversight of tasks to different department heads, functional leaders, or specialists. The solution prompts users to accept, reject, or reassign the task by a stated deadline. Manage the rollout and accountability of new requirements with the best workflow in the business.

Organization Liability: Impact and Risk Mitigation (Part II)

liability risks in healthcare denise atwood

Impact of Risk Liabilities 

Unmanaged or poorly managed risk can cause devastating effects to the organization from a reputational and financial perspective. 

An extreme example of financial risk, coupled with nationwide reputational risks, was the Tylenol case in the 1980’s. The New York Times describes how, in 1982, Extra-Strength Tylenol capsules were tampered with and laced with potassium cyanide. Seven people in the Chicago area died and copycats caused several more deaths across the U.S. As a result of those incidents, tamper-resistant packaging was created and implemented so over-the-counter products, such as Tylenol, could not unknowingly be laced with a poison which could cause injury or death. 

Despite the fact that the manufacturer had not introduced the poison, this event led to huge financial  and reputational liability for McNeil Consumer Healthcare, the makers of Tylenol. On just the financial side, this cost a considerable amount of money due to decreased sales and increased advertising costs. 

As this example demonstrates, financial and reputational risk for an organization in the healthcare field can have disastrous consequences that threaten to bankrupt or put the organization out of business. If the event or incident is sufficiently egregious, the organization could also face loss of accreditation or state licensure. If this happens, they may also lose Medicare and Medicaid contracts.   

Risk Mitigation 

Proactive risk mitigation strategies include transfer of risk, through such vehicles as contracts and insurance, and early reporting of incidents or events by staff. 

Transfer of risk in contracts in typically done with indemnity or hold harmless clause. Transfer of risk via insurance is done by ensuring the organization has adequate coverages and retentions to meet the organization’s needs.  

The intent of an indemnity clause is to transfer the risk of financial loss from one party to the agreement to another party to the agreement. Generally, this is financial losses or expenses caused by contract breach or default, negligence, or misconduct by one of the parties.  

Hold harmless language in the contract states one party will not hold another party responsible for potential risks or damages. Hold harmless clauses can be unilateral and apply to just one of the parties to the contract or can be bilateral and apply to both parties to the contract. Typically, bilateral hold harmless language is preferred for healthcare organization contracts because each party will assume their own risk and not sue the other party to the contract for the risk which was assumed.   

Early reporting by staff is crucial in order to ensure that appropriate action, discussion, documentation and reporting takes place. Most importantly, this is necessary to ensure that risk mitigation strategies can be implemented to eliminate or decrease risk to the organization.   

PRACTICE TIP:  

  1. Develop and conduct risk assessments of insurance policies and large contracts to identify areas for improvement. 
  2. Review contracts to ensure indemnity or hold harmless clauses have been included.  If not, add the clauses on renewal.  
  3. Work with Risk Management to conduct a risk assessment to evaluate organization risks and implement mitigation plans.  

Denise Atwood, RN, JD, CPHRM 

District Medical Group (DMG), Inc., Chief Risk Officer and Denise Atwood, PLLC 

Disclaimer: The opinions expressed in this article or blog are the author’s and do not represent the opinions of DMG.  

Denise Atwood, RN, JD, CPHRM has over 30 years of healthcare experience in compliance, risk management, quality, and clinical areas. She is also a published author and educator on risk, compliance, medical-legal and ethics issues. She is currently the Chief Risk Officer and Associate General Counsel at a nonprofit, multispecialty provider group in Phoenix, Arizona and Vice President of the company’s self-insurance captive.  

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 Manage your healthcare regulatory change process effectively and efficiently

YouCompli enables the compliance officers to assign ownership and oversight of tasks to different department heads, functional leaders, or specialists. The solution prompts users to accept, reject, or reassign the task by a stated deadline. Manage the rollout and accountability of new requirements with the best workflow in the business.

Organization Liability: Types of Risk (Part I)

liability types of risk denise atwood

Risk is an important concept for compliance professionals working in the healthcare space to understand. After all, there are many times where risk and liability have crossover to compliance.

For example, in response to a suspected email or electronic health record breach, compliance and risk professionals will need to work together. This work will include:

  • Evaluating the breach
  • Reporting to the insurance carrier
  • Collaborating with a breach coach or legal team to ensure the investigation meets legal requirements and timelines
  • Collaborating with the information technology team and a forensics firm to ensure risk mitigation strategies are implemented and effective

And so on.

Generally speaking, healthcare compliance professionals should have a good working knowledge of organization risks and liabilities, as well as risk mitigation strategies.

