A hospital compliance officer is responsible for ensuring that the facility meets all regulations set forth by governing bodies and completing all required reports. This can include governments, environmental agencies, and licensing agencies. Regulations under consideration can include those that involve the facility, the staff, and private patient information. In some instances, the officer can be named, along with the facility and its owners or governing officers, in court cases or complaints involving noncompliance.
A number of entities set the regulations that a hospital compliance officer must enforce. Local and national governments often pass laws that require hospitals to protect patient information. Another common requirement is to provide care to patients with life-threatening illnesses or injuries regardless of the patient’s ability to pay for services received.
Environmental agencies or health organizations, which may or may not be government funded, often make rules regarding sanitation. These might include sterilization of surgical equipment and adequate hand washing. Other such rules may involve the disposal of hazardous waste. Government insurance programs and, on occasion, private insurance programs may also place requirements on hospitals. The hospital compliance officer is responsible for knowing all such regulations, understanding how they apply to the hospital’s policies and practices, and ensuring that all requirements are met.
For example, many regulations contain posting, training, or notification clauses. A posting clause dictates that all or some of the regulation’s verbiage be posted, often in a specific area and at a minimum size. A hospital compliance officer is responsible for ensuring that these posters are created and put up and for ensuring that they are replaced if they get taken down.
A training clause, sometimes called a notification clause, specifies the way in which the regulation must be communicated to employees and, sometimes, to patients. The hospital compliance officer is responsible for drawing up any required written or electronic communications in accordance with the regulation. If the regulation requires that staff attend online or physical training, either as a one-time or recurring event, the officer usually works with the hospital’s training staff to create, deliver, and track the required modules.
In most cases, hospitals must prove that they are meeting regulations. This is generally accomplished by completing regularly scheduled reports. These reports are usually the responsibility of the hospital compliance officer. Many agencies also conduct both scheduled and unscheduled audits. When that happens, the compliance officer is responsible for making sure the facility is prepared and for working with the auditors to resolve any issues.