- Finding the right people for your compliance team
- Simplifying the process for everyone
- Conduct annual policy review cycles
- Streamline your workflow processes
- Improve your communication processes
- Use compliance management technology
When it comes to day-to-day operations, nearly every healthcare organization has a set of internal rules, standards, and best practices that specify how it will operate. Those policies and standards provide a level of safety and performance that protects the patients, healthcare workers, and the organization itself.
Healthcare accreditation is a stamp of approval from a professional accrediting body that says your organization follows the industry's accepted standards. It means that your staff has been trained on the best possible procedures and are up-to-date on the latest life-saving methods available.
It also means that your organization has passed a very thorough external review by that organization. One in which you have streamlined your operations, updated your procedures, and are in compliance with various policies and regulations.
Healthcare accreditation organizations such as the Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission, or the National Committee for Quality Assurance have each detailed a set of standards with the help of healthcare experts that cover everything from patient care, to labeling medication, to data management.
Of course, accreditation doesn't happen in a vacuum, and it doesn't happen in a matter of weeks. It can take months and years as the compliance team tries to "eat the elephant:" One bite at a time.
It requires the efforts of at least one – and more likely, more than one – dedicated individual that makes up a compliance team. This team will help organize your various training efforts, keep track of all your proof of compliance documents, and even update and manage your policies and procedures.
If you're fortunate enough to have a separate policy team and compliance team, accreditation should be a breeze, as each group works to eat the same elephant.
In this article, we'll talk about how a compliance team can help your organization achieve accreditation, how you can find the best people for the compliance team, how to simplify the process, and improve workflows and communication with your team.
Find the right people for your compliance team
Every accreditation process needs someone to take ownership of the entire effort on behalf of the organization. In healthcare, this falls to the compliance coordinator, whose specific title is often determined by the type of compliance they’re responsible for – whether TJC, regulatory compliance, HIPAA, or payment reporting (i.e. Joint Commission Compliance Coordinator). In some cases, there may be multiple compliance coordinators. These people are responsible for managing the accreditation efforts, compiling all the documents and proof of compliance, and ensuring the organization meets all its deadlines.
In a past episode of our Entrust Compliance podcast, Brandy Osborn, Accreditation Manager at the Springfield (MO) Police Department, said the accreditation manager was typically a type A personality.' She said those types of accreditation managers tend to steer away from letting people help them, but that may be because they were working under an old system of paper logs, spreadsheets, and emailing documents between departments for compliance proof.
Osborn realized that using PowerDMS could help her put together a good compliance team, and help the team streamline the process and save a lot of time in organizing everything. While law enforcement accreditation is very different from healthcare accreditation, some of the guiding principles remain the same.
Your compliance team needs leaders from different departments and units within your organization. For one thing, they've got a vested interest in ensuring their department meets its accreditation requirements. They may have some of their own accreditation and licensing requirements they have to meet. They understand it's in their interest to provide the necessary compliance proofs to the accreditation efforts. They can also help you motivate other members within their department to complete the necessary training and assessments required by your accrediting bodies.
Involving the leaders can also help ensure all departments are promoting consistent practices and ensuring compliance across the entire organization.
The compliance team also needs subject matter experts, the people who can ensure that your organization's policies are effective and fall within the accreditation and regulatory requirements.
One recommendation we've learned from several of our customers is to create the compliance team with the people you're going to work with regularly. For example, if you have two or three units that need to provide you with a majority of your accreditation documentation, recruit stakeholders from those units for your team.
Get them to buy into your vision for the compliance team and help them understand that your goals are their goals, and your accreditation deadlines are their accreditation deadlines. If they have bought into the compliance team accreditation efforts themselves, you no longer have to pester them to meet your deadlines; they're already feeling the pressure and personal pride to meet those deadlines on their own.
Simplify the process for everyone
One of the steps of the accreditation process is being able to demonstrate proof of compliance. Have all these people been trained on these processes? Have they been tested? What are the supporting documents?
In many healthcare organizations, the compliance coordinator may collect all of these proofs, requesting them from different departments and units, receiving them via email, or dumped to a shared drive.
You can simplify the process if you just have everyone upload their proofs directly to PowerDMS since that's where they're going to end up. Rather than storing your proofs in four different locations, or pestering the different units for their proofs, you can assign them specific deadlines and ask them to upload the documents by that deadline. You can even set up the PowerDMS system to send out automated reminders a few days before a deadline, as well as gentle reminders if a deadline is not met.
Conduct annual policy review cycles
Policies and accreditation go hand in hand. For some healthcare facilities, you may get some policies and procedures from the AAAHC, The Joint Commission, DNV, Accreditation Commission for Health Care (ACHC), or Utilization Review Accreditation Commission (URAC), to name a few.
