How to Create Hospital Compliance Action Plans

In 1998, the federal Office of the Inspector General issued a strong suggestion and guidelines for hospitals to create regulatory compliance programs. To assist hospitals in creating these programs, the OIG gave a framework for an action plan hospitals can use to get their compliance programs underway. There are several key elements hospital compliance planners should address when creating an action plan that meets federal standards.

Instructions

• 1

  Introduce your action plan with some history and background of the facility as well as the intent of the compliance program. Highlight in your writing the important of compliance to the hospital and how the new program will impact employees and operations.

• 2

  Create the first body section of your action plan focused on written policies, procedures and standards of conduct. Facilities usually have these already developed as part of their human resource policies and orientation materials.

• 3

  Designate a compliance officer and compliance committee. Describe what these people will do, how often they will meet and how employees can reach the officer about important issues.

• 4

  Outline the facility's commitment and intention to conduct effective training and education. If possible, be specific about particular subjects and training modules you will initiate. Specify which will be standard to orientations, which can be taken anytime and which may be offered only periodically.

• 5

  Discuss how your facility will develop effective lines of communication on compliance issues. List how information will be disseminated. Usually, this is a review of chain of command and which positions are responsible for educating workers on compliance as well as who oversees critical regulatory matters. Department administrators and nurse managers are often key people in this process.

• 6

  Develop a section explaining how your facility will enforce standards through well-publicized disciplinary guidelines. This means not only discussing consequences for impeding compliance or violating regulations but also instituting a plan to ensure that all employees understand your compliance plan and its seriousness. Employee handbooks requiring signatures of receipt are a common approach, as are postings to hospital intranets and educational workshops.

• 7

  Detail your auditing and monitoring plans. Your facility will need a thorough system of checks and oversight mechanisms. This may involve supervisors checking employees' work and documentation. It will also likely involve reviews and planned enhancements to information technology infrastructure.

• 8

  Describe thoroughly how your hospital will respond to detected offenses including corrective action initiatives. Basically, when there are problems, outline what the hospital will do and what the process for making changes will be. Obviously, the more swift and responsive, the better it will look to the OIG.