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Tip: Seven steps to establish by-department monitoring

Healthcare Auditing Weekly, February 17, 2009

While there is no right or wrong way to set up a compliance-monitoring program, we have created a list of steps for you to form a process best suited for your organization.

1. Develop a monitoring tool, a monitoring protocol, and report templates. The first step in getting operational management involved in compliance monitoring is to provide the right tools for the job.
2. Get feedback from departments. Set up a meeting with key departmental personnel to solicit feedback and arrange a pilot monitoring session.
3. Provide guidance to managers and review staff. Offer training to the departmental reviewers and make sure the staff is comfortable with the tasks required of them.
4. Ensure departmental follow-through. Once the process is off the ground, make sure that it continues.
5. Respond to negative results with corrective action. The action should resolve the problem, document the problem, and present a solution.
6. Audit to support the monitoring plan. The compliance office must continue to audit areas that departments monitor.
7. Create benchmarks, set compliance goals, and use results to demonstrate compliance effectiveness. Working on a monitoring program gives you a unique opportunity to drive performance over the long term and set higher goals for departments in the future.

This tip is adapted from the Guide to Monitoring: Tools and strategies to enlist department managers in hospital compliance. For more information about the book or to order your copy, visit HCMarketplace.

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