HIPAA compliance Archives

Establishing measurable compliance objectives enables organizations to track their progress, identify areas for improvement, and mitigate risks before they escalate into significant issues. Goals also provide a roadmap for navigating the complex regulatory environment. But how do you write healthcare compliance goals that accomplish this?

We’ll tackle that question and more in this article.

What is Healthcare Compliance Management?

Healthcare compliance management helps organizations meet various legal, regulatory, and ethical requirements. It includes various activities and protocols to prevent, detect, and address breaches of laws and regulations governing the healthcare sector. These regulations can encompass federal and state laws, directives from regulatory agencies such as the Centers for Medicare & Medicaid Services (CMS), Health Insurance Portability and Accountability Act (HIPAA) mandates, and standards established by accreditation bodies like The Joint Commission.

Download a list of The Joint Commission’s required compliance training.

How To Write Healthcare Compliance Goals

Step 1: Conduct a Risk Assessment

Risk assessments are essential for identifying potential compliance issues and vulnerabilities — every healthcare organization will have unique risks based on location, patient population, staffing, and more. Risk assessments help executives understand the “risk universe” by evaluating operational areas and responsible parties. The ultimate goal is to help the organization operate within the law’s boundaries while providing patients high-quality care. A healthcare compliance risk assessment typically involves the following key parts:

Regulatory Analysis: Evaluate the applicable federal, state, and local regulations that govern healthcare, including laws such as HIPAA, the Affordable Care Act, and Anti-Kickback Statutes. Stay updated on any changes or updates to these regulations.
Data Security Assessment: Assess the security measures in place to protect patient data and support compliance with HIPAA. Identify potential vulnerabilities in data storage and transmission.
Documentation Review: Examine documentation practices to see that medical records, billing, and other records are accurate, complete, and compliant with regulatory requirements.
Training and Education: Evaluate the effectiveness of compliance training programs for staff, seeing that employees are well-informed about relevant laws and regulations.
Internal Audits and Monitoring: Conduct internal audits regularly to identify non-compliance issues, billing discrepancies, or other operational problems. Implement a system for ongoing monitoring and reporting.
Policies and Procedures: Review and update policies and procedures to align with current regulations and best practices. Make them accessible to all employees.
Third-Party Vendors: Assess compliance risks associated with third-party vendors, contractors, and business associates. Determine that contracts include compliance requirements and monitoring procedures.
Incident Response Plan: Develop and maintain a robust incident response plan to promptly address potential breaches or violations. Educate employees on their roles in the event of a compliance issue.
Documentation of Remediation: Document any corrective actions to address identified compliance risks, including policy changes, staff training, or process improvements.
Continuous Improvement: Establish a culture of continuous improvement by regularly reviewing and updating the compliance risk assessment process to adapt to evolving regulations and industry best practices.

Step 2: Prioritize Compliance Needs

You’ve likely identified a large list of risks (if not, pat yourself on the back!). Not all compliance risks are equal, so you’ll need to prioritize to ensure you’re tackling the most pressing ones first. An easy way to get started is to use The Joint Commission’s SAFER Risk Matrix. You’ll rank each risk based on likelihood of harm and scope (limited, pattern, widespread). From here it should be easy to pinpoint either trends that you can overcome with targeted healthcare compliance goals, or specific risks that need their own goal.

Often as you go through this exercise, the areas where you need to provide additional education or reinforcement become clear. Even if you’re fulfilling your compliance requirements, staff may not be translating the knowledge into their daily routine, increasing the organization’s risk. You might need other ways to create or reinforce a compliance culture. Education is a great tool to use in your goals — to avoid burnout, maybe instead of adding full-length courses you set a goal to assign additional microlearning or refreshers. Or maybe you re-evaluate your learning management system to find one who delivers more engaging or applicable content.

Step 3: Draft Clear, Actionable Goals

With a firm understanding of regulatory requirements and your organization’s most pressing risks, the next step is writing clear, measurable, and flexible compliance goals. Many organizations use the SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) framework to create effective healthcare compliance targets.

Here’s a step-by-step guide to help you formulate these goals:

Define Specific Goals: Clearly state your goals. Example: “Implement a new HIPAA training program for all staff.”
Support Measurability: Define how you will measure progress and success. Example: “Reduce adverse incidents by 20%.”
Set Achievable Targets: Make sure the goal is realistic, given your resources and constraints. Example: “Complete Joint Commission training for 95% of staff within six months.”
Make it Relevant: Set goals that align with broader organizational objectives and compliance needs. Example: “Enhance data security measures to comply with updated HIPAA guidelines.”
Define a Time Frame: Specify a deadline or a period within which the goal should be achieved. Example: “Implement new and update existing compliance protocols by the end of Q3.”

Examples of Healthcare Compliance Goals

Reduce the Number of HIPAA Violations:

Specific: Develop and deliver a comprehensive HIPAA training program.
Measurable: Train 95% of staff members.
Achievable: Allocate training resources and schedule sessions.
Relevant: Help all staff be aware of and comply with HIPAA regulations.
Time-bound: Complete the training within six months.

Limit Risk Associated With Regulatory Updates:

Specific: Establish a task force to monitor and implement regulatory updates.
Measurable: Review and update compliance policies bi-annually.
Achievable: Form a task force from existing compliance and legal teams.
Relevant: Maintain up-to-date compliance with all relevant regulations.
Time-bound: Conduct reviews and updates every six months.

Compliance Software Helps You To Meet Compliance Goals

All-in-one healthcare compliance software can help you meet your organization’s compliance goals by automating workflows, maintaining audit trails, and simplifying reporting. Choose a vendor you can rely on to monitor and review requirements, so you stay current.

Compliance software supports your short- and long-term objectives with:

Document Management: Easily update, manage, and store policies, procedures, and manuals within the platform so it’s easy to improve, standardize best practices, and supply auditors with the most current information.
Tracking and Reporting: Automatic tracking and electronic signatures show complete compliance activities.
Reminders and Notifications: Automatic reminders ensure staff complete required compliance tasks and notify you when it is time to update policies or reassign annual training.
Approved Compliance Training: A built-in learning management system simplifies compliance training, and a healthcare-specific system means that courses are updated quickly when regulations change.
Online Incident Reporting: Built-in tools for managing incidents and data analysis eliminate reporting delays and allow managers to track and resolve events efficiently to improve compliance metrics and overall safety.

Consolidated, all-in-one software makes supporting your organization’s compliance efforts easier than ever. MedTrainer’s comprehensive suite of tools and resources offers valuable support to healthcare organizations, ultimately contributing to improved compliance and patient care. By systematically addressing compliance risks, healthcare organizations can foster a culture of accountability and help deliver ethical, safe, and high-quality healthcare services.