Depending on your organization and the types of policies, you may develop many of your policies based on what your accreditation association requires. And you may develop some based on national, state, and local regulations, such as HIPAA, transportation of patients, or referring patients to other healthcare providers.
If you're like most organizations, you review your policy manual on an annual basis. But rather than reviewing the entire policy manual once every year, review a certain number of policies each month, making sure you review the same policies once per year. So you could review your personal protective equipment and sharps handling policies every April, and then review your sexual harassment and bullying policies in May, and so on.
Whenever a policy is reviewed and updated, it's necessary to send out the updates to all affected employees. But rather than emailing everyone and collecting their emailed acknowledgments and signatures, you can use a policy management system to simplify the process this way:
- Push out all new updates. Assign a deadline for reviews and signatures.
- Track read receipts as everyone reads the new policies.
- Track and collect signatures as everyone signs off on the new policies.
- Send out automatic reminders a few days before the deadline, and again on the day of.
- Send out automatic reminders to anyone who missed the deadline.
- Collect all signatures as compliance proof for your accreditation.
Streamline your workflow processes
When writing a new policy, the old method was to get everyone in a room, write out the policy, hammer out the language, send it to subject matter experts and departmental leadership for review, make changes, and then send it out to leadership for final approval.
The difficulty is you could end up working with five, six, or ten different versions as people completed their review on different schedules, sending their changes back to the compliance team even as a newer version was already making the rounds.
Osborn said the first time she ever used PowerDMS for a policy review and update, they saved 15 hours of work over the old method of emailing updates and collating responses from everyone involved. And that was just for a single update.
With a policy management system, you can push out new policies, ask your experts and leaders to make changes directly in the original document, use version control to ensure you're working from the latest version, and then send it off to leadership for final review and signatures. Finally, you can send out automatic reminders for reviews and final signatures
And if you ever update a policy that is linked to other standards or policies, the changes in your original policy will result in automatic changes being made to those linked policies as well. That can save you countless hours in making updates and changes each time you update policies during your annual reviews.
Improve your communication processes
It's important that the compliance team regularly communicates with employees about new policies, updates to old policies, and other training opportunities and requirements. If they never hear about your policies until there's a problem, they won't understand the importance of these documents.
With the right compliance management solution, you can send automated notifications to all staff to remind them to review old policies or to see the changes made to new policies. You can also send out reminders to complete training sessions on different procedures and topics as a part of your organization's accreditation review.
By helping your employees understand these policies and how they relate to their jobs, your compliance efforts will be greatly enhanced and simplified.
Use compliance management technology
Your accreditation process can be greatly enhanced and improved with compliance management technology, like a good piece of policy management software.
Some of the important key features to any compliance team accreditation process include:
- Central repository for critical content storage. All policies and training content should be stored in a single cloud-based location, rather than different servers and drives, or worse, binders and folders. By having everyone upload their compliance proof and documentation, you can quickly assemble it and measure your completion.
- Map policies to standards to prove compliance. If you use policies created by your accrediting agency or professional association or create your own policies, you can map those policies to your accreditation standards and training content as a way to easily prove your compliance.
- Version control, version history. As you create new policies, it will be necessary to revise the policies until they are exactly what your hospital or healthcare organization needs. You can ensure that everyone is working on the same version of the new policy. And as policies are updated, you can push out the new versions to everyone within the organization without worrying that older versions are still lurking around. You can even highlight the changes between old and new versions.
- Workflows for compliance team collaboration. Good compliance management software will improve the compliance team's efforts at collaborating and communicating. Rather than juggling several different versions of the same drafts, everyone can work from a "single point of truth."
- Scheduling review cycles. A good policy management solution can send out reminders to review certain policies at certain intervals, such as annual reviews. Your compliance team will receive the reminders and can begin reviewing the policies before your meetings to hash out the new changes and updates.
PowerDMS' policy management software offers all of the above and more, including access to different standards manuals that have been created by different accreditation agencies and professional associations.
Accreditation takes a whole compliance team working together, assembling the right documents, reviewing and updating policies on a regular basis, mapping those policies to industry standards, and even providing training and professional development opportunities.
One tool that can help compliance teams streamline the entire effort is a policy management solution like PowerDMS. It's a cloud-based solution that lets you push out policy updates, collect and track signatures, map policies to industry standards, assess training, and deliver completed accreditation reports. Learn howPowerDMS is specialized for the needs of healthcare facilities like yours in a no-obligation demo.
PowerDMS serves other industries as well. Learn about the differences and similarities in compliance between different industries today.