“Privacy can make or break an organization. For healthcare systems in particular, it’s essential to lock down data … there are two sides to privacy: the positive benefit side and penalty side ….” – Jerry Shafran, CEO and Founder of YouCompli
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From fostering a culture of accountability to providing robust training programs, this insightful piece offers practical steps to enhance compliance, reduce risks, and ensure patient safety. Discover how organizations can navigate the complex regulatory environment and cultivate a workforce committed to upholding the highest standards of compliance. Read the full article for a comprehensive roadmap to success in healthcare compliance.
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Due to their violations of patient rights, covered entities and business associates are now facing increasing enforcement actions. In a breach, both parties bear financial and reputational risk. Shawn DeGroot recommends proactive compliance officers prioritize their agreements based on risk, establish communication channels, and collaborate on risk analysis to protect their organization.
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Healthcare risk assessments are essential for patient safety and compliance. By understanding the why, what, who, and when of risk assessments, healthcare organizations ensure high-quality care in a safe environment. In this article, Sharon Parsley discusses risk assessment from a “why, what who, and when” perspective. She also looks at ways that you, as an effective compliance officer, can lead this process with your colleagues.
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Compliance must build relationships with these healthcare functions – Legal, Internal Audit, Human Resources and Quality. Here are suggestions on how to effectively build relationships and collaborate with them to help achieve their goals.
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The stigma and complexities in behavioral health present compliance challenges that other healthcare organizations may not face. In this two-part series, I’m exploring how these challenges drive the need to minimize risk for behavioral health organizations through standardizations and building predictable processes.
Read Part I, “Establishing a Strong Compliance Culture in Behavioral Healthcare: Minimize Risk and Add Value Through Standardization and Metrics”
In Part I, I examined why establishing a strong culture is critical for behavioral health organizations to minimize risk. I highlighted how using the Office of the Inspector General (OIG) ‘s seven elements and making the most of metrics can help behavioral health organizations build culture and show how Compliance adds value.
Below are two more fundamental activities for creating a positive culture: being an effective influencer and emphasizing education. Prioritizing these activities – along with using the OIG’s seven elements and making the most of metrics – will enable you to build a culture that helps behavioral health organizations minimize risk.
Behavioral health is unique in that we have the stigma that goes along with our work. The population we serve has mental health and addiction issues, plus co-occurring medical, legal, educational, work, and family issues.
In addition to the lack of understanding around mental health and addiction, a big challenge in behavioral health is that we don’t have clarity yet on the differences between compliance, quality, risk, and safety. We’re still trying to define the differences and the commonalities and where they overlap.
We also face a lack of consistency in behavioral health. We’ve come a long way in my 35 years, with more evidence-based practices and more research-based approaches. But we lack a common approach to measuring outcomes and what works as well as consistency from state licensing and accrediting bodies.
In Part I, I explored how to successfully begin creating a healthy culture by using the OIG’s seven elements and making the most of metrics. Two more activities – being an effective influencer and emphasizing education – are key to navigating behavioral health’s complexities and building a culture that minimizes risk through standardizations and predictable processes.
Building solid relationships and being visible throughout the organization are crucial to building a strong culture of compliance. And acting with empathy helps you encourage others to proactively work with you to add standardizations and build in predictable processes.
This comes from my belief that people want to be compliant. They want to do the right thing. Assume that employees are doing their best with what they have, and lead with that.
If there’s an issue, it’s often because employees have not been given the right information, resources, or skills. Our job in compliance is to give employees the right information, resources, skills, and support they need – not to assume that they’re bad or lazy.
At my old organization, we practiced lean management, and one of my favorite sayings was, “Hard on the process, easy on the people.”
Being empathetic is more effective than blaming and pointing fingers. If I have a noncompliance issue, I approach it with employees as, “It’s my fault. Compliance failed you by not giving you a good enough policy, procedure, or training.”
When I take this approach, you can feel the energy in the room shift. It transitions from a negative and fearful moment to a foundation of empathy and a healthy culture for compliance.
It’s also helpful to have an open-door policy. If you’re new to an organization, have lots of conversations to assess what your colleagues’ previous experience was with Compliance. You have to be willing to hear things that are tough to hear and be responsive to that.
“Hard on the process, easy on the people.”
It’s key to building trust and being able to shape culture as an influencer. And it’s important to follow through on integrating their feedback into your compliance program.
I like to tell new colleagues, “Here are the things I’ve heard that didn’t work, and this is what we want to do differently.”
