What Is the Greatest Threat to Healthcare Compliance?

Julie Horibe, BSN, RN, CPN

Healthcare compliance teams have one of the hardest jobs in the organization. Every day there are new risks and plenty of these could be considered the greatest threat to healthcare compliance.

These risks all have something in common: Humans. 

People are unpredictable and imperfect. But, if they’re the greatest threat, I also think humans are the greatest asset to healthcare compliance. They’re proactive, observant, and well-intentioned.

I’ll explain my thinking in greater detail below, as well as offering some ideas on how compliance professionals can limit the human factor to tame some of the uncertainty that keeps you up at night.

Do Humans Pose the Greatest Threat to Healthcare Compliance?

As a compliance professional, you can’t control human behavior, which means you’re always worrying what a patient, vendor, visitor, or employee might do. To be clear, I don’t think people are intentionally putting compliance at risk. But, as I said earlier, they’re imperfect. 

People might say they’ve reviewed a policy when their understanding or level of review might differ from what we expect. They might accidentally share too much information. They might not fully wipe up a spill that causes a slip. They might make a mistake. Preventable medical errors are a leading cause of death in the United States, according to a study published in the Journal of Patient Safety

The current healthcare staffing situation also puts compliance in danger. High turnover brings in new staff who are less familiar with policies and protocols. When organizations are short-staffed, employees have more responsibility and less time, which can lead to shortcuts. Economist W. Edward Deming said, “94% of all failure is a result of the system…not people.” 

All of these things pose a threat to compliance, but none are malicious or intentional. The question becomes, how do you limit the risk that humans present?

Reducing the Chance of Compliance Surprises

Even the most knowledgeable, intelligent, and well-trained individuals will make mistakes, and incidents will occur. It’s up to compliance professionals to plan for all scenarios and be ready to quickly act. Here are a few ways to reduce threats to healthcare compliance and make people your greatest assets.

Automating Tasks

Using technology, specifically automation, can eliminate the human factor — when it makes sense. For example, remembering to complete required training. Automated reminders can be sent to employees until the course is complete. Automated exclusions monitoring can handle the tedious task of searching each database and notify a human when a change in status is found.

Maintaining and Enforcing Policies and Procedures

Having policies and procedures is great, but where you really limit threats is in keeping them updated and accessible to all employees. Don’t let your policies be something employees acknowledge when they’re hired and never see again. Digitally-stored policies can be accessed anywhere, right when employees find themselves needing to know what to do. Consistent enforcement of policies will also help everyone know what is acceptable.

Reducing Pressure

Employees who feel pressure to get tasks done more quickly or see more patients may be more likely to skip steps in favor of things they deem more important. This pressure is often felt by credentialers, who can be seen as holding up an organization’s revenue. Identify realistic workloads and consider solutions that help employees to be more productive. For credentialing specifically, use this worksheet to determine if it is even possible to complete what is expected.

Remove Barriers to Incident Reporting 

Create a proactive reporting culture where healthcare workers at all levels assume responsibility for reporting errors and participating in change initiatives that create a culture of safety. Enable employees to report incidents online to increase speed and accuracy. Customize your incident report forms by incident type so you get more accurate information and employees aren’t guessing what a question might mean. And always make sure a truly anonymous reporting option is available so staff don’t have a fear of blame or retribution. 

Tracking Progress and Trends

Understanding recurring problems can help you make broader organizational changes or implement new safety protocols. Using healthcare incident management software, organizations can better measure the effectiveness of their safety interventions and quality improvement initiatives. By understanding root causes, healthcare organizational leaders can make adjustments to prevent recurrences.

Continuous Learning

I’m a big believer that mistakes pave the shortest road to improvement. Proactive, ongoing training is how we turn errors into success. All new hires must complete training as part of their new hire onboarding, but don’t hesitate to assign refresher training or to use education as a standard corrective action. A healthcare learning management system will automatically track training completion, issue certificates, and enable customizable reporting. This helps with surveys and could also limit your liability.

Make the Right Thing the Easy Thing

We opened this blog with the question: “What is the greatest threat to healthcare compliance?” Hopefully you can agree that humans present a threat, if not the greatest threat. But, there are so many ways that healthcare compliance professionals can limit the risk and ensure humans are the greatest asset to healthcare compliance.

No one wants to make a mistake, so make it easy for employees to do the right thing. If you feel like you need help, compliance software, like MedTrainer, can help you to be proactive and prepared. Reach out to us for details. 


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