This raises two important questions:

  1. What areas of risk do healthcare organizations face?
  2. What are the potential liabilities related to unmanaged or poorly managed risk?

Areas of Risk for a Healthcare Organization

Areas of risk for a healthcare organization are vast, and can involve injury to persons, property and reputation. Several areas of risk include:

Patient safety risks

These include near misses, which are mistakes which almost make it to the patient, as well as events or incidents that do make it to the patient, causing the patient to experience an unanticipated outcome such as a longer hospital stay, disability or death.
For example, a nurse may realize before giving a vaccine to a child that the adult vaccine and dose was drawn up in the syringe instead of the pediatric vaccine and dosage. This would be a near-miss. Along those same lines, a mistake occurs if the adult vaccine dose is actually administered to the child and an allergic reaction occurs.

Operational risks

These include such things as business interruption or supply chain issues. Business interruption incidents may include fire, flood, or pandemic. If the electronic medical record system goes down, and staff have to chart by hand on paper, this would be a business interruption. Supply chain issues can occur due to higher than normal demand or decrease in output by the manufacturer. If an organization cannot obtain needed supplies – such as hand sanitizer or surgical masks – that would be an example of a supply chain issue.

Legal risks

These typically involve lawsuits filed against the organization. Most commonly, lawsuits result from allegations of inappropriate employment practices or medical negligence or malpractice. For example, if a child had an allergic reaction after receiving an adult dose of a vaccine and unfortunately passed away, the parents may file a lawsuit alleging medical malpractice or negligence on behalf of the organization, the provider or the nurse who administered the incorrect vaccine.

Insurance risks

Insurance risks generally stem from a lack of adequate or appropriate insurance coverage or failure to transfer risk. Insurance risks can also connect to legal risks, which can stem from contracts with inadequate risk transfer or failure to conduct due diligence to vet the vendor. In the case of a pandemic, healthcare and other organizations may not have realized that pandemics and resulting business closures may be excluded from their business interruption insurance policy.

Human capital risks

These encompass the inability to hire, contract or retain appropriately trained staff. A lack of ICU level nurses causing staffing shortages would be an example. Human capital risks can also include professional board or licensing complaints against the organization’s doctors, nurses, therapists, or other licensed staff.

Reputational risks

Reputational risks are often forgotten or invisible to an organization until a bad event happens and it is announced to the public – at which point it is too late.

Reputational risk used to be limited to bad publicity which was published in print or reported on television. However, with the increased acceptance and use of social media, reputational risks are more far-reaching than the local newspaper or evening news program, and could potentially have national reach and negative impact on the organization . A newspaper may not run a story about a child who received an incorrect vaccine, but the child’s mother could post to Facebook or other social media platforms that the organization and providers are terrible and not to be trusted.

Practice Tips:

  1. Schedule a meeting with your insurance broker to evaluate your insurance policies by product line (i.e., general liability, property, cybersecurity, etc.) to ensure the organization is adequately covered to protect against most business losses.
  2. Educate staff to ensure they know how and where to report near-misses and mistakes that occur in the organization.
  3. Work with Risk Management to conduct a risk assessment to evaluate organization risks and implement mitigation plans.

Denise Atwood, RN, JD, CPHRM
District Medical Group (DMG), Inc., Chief Risk Officer and owner of Denise Atwood, PLLC
Disclaimer: The opinions expressed in this article or blog are the author’s and do not represent the opinions of DMG.

Denise Atwood, RN, JD, CPHRM has over 30 years of healthcare experience in compliance, risk management, quality, and clinical areas. She is also a published author and educator on risk, compliance, medical-legal and ethics issues. She is currently the Chief Risk Officer and Associate General Counsel at a nonprofit, multispecialty provider group in Phoenix, Arizona and Vice President of the company’s self-insurance captive.  

Sign-up for the YouCompli Blog to Stay Up to Date on Compliance Related News!

Manage your healthcare regulatory change process effectively and efficiently

YouCompli enables the compliance officers to assign ownership and oversight of tasks to different department heads, functional leaders, or specialists. The solution prompts users to accept, reject, or reassign the task by a stated deadline. Manage the rollout and accountability of new requirements with the best workflow in the business.

Earning the Gold Seal of Approval from the Joint Commission

Revised September 2022

Complying with the latest regulations will always be a critical priority for healthcare compliance professionals. But earning approval from The Joint Commission, the recognized global leader for health care accreditation, is growing in importance across healthcare organizations, including hospitals, physician group practices, surgery centers, and other treatment facilities. 

This accreditation, known as The Gold Seal of Approval®, acknowledges an organization’s dedication to providing quality care and services to patients. Some states require health care organizations to be accredited by the Commission in order to participate in particular insurance programs.  

