The Healthcare Hub

Standardization and Measurement: Keys to the Next Phase of Healthcare Compliance

Tuesday, December 14, 2021

We are in a new era of healthcare compliance. The landscape has changed. As health systems emerge from the worst days of the pandemic, it's imperative that providers reengage their staff to continue the ongoing process of compliance.

The relaxed HIPAA restrictions and compliance regulation waivers that were designed to help hospitals provide care without the red tape are unlikely to last forever. Regulations may become even more stringent as a result of the pandemic, which will increase the need for compliance and safety just as 9/11 did for travel and airport security.

With 629 regulatory requirements across nine domains, compliance is clearly about avoiding issues with laws and regulations. But it’s important to remember that it’s fundamentally about protecting the organization, staff and patients.

A system-wide approach – supported by a top-down directive to establish and cultivate a culture of compliance – is essential to success in this new era. Taking a fresh approach to standardization and measurement/monitoring can ensure that success. During a recent GHX webinar, three healthcare leaders share their organizations’ approaches.

Case Study: What Standardization Did for Parkview Health

At a time early in the pandemic when health systems were struggling to get respirators through their traditional supply chains, Parkview Health in Fort Wayne, IN, relied on the comprehensive vendor credentialing system it had already established to make sure the new vendors they were negotiating with could deliver the respirators they needed when they needed them.

“With the rapidly shifting availability of products, our supply chain professionals had to procure at breakneck speeds while taking extra steps to vet vendors, including non-US-based manufacturers,” said Jesse Stanton, Parkview’s Director of Supply Chain Integration. “We relied on our credentialing platform to help us make successful purchases while avoiding the many fraudulent scams that were out there.”

And because Parkview already had standards like visitation guidelines, vendor registration and mobile badging technology in place for its acute settings, it was well positioned to expand these compliance tools to its physician practices and other non-acute facilities.

“This way, we can ensure that all vendors coming into our physician practices are following our compliance guidelines, which helps us provide the best care and safety for our patients,” Stanton said.

What Compliance Teams Can Learn from Aircraft Carrier Process Management

Sam Grove is Director of Bundled Care at Hackensack Meridian Health, New Jersey's largest health system. As a former Marine Corps pilot, he sees parallels between the compliance process and the process of managing, measuring and improving landings on an aircraft carrier.

“Onboard a ship, there are cameras everywhere, always watching. Other mechanisms monitor and report on what happens. So if a deviation occurs, people generally know why,” he said. “But more importantly, they can improve upon and prevent further mistakes. This enhances both the standardization and safety of the entire operation.

“When measuring the process of landing a plane onboard the ship, it’s more agile to describe the whole planning process. That starts at three-quarters of a mile from the end of the ship. And it continues all the way to the impact on the deck. Each approach and landing is monitored, gets graded and there’s a debrief with the individual pilot immediately. The flight, a grade in this case, a measure is provided and it's mandatory for each pass. That’s how the limits of that particular metric are identified.”

Grove said that thinking about compliance as a process like that of managing landings on a ship, can allow health systems to use process improvement tools and techniques to measure, monitor, and take appropriate to and improve the overall process.

“For measures and metrics to be good, they should relate directly to the process, accurately representing what's happening,” he said. “They should be well understood, timely, and able to identify trends. They should help us see where there are opportunities and improvements. And there should be a method for the storage of the data and any reports that go out.”

Grove outlined six basic characteristics of this process:

  • Compliance is a continuous process
  • Compliance identifies known requirements
  • Compliance identifies how and why we do what we do
  • Compliance enhances standardization
  • Compliance enhances safety
  • Compliance makes it easy to see and improve upon mistakes

“I find that people respond much better to top-down change management initiatives if they know the reasons why,” he said. “When it's about safety, understanding the risks associated with doing or not doing what’s outlined can be important to getting buy-in across the organization."

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