Hospital Compliance Work Plan

In the evolving healthcare industry, adhering to compliance rules and standards while staying on top of regulatory changes is paramount. This commitment is essential for safeguarding patient and employee well-being, handling sensitive information appropriately, and upholding credibility and public trust. A comprehensive hospital compliance work plan is pivotal for achieving these objectives.

Hospital compliance officers, c-suite executives, and other decision-makers must constantly stay abreast of the latest developments in healthcare compliance. Here, we review the function and components of hospital compliance work plans and focus on important updates to the law effective in 2024.

What Are Hospital Compliance Work Plans?

Compliance work plans help hospitals and other healthcare organizations comply with regulations and uphold the highest ethics regarding patient care, federal funding use, and personal information protection. These plans provide a structured framework for continuous improvement, fostering a culture of vigilance and adaptability to evolving healthcare regulations, which ensures that organizations remain at the forefront of ethical and legal standards.

On November 6, 2023, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) released new guidelines for healthcare compliance programs, the first updates in 15 years. Here is a summary of OIG’s updates as they apply to the key elements of healthcare work plans.

Hospital Compliance Training

The work plan outlines the content and format of required compliance training for all personnel. Training includes information and practical skills that help members maintain compliance with state and federal laws and know how to identify and report misconduct.

Updates: The OIG clarifies who should be required to attend compliance training, including employees, contractors, medical staff, and board members. Also, completion of compliance training is now a condition of employment and part of an employee’s annual performance evaluation.

Incident Reports and Investigations

The work plan outlines procedures for disclosing and investigating each type of noncompliance incident. Also, reports of misconduct should be confidential, and there should be protections against retaliation for reporting.

Updates: In addition to having multiple channels for reporting, including phone numbers, email addresses, and websites, the OIG recommends that one of those channels be independent of the business or organization.

Internal Audits

Procedures describe how the organization should conduct regular internal audits to assess compliance. Information about internal audits also provides guidance on pinpointing limitations in the current system and how to make corrections promptly.

Updates: The OIG provides more detailed guidance for compliance officers in reporting compliance violations. In particular, compliance officers should keep records of investigations that include:

  • Documentation of each alleged incident
  • Detailed description of the investigative process
  • Log of reviewed documents and interviewed witnesses
  • Copies of all documents, including interview notes
  • Results of each investigation and disciplinary and corrective actions

Policy Development

Compliance-based policies describe privacy protections, measures to prevent and report fraud, accurate billing practices, and employee codes of conduct. These policies and procedures should delineate behavior that promotes compliance across the organization. A hospital compliance officer forms a compliance committee, and they both oversee the development and implementation of organizational compliance policies.

Updates: Besides holding all personnel accountable for noncompliance with safety and privacy standards, companies should cite staff in leadership positions for foreseeable incidents attributed to subordinates when contributing factors are negligence, ignorance, or recklessness.

A company’s annual risk assessment should be included in the policies and procedures. The OIG also identifies the quality of patient care as an additional risk factor the compliance officers and compliance committees should work to mitigate. Further, the hospital compliance officer’s responsibilities must not include:

  • Reporting to, advising, or leading the organization’s finance or legal departments
  • Delivering healthcare services or items, nor claims billing, submission, or coding
  • Administrative appeals, contracting, or medical reviews

Risk Assessment

The work plan identifies the organization’s vulnerable areas and outlines steps to mitigate factors contributing to non-compliance. A thorough risk assessment involves identifying, analyzing, and responding to risk factors attributed to failures to comply with federal privacy and safety requirements.

Updates: The compliance committee should spearhead the planning and implementation of annual risk assessments. The hospital compliance officer should continue surveillance of potential risks between yearly assessments.

Creating and implementing a proper hospital compliance work plan can be complicated. At Compliancy Group, we want to eliminate the stress of tracking and managing this essential document. Contact us today to learn about the software and resources we offer to help organizations comply with healthcare regulations. 

Track All Regulations on One Platform

Centralize and streamline healthcare compliance management effortlessly.

Global CTAs Image