The Six Most Critical Standards for Keeping your Healthcare Organization Compliant

• By Dr. Jennifer Williams
• Oct 04, 2021

When most people think of workplace health and safety, issues like ensuring construction workers wear proper protective equipment or forklift engineers are certified to safely operate machinery come to mind. In the healthcare industry, however, compliance has taken on a new meaning and importance in the past 18 months, driven by two primary factors. The first is COVID-19 and its role in significantly heightening the importance of compliance and creating new medical sourcing, test verification and tracing challenges for healthcare organizations. The second is the evolving healthcare regulatory environment. Healthcare regulations are shifting (both in terms of sheer number and their evolving nature), making it feel like a moving target for organizations that are endeavoring stay current with policy changes and remain compliant.

Regulations are in place for good reason: to create safer spaces for patients, providers, visitors and vendors, while reducing organizational risk exposure. For example, one West Virginia hospital was recently ordered to pay $50 million as a result of not properly adhering to a Medicare-related standard. With this in mind, here are the six most important standards for healthcare providers and suppliers to keep top of mind in today’s fast-changing healthcare environment:

1. OSHA’s COVID-19 Emergency Temporary Standard

COVID-19 changed nearly every aspect of our lives, and this extends to safety standards and how they impact the compliance and credentialing space. On that note, the Emergency Temporary Standard (ETS) is an outcome of President Biden’s executive order “Protecting Worker Health and Safety,” and its implications extend to the compliance and badging process. A well-organized and robust badging process is vital to a health system’s ability to adhere to the many aspects of this standard, from employer notification to communication & coordination to health screening and beyond.

2. OSHA’s 1970 ACT to Reduce Workplace Violence

OSHA’s New and Revised Workplace Violence Prevention Requirements are specifically applicable to hospital accreditation. Those requirements are currently in review and will become effective in January 2022. Safety and security risks are present in most health care environments and these risks impact patients, visitors, hospital staff and beyond. It will be vital for healthcare providers to adhere to the new and revised requirements to maintain the safety and security of these stakeholders.

3. Joint Commission Standard EC.01.01.01 EP 5

This Joint Commission standard requires health systems to develop a tailored security management plan based on its facility circumstances. At the heart of adherence is the importance of training staff to “set a tone from the top” to ensure hospital systems are maintaining safety within the credentialing and compliance space for the benefit of hospital staff, vendors and visitors.

4. Joint Commission Leadership Standard LD.01.03.01

The governing body of a healthcare system is ultimately accountable for the safety and quality of care, treatment and services at its facilities. This Joint Commission standard calls on healthcare system leadership to create a “culture of safety” by establishing patient-centered care as a top priority throughout the hospital system. Not unlike the previous point of “setting a tone from the top,” the credentialing and compliance process is vital to ensuring the creation of this leadership-driven culture of safety.

5. OIG § 1001.1901(b)

The Office of Inspector General—a government organization whose primary duty is to track the use of taxpayer dollars—implemented this standard related to Health & Human Services (HHS). Failure to comply with this standard may result in individuals and entities’ exclusion from participation in Medicare, Medicaid and all other Federal healthcare programs. Additionally, physicians can lose licenses and hospital systems can be fined for failure to comply. A robust credentialing and compliance system allows for “sanction checks” to identify which hospital systems are not adhering to this standard, potentially endangering patients.

6. HIPAA Security Rule

The HIPAA Security Rule focuses on the protection of personal health information (PHI) and the security around which business partners have access to private data. Compliance and credentialing are important when identifying security risks through a HIPAA security risk analysis. By implementing well-documented credentialing practices and adhering to this standard, healthcare systems can protect the privacy of patients and prevent liability issues.

Proper adherence to compliance and credentialing standards is about promoting patient safety while ensuring suppliers can continue to conduct vital business with their provider partners. In today’s ongoing “COVID era,” it’s more important than ever for health systems to dedicate resources to reaching key credentialing and compliance goals. Familiarity with these six standards is the first step for hospitals to achieve their compliance goals heading into 2022.