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24-WD-Q&C-593-Culture of Compliance Blog Pt 2 02. Blog Image-CN-FINAL (1)

Creating a Culture of Compliance in Healthcare: Meeting CMS and OSHA Requirements

October 22nd, 2024
October 22nd, 2024

In today’s highly regulated healthcare environment, compliance isn’t just a checkbox—it’s a core component of delivering safe, effective patient care. Healthcare organizations must navigate a myriad of regulatory requirements from various governing bodies. Two of the most influential regulators are the Centers for Medicare & Medicaid Services (CMS) and the Occupational Safety and Health Administration (OSHA).

Both CMS and OSHA play critical roles in ensuring healthcare providers adhere to standards that protect both patients and employees. Building a culture of compliance with these regulations is essential, not only for legal and financial reasons but also for fostering an environment where safety and quality are prioritized.

Overview of CMS and OSHA Requirements

Before diving into how to create a culture of compliance, it’s important to understand the role CMS and OSHA play in healthcare regulation.

  • CMS is a federal agency that governs many aspects of patient care quality, safety, performance, and privacy for any healthcare organization that accepts Medicare or Medicaid. It develops Conditions of Participation (CoPs), which healthcare organizations must meet to be eligible for reimbursement. The CoPs cover areas like infection control, patient rights, and quality improvement.
  • OSHA’s focus is on worker safety and health. For the healthcare industry, this means protecting staff from workplace hazards such as exposure to radiation, infectious diseases, bloodborne pathogens, or toxic chemicals. OSHA regulations also emphasize the importance of a safe working environment where workers are protected from falls or other physical injuries.

5 Ways to Build a Culture of Compliance

Embracing compliance goes beyond meeting regulations. It’s having a mindset that values safety, accountability, and adherence to best practices throughout your organization. Here are five key components that can help you develop a culture of compliance:

1. Leadership Commitment

Compliance starts at the top. It’s important that the leaders in your organization understand regulations, but it is equally important they are committed to enforcing them. Ensuring resources are allocated for staff training, process improvements, and technology investments is imperative. Leaders must champion a compliance-first attitude and model the behavior they expect from the entire organization.

For CMS and OSHA compliance, leadership will need to work closely with compliance officers to assess areas of risk and track whether protocols are being followed. Leaders can also set the tone by integrating compliance as a core value in the organization’s mission.

2. Provide Regular Employee Education and Training

Education is the cornerstone of compliance. Staff members need to be aware of the regulations that impact their work and know how to follow protocols effectively. Regular training is essential. Training should be ongoing, with refresher courses being provided periodically to ensure that employees are current with compliance knowledge. In healthcare, where regulations are constantly evolving, it’s also critical that training is adaptable and accessible.

3. Establish Clear Policies and Procedures

Healthcare organizations need clear, comprehensive policies and procedures that align with CMS and OSHA requirements. Company documents should outline all safety and compliance measures, such as patient care protocols, infection control practices, employee safety guidelines, and emergency response plans.

Having well-documented procedures allows employees to easily access the information they need. Proper documentation also provides a reference point for audits and inspections, as well as demonstrates that the organization takes compliance seriously.

4. Promote Monitoring and Accountability

To encourage compliance, organizations must implement systems that allow for regular monitoring and evaluation of compliance efforts. A facility should conduct internal audits, track key performance indicators, and proactively address gaps in compliance.

For CMS, this could involve monitoring infection rates, patient outcomes, or the rate of adherence to patient rights policies. For OSHA, organizations might track injury rates, employee safety incidents, or exposure levels to hazardous substances.

Employees must also be held accountable for compliance. When violations occur, it’s important to address them promptly and fairly so staff members understand the impact of non-compliance on patient safety and organizational integrity.

5. Invest in Technology and Tools for Compliance

The use of technology can drastically streamline compliance work. From electronic health records that provide accurate documentation for CMS audits to safety management software that tracks OSHA compliance, healthcare organizations can leverage digital tools to reduce the burden of manual compliance tracking.

Technology also supports real-time monitoring and reporting, which can help identify compliance risks early. For instance, automated infection control reporting can alert leaders to potential CMS violations before they become systemic problems.

What are the Benefits of a Compliance-First Approach?

A compliance-first approach creates a safer, more efficient, and higher-quality work environment. Here are four key benefits for healthcare organizations to consider:

  • Improved Patient Safety: Compliance with CMS regulations directly impacts the quality of patient care. By following best practices for infection control, documentation, and patient rights, healthcare organizations can reduce errors and improve outcomes.
  • Enhanced Employee Safety: OSHA compliance protects healthcare workers from workplace injuries and illness. A strong focus on employee safety can also reduce staff turnover and increases team morale.
  • Financial Stability: Non-compliance with CMS can lead to costly penalties or the loss of Medicare and Medicaid reimbursements, which can devastate healthcare organizations. Similarly, OSHA violations can result in significant fines. A proactive approach to compliance reduces these financial risks.
  • Reputation and Trust: Patients, employees, and the broader community place their trust in healthcare facilities that prioritize safety and quality. Complying with standard regulations enhances the organization’s reputation and builds trust with stakeholders.

Building a culture of compliance within a healthcare organization requires commitment, education, and vigilance. By focusing on the requirements established by CMS and OSHA, healthcare providers can avoid regulatory pitfalls as well as enhance the safety, quality, and overall performance of their facilities. Compliance is not just about avoiding penalties; it’s about creating a safe environment where both patients and employees can thrive.

Request a demo to learn how HealthStream’s SafetyQ can help your organization stay compliant with OSHA and CMS regulations.

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