Compliance project management 101

by Tish Henderson, MSIT, CHC, CCA

Tish Henderson (lhenderson@ethicahealth.org) is the Director of Compliance at Community Health Services Georgia (CHSGa), based in Macon, GA.

At a recent conference, I met a few people who asked curiously about how to move a compliance program from paper to electronic. Although there is no easy answer that can adequately be shared over lunch, there are simple steps for managing large projects, and as a result of our very thoughtful conversation, this article was born. If you have spent any time in the past few months thinking about how to strengthen your existing compliance program, for any reason, but have been paralyzed by how much time, money, and effort it would take — keep reading.

Compliance programs are subjected to greater scrutiny

The prevention, detection, collaboration, and enforcement of an organization’s mission and goals are fortified by a good compliance program. In 2019, Medicare and Medicaid requirements for participation for long-term care (LTC) will be surveyed under section 42 CFR, Part 483, Subpart B, Section 483.85 and 483.95 for Compliance and Ethics program and training requirements.[1]

By issuing regulations and guidance, it is clear the government seeks to change the corporate conduct of healthcare organizations by giving guidance into a better model of self-governance and corporate compliance. Getting tagged by a federal or state agency can be enough to inform the quality of any compliance program, but it is equally important for a healthcare organization to develop and tailor a compliance program for the benefit of living out its mission and goals.

Before starting a compliance project

Getting proper buy-in from the top helps set the tone. In Compliance 101, Fourth Edition, the authors share the organizational steps for tailoring a compliance program.[2] Those steps include:

  • Gaining support and commitment

  • Developing a Compliance budget

  • Developing a Code of Conduct

  • Identifying staffing needs

  • Conducting risk assessments

  • Developing a mission and goals

  • Having a Plan, Do, Check, Act (PDCA) arrangement in place[3]

After approval and buy-in, the next step is to implement.

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The Society of Corporate Compliance and Ethics (SCCE) is a non-profit, member-based professional association. SCCE supports our members' work with education, news, and discussion forums. We are a community of leaders, defining and shaping the corporate compliance environment across a wide range of industries and geographic regions. In developing and maintaining effective ethics and compliance programs, our members strengthen and protect their companies.

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About HCCA

The Health Care Compliance Association (HCCA), is a 501(c)6 non-profit, member-based professional association. HCCA was established in 1996 and is headquartered in Minneapolis, MN. We provide training, certification, and other resources to over 10,000 members. Our members include compliance officers and staff from a wide range of organizations, including hospitals, research facilities, clinics and technology service providers.

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