A hospital’s compliance program should be alert to the following compliance concerns in each evolving area of compliance focus.
Quality of care
- Consistently low event reporting
- Joint Commission citations
- High turnover in clinical areas and staff working outside their scope of practice
- Clinical and quality outcomes areas working in silos
- Physicians who perform far greater numbers of specific procedures than are performed by other physicians or institutions
- Physicians who have not completed the conflict-of-interest attestation
Compliance leaders should routinely discuss these concerns with clinical and quality leaders to assess the level of risk and determine root causes and the status of any corrective actions. They also should collaborate with clinical and quality leaders to ensure areas identified as deficient by external surveyors are addressed, and clinical processes such as event reporting are routinely audited.
Patient abuse
- Inadequate follow-up to patient grievances
- Staff found outside their assigned unit
- Staff coming in on their off days to check on patients
- Inadequate surveillance of safety events
- Lack of a robust background-check process
Compliance personnel should collaborate with clinical (and possibly human resource) personnel to understand the nature of the issues and any remediation activity. An audit of key processes such as patient grievances can provide greater insight into whether these cases are handled appropriately. Patient-grievance processes should adhere to CMS requirements for the timeliness and nature of follow-up activities.
Quality reporting
- Pressure to meet financial goals
- Lack of oversight and validation around quality reporting
- Unclear definitions of quality metrics
- Lack of understanding of current quality reporting requirements
- Frequent data integrity issues or data coming from multiple disparate systems
The compliance leader should ensure the quality reporting process is audited to validate whether the process supports accurate reporting and the ability to respond to changing requirements.
Emergency preparedness
- Lack of emergency drills
- Poor risk-assessment process
- Lack of a holistic approach that involves all key stakeholders
- Failure to consider billing procedures (for example, billing when the system is down or suppressing inappropriate billing)
- Unassigned ownership of critical components
Compliance personnel should be active participants in emergency preparedness committees to anticipate risk, evaluate preparedness activities and assess
remediation efforts.
Case management
- Inactive utilization review committee
- Excessive avoidable days or lack of avoidable day tracking
- High readmission rate
- Perception of low stature within the organization
- Excessive clinical denials
The compliance area should collaborate with the case management area on routine auditing and monitoring to assess compliance with CMS conditions of participation.
See related article: Evolving compliance risks that should be on your radar
