The Role of a Risk Manager/Compliance Expert
During Your Inspection

By: Eric Conn, CEO Universal Healthcare Consulting, Inc.

The day of any inspection survey is very stressful in and of itself. The days leading up to a survey, the hours of preparation, the unknown if everything is being completed and properly documented can be even more stressful than the actual survey. We have heard countless times from nurses, administrators and doctors themselves on how sick they sometimes make themselves in the days leading up to a survey.

Whether its state, federal or accrediting body surveys, when the surveyor walks in your door, the stress level rises. We like to think that we do things the "right" way all the time, but when under the scrutiny of a surveyor we all question ourselves. Surveyors can definitely be intimidating.

Preparing for an inspection starts with a firm understanding of the rules and regulations that must be met. There are actually quite a lot of rules, laws and regulations. And guess what? They change frequently. And when AHCA updates their rules, the next year the accrediting body updates their regulations and then an oversight agency such as OSHA, APIC or AORN come out with new standards the next year and after that the cycle starts back up again. And then there always is the question of how you are going to meet the new standards.

We hire lawyers, accountants, real estate agents and other professionals to help us navigate the intricacies of their respective areas of expertise. Why not hire a healthcare risk manager and compliance expert to help ensure your facility is not only compliant on a day-to-day basis but is fully prepared for all inspections including the dreaded unannounced inspections.

A good risk management firm is a valuable resource for every surgical facility prior to, during and after an inspection or survey. Here are a few tips on how to choose a good risk management compliance expert for your facility. In future articles we will look more in depth into each of these areas.

  1. The Risk Management/Compliance expert should be part of a company that devotes sufficient time and resources to monitor and stay abreast of regulatory changes. This a full time job, not something someone can do part time. The Risk Manager also needs to devote time to understanding regulatory changes, and how to meet these changes. Do they require the facility staff to be re-educated? Do they entail policy changes and what about the logs and forms?
  2. Is the Risk Management/Compliance expert on-site for the surveys and inspections? There are 2 reasons why your Risk Management/Compliance expert should be on-site for your inspection. First, it will put you, the client, at ease to know they have an expert to assist in getting through the survey process. And two, the only way your risk manager can explain what the inspectors may be looking for and how they are looking for it is to be present and interact with the inspectors.
  3. Tracking of occurrences for statistical significance is essential for your risk manager to understand what is occurring in your facility that could affect patient safety or patient satisfaction. All occurrences should be communicated to the risk manager before the end of the day. The risk manager should track and trend these events to see which should be discussed in quality assurance meetings, which need to be acted on immediately and which are one off events.
  4. Adverse incident and Sentinel Event reporting can sometimes be confusing as to what constitutes and adverse incident, and how it should be reported. There are many times when filing an adverse incident is not required.

Of course there are many other functions your risk management firm needs to perform in order to ensure your facility is compliant. Such as chairing the quarterly CQI meetings, quarterly reports to the governing body, annual staff education, and emergency drills to name just a few. But the basic requirements discussed above will let you know if your Risk Management and Compliance Firm will work for you and ensure a great inspection that is stress free.

For more information regarding this topic and other risk management and compliance issues
please feel free to contact Universal Healthcare Consulting at 888-457-0393.

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