Tip: Find common ground in compliance codes

A compliance code describes how the hospital intends to comply with laws and regulations by establishing requirements its staff must follow in their course of work. The hospital administrator or a dedicated compliance officer typically oversees the compliance code and relevant program.

A well-run compliance program focuses on education. Yet a common flaw of compliance codes suggests that medical staff offices and members may not be well-educated about these organizationwide resources.

The flaw? Complete disconnect between what the compliance code says and what the medical staff bylaws and other medical staff documents say, which can incite confusion over what rules apply to whom in which circumstances.

Can compliance and medical staff governance be reconciled? Not only is it possible, there are solutions that protect all involved. The best practice for compliance, as for most issues across the spectrum of hospital–medical staff relationships, is collaboration. Medical staff and hospital leadership should agree on which mutual standards their respective constituencies must meet. For example, certain business and professional behavior may be expected of everyone working at the hospital regardless of their source of income, such as promoting a healthy work environment by prohibiting sexual harassment.

To get the process rolling, go over the compliance plan and highlight apparent conflicts with medical staff procedures. Connect medical staff counsel with the hospital compliance office to sort out the inconsistencies and propose revisions for medical staff and hospital approval.

The medical staff can address matters that go beyond these across-the-board standards in its governance documents. For example, the medical staff should adopt, either as policy or medical staff bylaws provisions, specific conflict of interest provisions that are geared toward protecting clinical decision-making without barring private practice.

Enforcement of these medical staff–specific compliance standards is best carried out through existing medical staff structures. Thus, questions of unnecessary care should be brought to the medical staff utilization review committee.

Source: Credentialing Resource Center Journal