Denise A. Atwood (email@example.com) is Chief Risk Officer, District Medical Group Inc. in Phoenix, AZ. Nathan J. Ward (firstname.lastname@example.org) is Manager, Compliance & Content Development, youCompli in Pittsburgh, PA.
Under the traditional paradigm, the interests of quality and compliance are divergent. Compliance is a risk-averse function, looking to protect the healthcare organization from litigation, public relations problems, and audit failures. Quality, by contrast, is focused on improvement of patient care. These separate functions and paths can contribute to a siloed mentality.
So, if a patient is harmed due to medical error, compliance would look for nonadherence to a process or policy and conduct an investigation to assess the level of liability exposure to help mitigate future loss. A quality investigation, however, would look for lessons that can be learned and ways in which patient care can be improved so that the patients are better served.
This traditional paradigm no longer applies. Quality and compliance work with each other and with other departments across the hospital. Like compliance, quality is something that requires commitment from many different teams, including hospital leaders, providers, and employees. And a robust quality program helps support compliance objectives.
Depending on the situation or area of concern, two or more departments may be required to work together and share cross-functional responsibilities to address quality concerns or areas of noncompliance. Moreover, quality and compliance cross-functional responsibilities may be similar and overlap. It is important to have open communication between the department leaders to decrease duplication of effort. Some responsibilities of department staff may include:
Conducting audits to assess adherence to regulations and policies and procedures,
Identifying and reporting trends,
Deploying solutions and education, and
Conducting ongoing monitoring to ensure compliance with the solutions implemented.
Consider the following scenario demonstrating quality and compliance cross-functional responsibilities. The quality nurse is conducting audits of the electronic health records to ensure that annual diabetic eye and foot exams are completed and documented during visits in the hospital-owned clinics. During the audit, the nurse discovers that the medical director is cosigning all of the notes in both of the nurse practitioners’ charts, even though it is not required by clinic policy. The nurse asks the clinic manager for an explanation and is told that it has something to do with incident-to billing for higher reimbursement rates. As the nurse’s audit does not address billing and coding issues, these findings are reported to the quality director, who then reports them to the compliance director.
Billing and coding audits clearly fall under the compliance department, so the director initiates another audit of the electronic health records to ensure that the requirements under the Centers for Medicare & Medicaid Services (CMS) are being met. If the audit reveals that all is well, then no further action is needed, beyond reporting these activities to the compliance committee and the quality committee to close the loop.
If, however, the audit reveals the practice is not in compliance with CMS requirements, education must be completed with the medical director and the nurse practitioners. The findings, solution, and education are all reported to the compliance committee and the board. And, in some cases, the overpayments may need to be reported to CMS.
There are many situations where quality and compliance may have cross-functional responsibilities in investigating areas of noncompliance or quality concern. Communication between the team members will ensure the right decisions are made to improve patient care.