There have been many times where we have talked to auditors or inspectors who wanted to know if training occurred. While the answer was yes, there also have been times where we didn’t have any concrete documentation to support it, save for the Outlook meeting invite with everyone’s name on it. Even more surprisingly, there have been times where that has been accepted. Now, call it chance, dumb luck, or we dodged a bullet, but this is not always the case.
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As compliance officers, we spend a lot of time focused on how others perform their jobs. However, being self-aware of how we do our own work is paramount for an effective compliance program.
Incorporating self-awareness into your healthcare compliance program can significantly enhance its effectiveness. For example, it improves your ability to empathize with the challenges operational leaders face when adjusting a process to meet a regulatory requirement.
To help build awareness, explore these 18 actionable tips for compliance officers.
Be aware of how your policies are viewed. Are my policies easy to read and understand? Do impacted staff follow the policies in practice? If not, why? Are they cumbersome to navigate from the end user’s perspective?
Tips for Better Compliance Awareness
1 – Clarity and Usability: Be aware of how clear your policies are. Ensure that the practices are easy to read and understand. Be intentional about avoiding jargon and using plain language. Also, engaging operational leaders who must live with the policies helps ensure the interpretation is clear.
2 – Real-World Application: Regularly assess whether operational staff are following policies in practice.
3 – User Perspective: Solicit feedback from end users to identify any challenges they experience when navigating policies. Be open to making necessary adjustments.
Self-aware compliance professionals must ask themselves questions like these: Am I physically present in my organization such that people know I exist, or am I hiding behind my keyboard? Am I getting to know others in the organization?
Tips for Better Compliance Awareness
4 – Physical Presence: Are you visible within your organization? Do you attend non-compliance related meetings, participate in organizational events, and engage with staff to foster relationships?
5 – Build Connections: Take the time to get to know others in the organization. This helps develop rapport, which builds stronger relationships that lead to establishing trust and improving your compliance culture.
Compliance Committee Engagement
With greater awareness comes greater engagement with colleagues. Use these engagement tips to raise your profile.
Tips for Better Compliance Awareness
6 – Awareness: Ensure that organizational leaders who are not on the committee are aware of the group, its members, and the role it serves.
7 – Role Clarity: Clarify the role of the compliance committee to both leaders and members. You can do this by sharing visual aids or other documentation that outlines responsibilities.
8 – Obligations Training: Regularly review and communicate the obligations of committee members to strengthen understanding and foster accountability.
Have I done enough training with our staff about a particular requirement? Am I clear with my audience about what I expect of them? Am I using examples that relate to their work when illustrating how the requirement applies to their job role? Understand your role in making sure this important compliance step isn’t neglected.
Tips for Better Compliance Awareness
9 – Relevance: Be mindful to tailor training to include examples that directly relate to your audience’s job roles. For example, when talking with physicians about safeguarding patient information under HIPAA, a common scenario is determining who can be involved in a discussion about a patient’s treatment plan.
10 – Expectation Setting: Communicate what you expect from staff and providers during training sessions. Make these expectations clear and achievable by answering these questions, “What actions do I need my audience to take?” and “What do I need them to know after I have trained them?”
Have I communicated with my audience about how to report issues? Do the staff feel comfortable reporting issues? If not, why? Have I educated them about how the hotline process works? The self-aware compliance leader cares about the answers and uses these tips to continually emphasize communication.
Tips for Better Compliance Awareness
11 – Reporting Mechanisms: Clearly communicate the process for reporting issues and concerns. You can accomplish this by explaining the process as if you were reporting an issue and asking yourself “What information would I want to know?” Also, it helps to use multiple channels (e.g., email, intranet) for accessibility.
12 – Comfort and Anonymity: Assess whether staff feel comfortable reporting issues. You can hold a random sample of individual discussions or conduct a survey. If they don’t feel comfortable, find out why, and take specific steps to overcome those concerns.
13 – Hotline Awareness: Educate employees about how the hotline process works and reassure them on confidentiality measures in place and why they are important (i.e. to ensure staff can trust the process).
The self-aware compliance leader constantly asks themselves about their performance, including investigations. Has my investigation been thoroughly conducted? Can I defend my work product to a government agency if we’re investigated or audited? Use this tip for more confident investigations.
Tips for Better Compliance Awareness
14 – Thoroughness: Ensure that investigations are comprehensive and well-documented by continually assuming you will need to defend your work in a courtroom or to a government regulator. Since conclusions of compliance investigations are based on fact, keep detailed records to support your findings.
Ask yourself these questions to get a sense of your awareness around program auditing. Am I communicating with those I’m auditing? Do they understand my expectations? Do I understand how they are performing the work being audited?
Tips for Better Compliance Awareness
15 – Communication: Maintain open communication with those being audited by clearly conveying your expectations and the purpose of the audit.
16 – Understand the work: Engage with operational staff during audits to make sure you understand how they are performing the work and any challenges they face versus making assumptions.
Sometimes compliance awareness is related to risk. Are you aware if the need to monitor an operational activity is connected to a medium-to high level of risk, or does it just seem like a good idea? An example would be how a department documents a service provided to a Medicare patient, so it is compliant with Medicare billing guidelines. Also has your audience been given a reasonable amount of training about requirements before you monitor their work?
Tips for Better Compliance Awareness
17 – Risk Assessment: Connect the need for monitoring to a defined level of risk instead of arbitrary reasons. Use risk assessments to guide your monitoring activities.
18 – Training Prior to Monitoring: Be mindful to provide necessary training to your audience regarding requirements before implementing any monitoring practices. Ensure they understand what will be monitored and why.
By prioritizing self-awareness and incorporating these tips, compliance officers can create a more effective, responsive regulatory program within their healthcare organizations.
Reach out to YouCompli if you’d like some ideas to guide your compliance strategy.
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.
“Any discussion or plan that doesn’t take into account whether or not you can actually execute on it is an exercise in fantasy.”
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“Healthcare compliance professionals face significant challenges when managing who is responsible for completing compliance activities. From identifying the right individuals to ensuring accountability and avoiding duplication, the process can be fraught with inefficiencies.”
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“The first thing that you should understand is this: you don’t have to build the perfect program. Your education program just needs to be good enough to ensure employees have the training needed to demonstrate core knowledge and pass audits and inspections.”
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“Radiology services have unique characteristics, and some unique compliance considerations that accompany them include compliance rules associated with physician orders, medical necessity, local coverage determinations, and teaching physician settings.”
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“There’s another incredibly helpful resource that some might not be as familiar with: the list of services that Medicare Administrative Contractors (MACs) include in their Target, Probe and Educate (TPE) plan.”
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“Whether you’re resolving a complex billing issue, or advising your leadership team about a business proposal, the ability to effectively make decisions is a valuable asset for any compliance officer.”
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“Keep in mind that your healthcare leaders often will not be as knowledgeable about requirements in regulations or something else as you are. For that reason, what may seem like an obvious concern to you may not be so obvious to them. Be open to the fact a gap may exist, and give them grace if they made a decision that unintentionally creates an issue that needs to be corrected.”
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