How Often Should Healthcare Organizations Assess Their Compliance Programs?

Sarah Jones
How often should healthcare organizations assess their compliance programs is known by these medical workers walking confidently down a hallway

Compliance programs are a crucial part of delivering superior healthcare. When a healthcare organization and its staff are aligned on standards, practices, and protocols, it paves the way for accountability and excellence across the board. That said, healthcare is constantly evolving. It begs the question: how often should healthcare organizations assess their compliance programs?

Managing a healthcare compliance program is no simple task. When it comes to regular and routine assessments, it takes a village — or a helping hand from compliance software. 

What Is a Healthcare Compliance Program?

A healthcare compliance program is a system of protocols that ensures healthcare organizations adhere to legal and ethical standards in the delivery of services. These programs are designed to prevent and detect violations of healthcare laws and regulations, promote patient privacy and data security, and uphold the highest standards of patient care. 

Healthcare compliance programs typically involve policies, training, auditing, monitoring, and reporting mechanisms. Together, these protocols serve to mitigate risks, foster a culture of compliance, and safeguard both the organization and its patients from potential legal and ethical breaches. 

How Often Should a Healthcare Compliance Program Be Assessed?

Healthcare compliance programs should undergo assessments to ensure their effectiveness in maintaining legal and ethical standards. Auditing these programs can involve both external and internal assessments.

External Assessment

External assessments are conducted by independent third-party experts, and can either be scheduled or spontaneous. They typically involve a comprehensive review of policies, procedures, and practices to identify any weaknesses, gaps, or potential compliance violations. Most importantly, they help to keep healthcare organizations accountable. Avoiding negative press as a result of violations, is a powerful incentive for organizations to stay up to date with evolving regulations and best practices. 

Internal Assessment

Internal assessments are self-assessments carried out by the healthcare organization’s own compliance team, officer, or privately contracted company. Internal assessments involve ongoing monitoring, auditing, and evaluation of the program’s components to identify areas that may need improvement or modification. But how often should healthcare organizations assess their compliance programs? The answer is, they should be conducted regularly throughout the year, with specific areas of focus rotating in accordance with risk assessments and regulatory changes.

7 Effective Compliance Program Elements

Effective compliance programs encompass a range of elements to ensure an organization’s adherence to legal and ethical standards. While there can be variations based on specific industry requirements, here are seven fundamental elements often considered essential:

  1. Written Policies and Procedures. Clearly documented guidelines that outline compliance expectations and regulatory requirements.
  2. Leadership and Governance. Strong senior management support and dedicated compliance oversight.
  3. Training and Education. Ongoing programs to educate employees about compliance standards and their roles.
  4. Risk Assessment and Mitigation. Regular identification of compliance risks and the implementation of control measures.
  5. Monitoring and Auditing. Continuous evaluation and assessment processes to detect and address compliance issues.
  6. Reporting and Response. Mechanisms for reporting concerns and a structured process for investigation and resolution.
  7. Enforcement and Discipline. Consistent approaches to enforcing standards and addressing violations.

These elements form the foundation of an effective compliance program. They help organizations prevent, detect, and respond to compliance violations, while fostering a culture of ethics and integrity.

How To Use Technology To Keep Your Compliance Program Up to Date

When you consider how often healthcare organizations should assess their compliance programs, it becomes clear that a manual approach isn’t the best one. Maintaining a robust healthcare compliance program takes an ongoing, concerted effort. Thankfully, compliance management software is paving the way for better oversight by making it easier for compliance management professionals to focus on continuous improvement. 

Here are some of the best use cases for technology in keeping compliance programs up to date:

Version and Approval Tracking 

Digital tools help organizations efficiently manage and document changes in policies and procedures. They track revisions, capture approval details, and provide a clear audit trail, to ensure compliance documentation remains current and aligns with evolving regulations and internal standards. This real-time visibility and accountability streamline compliance management, enhancing the program’s overall effectiveness and adaptability.

Track Employee Training

Digital platforms and learning management systems (LMSs) enable organizations to deliver and manage compliance training efficiently. They provide real-time tracking and reporting of employee progress, completion, and performance, to better-align comprehension and identify courses that may need to be updated.

Survey Employees

Surveying employees is critical in assessing and improving compliance standards. To effectively gather feedback, organizations should use digital surveying tools that accurately capture employee engagement and understanding. This also emphasizes the relevance of asking good questions, such as:

  • Can you readily access or reference policies and procedures?
  • Do you know how to search for specific policies?
  • Do department policies assist you in doing your job?
  • Do you feel adequately trained to do your job compliantly?
  • Do you have suggestions for policies or procedures?
  • Do you feel like the compliance team is approachable?
  • Is the organization’s incentive system consistent with the compliance program?
  • Are there processes in place to disclose conflicts of interest?

Incident Reporting and Tracking

Advanced software solutions can streamline incident reporting by allowing employees to easily report compliance concerns. This, coupled with automated tracking systems, provides real-time visibility into reported incidents. This creates accountability and prompts compliance teams to promptly investigate and address potential breaches by taking appropriate action. Incident data further enables compliance teams to identify trends or common issues.

All-In-One Compliance Software Helps With Compliance Program Assessment

MedTrainer offers comprehensive tools for monitoring, tracking, and evaluating various compliance elements within healthcare organizations. Our platform centralizes data and documentation, making it easier to assess policy adherence, employee training, and incident reporting. With a user-friendly interface and automated features, MedTrainer also streamlines the assessment process, to help healthcare compliance teams keep their programs current, efficient, and well-documented.


See how MedTrainer can streamline your compliance.