If a healthcare organization is accredited by The Joint Commission, it may be deemed to exceed Centers for Medicare and Medicaid (CMS) requirements, along with state law requirements. Additionally, with the public’s attention increasingly focused on becoming informed consumers, earning accreditation also offers organizations a competitive edge.   

Meet the Joint Commission 

The Joint Commission is an independent, not-for-profit organization based in Illinois. Founded more than 65 years ago, the Commission provides an unbiased assessment of a health care organization’s quality achievements in patient care and safety. 

It offers the following accreditation programs: 

  • Ambulatory Care Accreditation 
  • Behavioral Health Care Accreditation 
  • Critical Access Hospital Accreditation 
  • Home Care Accreditation 
  • Hospital Accreditation 
  • Laboratory Services Accreditation 
  • Nursing Care Center Accreditation 
  • Office-Based Surgery Accreditation 

In addition, The Joint Commission offers 20 different certifications for a variety of clinical programs and services. 

Understand the Accreditation Process 

The Commission’s standards set expectations for an organization’s performance that are reasonable, achievable, and measurable. Its on-site surveys are rigorous and are customized for each organization and its efforts to improve patient outcomes. And the start of a survey is usually unannounced. 

During an on-site survey, Commission surveyors perform their evaluation by: 

  1. Tracing the care delivered to patients, residents, or individuals served 
  1. Reviewing the information and documentation provided by the organization 
  1. Observing and interviewing staff and, when appropriate, patients 

The Commission provides a Summary of Survey Findings Report at the conclusion of the on-site survey, with a final accreditation decision made at a later date. Surveyors could recommend: 

  1. Preliminary accreditation 
  1. Accreditation 
  1. Accreditation with follow-up survey 
  1. Preliminary denial of accreditation 
  1. Denial of accreditation 

An organization’s accreditation is continuous as long as it has a full, unannounced survey within 36 months of the previous survey and it meets all accreditation-related requirements. 

Benefits from Accreditation 

The Gold Seal of Approval is a way to let medical professionals, government regulators, and patients know that an organization stands for quality care, and that it’s always seeking ways to identify known or unknown risks to patient safety. 

For example, healthcare organizations that want to participate in Medicare have to be certified to have met specific CMS quality-related standards. If the organization is accredited by The Joint Commission, CMS will have deemed the entity to have met or exceeded these requirements. That means the organization is not subject to Medicare’s survey and certification process because it has already gone through the Commission’s survey process. 

Additionally, being Commission-accredited may allow the organization to be exempt from meeting state law survey or quality or requirements. Here you want to be sure and check your state laws to see if they exempt entities accredited by The Joint Commission. 

In what other ways can an organization benefit from Joint Commission accreditation? 

  • It can earn various Joint Commission certifications for continued improvement and maintaining performance excellence 
  • It can connect with other like-minded organizations to collaborate on issues affecting the quality and safety of patient care 
  • It can attract more qualified personnel who prefer to serve in a prestigious environment 

Earning Accreditation Means Maintaining Compliance 

Earning the Joint Commission’s Gold Seal of Approval depends on a strong culture of compliance. Organizations that are challenged to manage compliance, or effectively demonstrate compliance, are unlikely to meet the Joint Commission’s rigorous standards. (Read more about Compliance Culture on the YouCompli blog.) 

A culture of compliance is a commitment throughout all levels of an organization to do the right thing and do things right.  When an organization has a strong culture of compliance, there is a spillover effect to obtaining and maintaining Commission accreditation.  Employees see their leaders ensuring the organization is maintaining compliance with elevated standards. Additionally, they see their leaders making business decisions based on organizational policy requirements.  The end result is actions being taken that demonstrate leading by example and modeling that behavior to employees. 

The Gold Seal of Approval accreditation is an important acknowledgment of an organization’s dedication to providing quality care and services to patients. The effort to earn this accreditation is certainly significant, but the payoff in terms of reputation, recruiting and deeming status is worth the effort. Not only that, the process of earning accreditation can help you uncover opportunities to further shape your culture of compliance so that a mindset of always doing the right thing permeates all levels of your organization. All of that is good for the long-term health of your business – and your patients.  

The accreditation process requires significant metrics to demonstrate the effectiveness of your compliance program, YouCompli can help you verify that you took the proper steps to comply with the regulations that apply to you. Find out how.  

Jerry Shafran is the founder and CEO of YouCompli. He is a serial entrepreneur who builds on a solid foundation of information technology and network solutions. Jerry launches, manages, and sells software and content solutions that simplify complex work. His innovations enable professionals to focus on their core business priorities.

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