Introduction
Healthcare regulatory compliance is the compliance of a health care organization with laws, rules, guidelines, and specifications. It is a continuous process of meeting or exceeding the legal, ethical, and professional standards applicable to a particular healthcare organization. Health care organizations need to develop effective processes, policies, and procedures to determine appropriate behavior, train the organization’s staff and monitor adherence to processes, policies, and procedures. Healthcare compliance covers many areas, including, but not limited to, patient care, billing, reimbursement, managed care contracts, privacy, and security. The main purpose of healthcare compliance is to improve patient care. There are four basic ethical principles in health care: autonomy, beneficence, justice, and non-maleficence. Patients should always have the right to make decisions based on their beliefs and values. Accreditation is usually a voluntary program sponsored by a non-governmental organization in which trained external reviewers evaluate the compliance of a medical organization with requirements and compare it with pre-established performance standards. Accreditation is especially important for medical organizations, as it allows assessing the literacy of the services provided.
The Risks and Consequences of Noncompliance and Ethical Breaches
The potential risk associated with the healthcare field is far-reaching. Failure to comply exposes the organization to financial loss, security breaches, revocation of licenses, operational disruptions, poor patient care, loss of trust, and damaged reputation. In addition to the consequences in the form of fines and penalties, non-compliance in the health sector also leaves the organization open to lawsuits. The cascading effect of non-compliance with ethical standards also affects the quality of care provided to patients. If the institution does not meet the rules and standards, the very patients it promised to serve will eventually feel the consequences.
Important Health Care Regulations
Federal, state, and local governments—in addition to various regulators—set rules designed to protect the public, increase access to care, and ensure that healthcare workers are held to high standards and are compensated as they are due. Under HIPAA, the Health and Human Services Department limits the use and disclosure of medical records (Sheppard & Vine, 2019). It also outlines measures to protect patient information and establishes civil and criminal penalties for violations. In addition, the law regulates business associates such as third-party administrators, pharmacy claims managers for health plans, billing and transcription companies, and professionals doing legal, accounting, or administrative work. The HITECH can be considered the enforcement part of HIPAA. The law provides providers with financial incentives to offset the upfront costs of moving to electronic health records and stricter data security requirements and penalties for both healthcare organizations and their business partners. Medical necessity is an important aspect of modern health care management, even though it is not legally defined at the federal level (Skinner, 2019). Medical necessity means that if treatment is not medically necessary, the payer does not cover the costs.
Key Ethical Considerations All Staff Must Understand
There are several basic principles of medical ethics that all medical personnel must understand. Ideally, for a medical practice to be considered “ethical,” it must respect all four principles: autonomy, justice, beneficence, and non-maleficence (Then & McDonald, 2019). Autonomy requires the patient’s ability to have autonomy of thought, intention, or action in making decisions about health care. A patient must understand all the risks to make a truly informed decision. The right to justice requires that procedures be in the spirit of existing laws and be fair to all players involved. Beneficence requires that the procedure be done to benefit the patient. Non-maleficence requires that the procedure does not cause harm to the patient involved or other people in the community.
How the Concept of Continuous Readiness Applies to Compliance
Continuous compliance also has been called continuous survey readiness. It involves proactively maintaining a safe health care environment conducive to high-quality patient care. It essentially means having staff at all levels doing the right things for the right reasons because they understand those reasons. The two concepts directly correspond to each other because they pursue the same goals: first of all, providing adequate care to patients.
Compliance Training Effectiveness
Best Practices for Training Health Care Staff on Compliance
A culture of compliance in a medical organization can be created in many ways. Signs, posters, reminders are a few ways to do it. Another way is to talk about it in a formal or casual conversation. The organization can also remind people what they need to do to qualify. A simple reminder of health rules will help employees do their work better. It is beneficial to educate not only people directly involved in patient care but staff working with patients’ data.
The first step in making an organization meet the requirements is training. Compliance training should be ongoing and mandatory whether the team is new to the field or has been involved in the industry for many years. The most effective way to educate employees is to use up-to-date and easy-to-learn learning resources. Each type of compliance training requires a different set of skills, such as computer and mobile device training, project management skills, and project training. It is important to create a personalized training plan that teaches employees the basics of their job and teaches them how to deal with compliance issues.
Conclusion
Thus, healthcare compliance affects every type of healthcare provider and healthcare organization, from the solo practitioner to the largest global healthcare conglomerate. The goal and main benefit of healthcare compliance are to improve patient care. Healthcare compliance also helps organizations and health care providers avoid problems with government agencies. An effective health care compliance program can identify problems and find solutions to those problems before a problem is discovered by a government agency. Healthcare compliance must be at the heart of any healthcare organization.
References
Sheppard, J., & Vine, S. (2019). First Healthcare Compliance HIPAA Privacy and Security. First Healthcare Compliance, LLC.
Skinner, D. (2019). Medical Necessity: Health Care Access and the Politics of Decision Making. University of Minnesota Press.
Then, S., & McDonald, F. (2019). Ethics, Law and Health Care: A Guide for Nurses and Midwives. Macmillan Education UK.