Audits in the hospital setting4
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Metropolitan Community College, Kansas City *
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Course
0105
Subject
Health Science
Date
Dec 6, 2023
Type
docx
Pages
2
Uploaded by ProfessorKingfisher2276
As a multi-trillion-dollar industry focused on patient care and safety, it should come as no surprise that
healthcare is highly regulated, and penalties for noncompliance are steep. There are regulations for just
about everything: protecting confidential health information, following safety protocols when dispensing
medications or performing procedures, documenting care accurately and completely, coding and billing
accurately, and much, much more.
What is healthcare compliance?
Healthcare compliance refers to the process of abiding by all legal, professional, and ethical compliance
standards in healthcare. Basically, it’s about following the rules, and in healthcare, there are plenty of
them. These rules are highly complex, and they change frequently, often requiring operational and
workflow changes, ongoing education, internal audits, health IT compliance updates, and more.
An important point to remember: Healthcare compliance pertains to all healthcare organizations, both
large and small. It's a part of the holistic approach called healthcare governance, risk management, and
compliance—or GRC—crucial to creating a safe, high-performing, high-reliability environment.
Healthcare governance, risk management, and compliance (GRC)
GRC spans your entire organization, and helps:
ensure safety and compliance
measure quality and performance
optimize your workforce
credential and enroll providers
and track facility access and security
Who regulates healthcare compliance?
A variety of federal and state agencies govern health compliance. For example, the Drug Enforcement
Administration (DEA) and the Food and Drug Administration (FDA) both regulate the creation and
distribution of medication. They ensure the safety and efficacy of medications, biological products, and
medical devices. The FDA also provides the public with accurate, science-based information.
The Department of Health and Human Services (HHS) and the Office of the Inspector General (OIG)
protect against fraud by auditing healthcare organizations to help reduce waste, fraud, and abuse of
healthcare dollars. The OIG publishes an annual Work Plan to announce specific topics that it intends to
target that year, giving organizations a “heads up” on the types of audits they could face. Both the OIG
and HHS also provide wide-ranging educational materials so healthcare organizations can strive to
proactively comply with healthcare rules and regulations.
Other important entities are focused on compliance as well. For example, The Joint Commission (TJC)
accredits and certifies organizations, mostly hospitals and healthcare systems, that meet certain
compliance standards in healthcare for patient care quality and safety. The National Association for
Healthcare Quality (NAHQ) fulfills a role similar to TJC’s, but primarily for health plans and credentialing
verification organizations. The Centers for Medicare & Medicaid Services (CMS) and other payers have
also implemented various quality initiatives to promote high-quality health care through accountability
and public disclosure. These measures play an important role in quality improvement, pay-for-
performance models, and public reporting. In addition, the Agency for Healthcare Research and Quality
(AHRQ) provides a host of resources to help healthcare organizations provide safe, high-quality care.
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