The change management process is a continual effort to build and make it better, and it takes time to get everyone’s buy-in. Resistance is absolutely normal and expected.
To overcome resistance, communicate the why behind what you’re doing. Communicating and doing a lot of listening builds trust.
If you’re changing policies or processes, explain why you have a better way to do it. Emphasize the importance of following the seven elements and integrating them into daily workflows.
Be confident that you have the knowledge, skills, and abilities to address the compliance issues the organization is facing. Be confident to push back, to question, and to challenge.
As compliance officers, we bring a specialization that is rare. Don’t be afraid to be a person of influence.
It’s helpful to embed yourself into each operational area. Be part of each area’s initial orientation with staff, go to trainings, do mock surveys, and attend team meetings.
When you’re embedded, you’ll start hearing about issues to look into. Then you can follow up with teams and say, “I wonder about this. Do you have any concerns in this area?”
The more visible you are, the more that colleagues see you and trust you as a partner. They’ll appreciate what you bring, and in turn, they’re more likely to bring issues to you. This can help you catch a potential problem early to prevent it from becoming a bigger issue.
Education is closely related to using influence, and ongoing training is key to helping the organization minimize risks through standardizations and building in predictable processes.
In an earlier role, I joined an organization where policies had not been updated in about 10 years. There were missing policies as well as conflicting and duplicative policies.
I worked with each department – from nursing to medical directors to human resources – to review their policies and make sure they were aligned with their actual practices. This allowed each operational area to contribute to their policies and to secure any funding and training needed to resolve the discrepancy issues.
Building cohesive policies across the organization was an opportunity for education around regulations and why they were in place. It also helped get employees’ buy-in and positioned them to champion compliance. They’re putting the policies to work every day and now they understand why.
Monthly check-ins are also valuable for ongoing education and training. I do monthly phone calls with all our medical leads and nursing leads. It’s an opportunity for sharing and cross-training across different levels of care, or different settings; everyone can learn best practices from one another.
Sometimes training becomes a check-the-box exercise. But effective training – testing for competence and making sure employees understand how to apply it in their daily work – is crucial.
In behavioral health, we conduct trainings around critical care areas such as diagnosing substance and suicide prevention. We have to ensure that our training is updated and affecting care.
As you build a compliance culture, it’s helpful to get involved with the HCCA (Health Care Compliance Association).
Using HCCA resources and asking for help from the compliance community – not normally people who we interact with in behavioral health – keeps you from having to start from scratch. Leverage existing programs and talk with people who are already doing the work.
Also, using a tool like YouCompli gives you some of the structure you need for procedure development – the forms, trainings, whatever it might be. It will save you so much time and resources.
The stigma and the complexities we deal with in behavioral health present extra compliance challenges. Yet there are ways to effectively tackle these challenges to help behavioral health organizations minimize risk and show how Compliance adds value.
Establishing a positive culture in behavioral health and showing how Compliance adds value includes four activities:
Prioritizing these areas will help give you the knowledge, resources, and confidence to address the organization’s compliance challenges. Compliance officers bring a specialization that is rare. Don’t be afraid to be a person of influence to build the culture you know will add value for your organization.
Read Part I, “Establishing a Strong Compliance Culture in Behavioral Healthcare: Minimize Risk and Add Value Through Standardization and Metrics”
Maeve O’Neill, MEd, LPC-S, CHC, CDTLF, National Compliance Director for Circa Behavioral Healthcare Solutions, has worked in behavioral health for 35 years. Maeve has a passion for quality and safe care as well as happy and healthy staff. A former behavioral health surveyor with The Joint Commission, she is committed to excellence.
At YouCompli, we believe compliance professionals create value in healthcare organizations through standardization and metrics. That’s why we supply tools for our customers that they can be confident in using to educate and influence their stakeholders. YouCompli subscribers receive regulatory tools including primary research and regulatory alerts, practical analysis and impact, decision criteria and affected departments, business requirements, and model procedures. Every regulatory tool is validated by Horty Springer LLP, the nation’s top law firm.
Stigma and complexities of behavioral health create the need to minimize compliance risk through predictable processes, metrics, and the OIG’s 7 elements.
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The tips below explore how you can convince leaders that a strong compliance culture adds value to the organization. These best practices can help you establish a healthy compliance culture with effective training and measurement and, in turn, enable your organization to better manage and control risk.
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How to use the OIG’s seven elements and HHS roadmap to guide Compliance and Operations – helping healthcare organizations ensure quality patient care post-PHE.
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