Corporate Compliance

How to establish by-department monitoring

Healthcare Auditing Weekly, October 3, 2006

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.

  • Step 1 Develop a monitoring tool, 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.

  • Step 2 Get feedback from departments. Set up a meeting with key departmental personnel to solicit feedback and arrange a pilot monitoring session.

  • Step 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.

  • Step 4 Ensure departmental follow-through. Once the process is off the ground, make sure that it continues.

  • Step 5 Respond to negative results with corrective action. The action should resolve the problem, document the problem, and present a solution.

  • Step 6 Auditing to support the monitoring plan.The compliance office must continue to audit areas that departments monitor.

  • Step 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 the departments in the future.

    Source: Guide to Monitoring: Tools and strategies to enlist department managers in hospital compliance.

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