Corporate compliance: Get ready for health care quality’s new frontier
Merging of fields inevitable, experts say
There’s a new sheriff in town, and it could be you. With the growth of corporate compliance in hospitals, many administrators are learning what quality managers have known for years: Compliance and quality are not-so-distant cousins; both have a strong focus on process improvement. While quality personnel in small hospitals have always had to take on a wide variety of responsibilities, sometimes including infection control and risk management, now even larger hospitals are getting into the act by combining their compliance and quality functions.
Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Canton, MI, says she’s seen the trend emerging among her clients. "There really should be crossover," she says. "I can see where it would make good sense for compliance and quality to be hand in hand, just because of the standpoint of looking at systems and processes in your organization. When you look at [a compliance] issue, it certainly has implications not only for corporate compliance but also risk, quality, accreditation, and case management — the whole nine yards."
Bret Bissey, chief compliance officer at Deborah Heart and Lung Association in Browns Mills, NJ, agrees that compliance has to be about more than simply putting out fires. "If you have an effective compliance program, regardless of the type of organization you have, you have to step beyond the fraud and abuse issues."
Homa-Lowry says that when deciding where the compliance function should be housed, the biggest consideration should be how the organization performs data collection. "And hopefully, the organization has an infrastructure that supports compliance. I’ve seen in some organizations, large and small, that they have a compliance officer and then they try to train employees to identify compliance issues and bring them forward. But clearly, the folks who are in the records all the time are the ones who are trained, or should be trained, to bring those issues forward so they can be addressed through that process. [Compliance] is probably going to fall to the group or the individual who does a better job of either having access to the data and/or the opportunity to effect change."
Bissey adds that as compliance programs evolve, those with compliance responsibilities will want to make sure that issues central to accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) also become part of the oversight process, even if they are not part of their direct purview.
Homa-Lowry notes that many hospital administrators don’t make a big distinction between complying with federal fraud and abuse regulations and complying with JCAHO standards, so combining oversight for those functions is a natural. "My approach is that they lay out all the [regulations and standards] or keep an ongoing matrix of the ones that affect them the most, then look at the strictest of the lot and try to design their systems and processes to address them with that in mind. I see it as part of the same process."
Lisa Murtha, JD, chief compliance officer at Children’s Hospital in Philadelphia, takes a similar view. "Many of those [accreditation] people recently have been appointed as the compliance officers for their institutions, which means they are inevitably going to have the quality assurance focus that goes along with what they do concerning JCAHO," she explains.
"That does not mean that regulatory requirements take a back seat," she adds. "It just means that [compliance] is incorporated into operations, as opposed to being seen as an afterthought or as merely an oversight function." In fact, she says, the most successful programs she has seen are ones that incorporate compliance monitoring and training into the day-to-day operations of the organization.
Murtha also points out that both the Joint Commission and the National Commission on Quality Assurance (NCQA) have warned that failure to comply with the looming privacy requirements included in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) would be considered a violation of NCQA and JCAHO standards. "While we [view] the privacy and security aspects of HIPAA as more of a compliance-related issue, they are now being actively incorporated into the accreditation process and the quality initiative," she asserts.
Al Josephs, chief compliance officer at Hillcrest Health System in Waco, TX, says that while many organizations already have quality assurance departments, their efforts increasingly will merge with compliance efforts. Like Murtha, he says that the more he becomes involved in quality assurance, the more compliance-related activities he discovers. He also agrees that HIPAA is the "800-pound gorilla" just around the corner.
Joe Murphy, president of Compliance Systems Legal Group in Haddonfield, NJ, sees a distinct trend in health care compliance moving from a very narrow focus on areas such as coding and billing to a broader focus including values and ethics. "Fundamentally, I don’t have a problem with the compliance officer dealing with issues of accreditation because that is very similar to compliance," he says. "My concern is whether there are sufficient resources focused on compliance."
According to Murphy, all of the issues point directly back to the debate over the appropriate role of the compliance officer. He says one facet of that debate is whether the compliance officer position should be a stand-alone position or a position combined with other functions. "[Health and Human Services] has taken the position that it is better to make it a stand-alone position, but my analysis is a little different," he says. "I would rather have a compliance officer with some clout, and any time you take a compliance officer and give him a narrow compliance/ethics function, you run the risk of marginalizing that person."
Homa-Lowry agrees that integration is the key, because "when you have hoarding of data [by one group within the hospital], everybody loses." But she offers a caveat, as well. "There are going to be times when you’re going to want a legal opinion. Because of the nature of the penalties and because it’s difficult to become an expert at things like the Stark self-referral regulations, safe harbors, and other laws, it’s important to have accurate legal interpretations. Whereas interpretations of Joint Commission standards don’t necessarily have those severe penalties attached to them if the interpretation isn’t on target."
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