Creating a Compliance Culture is a Must for Healthcare Facilities

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Front entrance to a hospital with palm tree landscaping and blue sky

By Jack Evans, Director of Regulatory Compliance, and Kathy Neal, Director of CMMS and Facilities Support, Medxcel

Why do we visit healthcare facilities? We can promise you most of the time it’s not because you want to say hello to your doctor. We utilize healthcare resources when we likely need them most, and we expect a high level of care. Part of delivering quality medical care is evaluating risks and mitigating them even if that means adjusting plans that go above the set standard. 

A common misconception is that compliance standards are the best practice or ideal level of regulation. In reality, they are the baseline standards a facility should meet. For example, the Americans with Disabilities Act states that a handicap restroom stall must have at least a 60-inch turn radius for those using a wheelchair. That 5-foot radius is the minimum standard, which could always be larger to further accommodate a user’s needs and comfort and limit a potential risk. 

Reaching above and beyond with compliance standards, when appropriate, comes from creating a compliance culture through communicating the “why” behind standards, adhering to more stringent requirements and taking proactive action to assess and address risks. These are tactics that should be used across all facilities in order to provide patients and their families with top-notch care while also keeping them and healthcare workers safe. 

Communicate the “why” behind every standard

Remember when your parents would ask you to do something “because I said so”? Did that reasoning ever sit well with you? More importantly, did it ever incentivize you to follow through with the task? Maintaining compliance standards should be communicated with facilities with this same thought in mind, that is, sharing why a standard is set and not dictating it “because TJC said so.”

When you share the reason why a standard is in place, it provides staff with a deeper understanding of the potential safety issues that could arise. Unfortunately, many standards are developed in response to serious safety incidents, and sometimes simply sharing what hard lessons were learned is the best way to cement the importance of standards and why they are in place. For example, fire door latches must be inspected on both sides so if a fire were to break out, you are certain that those latches will work. In this case, the “why” behind inspecting both sides is to ensure no matter which side a fire breaks out on, people are protected and the door can stop the fire’s spread.  

Ensuring your staff understand the risks of being non-compliant takes your efforts a step further than satisfying an inspector in order to maintain a safe and healthy healthcare facility. 

When in doubt, follow the most stringent compliance standard

While many compliance standards are written into federal law, they can also vary by state or even local municipality. In some cases, you could find yourself dealing with three different standards for one issue. When encountering these situations, facilities should always honor the strictest requirement. In Alabama, for example, the standard for firewatch is more detailed than what we find in other states and the federal regulatory requirement. In this case, inspectors and facilities would honor the requirement written in the Alabama state version rather than the one laid out by the federal government.

Because a compliance standard is the bare minimum, we know we can take matters a step further to ensure the health and safety of patients, their families and healthcare workers within each facility. 

Proactive action is key

The cornerstone to creating a compliance culture is proactive action. Facilities need to focus on being proactive rather than reactive when it comes to evaluating risks. Searching for and evaluating healthcare facility compliance risks is like noticing there’s no tread on your tires before getting behind the wheel to drive. You know the risks that come with driving on bald tires, and you don’t need a police officer to pull you over to tell you it’s time to get replacements. Similarly, there are risks within healthcare facilities that should not have to be pointed out by an inspector before addressing the potential issue.

For instance, how does a healthcare facility prepare for a severe weather event so it can continue to provide its patients with a high level of care during a storm or natural disaster? This is something that can be addressed through programming with staff prior to weather events so they are prepared and ready to handle any potential situation that may come their way.

Final thoughts

Our healthcare facilities house thousands of patients, their families and employees every day. Knowing this, we should always make every effort possible to create a compliance culture among our facilities to ensure risks are assessed and addressed – even if that means performing above the standard. Whether it’s by communicating why a standard is in place, honoring the stricter standard, or proactively addressing an issue, these are all critical steps that should be taken to ensure we maintain a safe and healthy environment for our patients and healthcare workers. 

About the Authors

Jack Evans is the Director of Regulatory Compliance at Medxcel, providing regulatory compliance leadership across more than 160 hospitals in the United States including the areas of facilities engineering, environment of care safety, emergency management and construction safety. Evans is an advocate for evidence-based process improvement and risk-based regulatory compliance in healthcare settings.

Kathy Neal is the Director of CMMS (Computerized Maintenance Management Systems) and Facilities Support at Medxcel, providing leadership to the CMMS teams and a compliance support team supporting over 160 hospitals in the United States. The Medxcel compliance team provides regulatory support in the areas of facilities engineering, environment of care safety, and construction safety. Neal partners with the CMMS teams and operations leadership to support local teams in the hospitals, facilitating boot camps to ensure all teams are current on regulatory requirements, sharing best practices across the Medxcel organization, and improving standardization.