In this LearnScape, the student is the Director of Quality Improvement for Bright Road Healthcare System. The student’s team is in the process of establishing organizational policies and procedures to ensure health law compliance.

The healthcare industry is one of the most heavily regulated industries, so it is incumbent on healthcare leaders to remain current on proposed legislation, newly enacted laws, amendments to existing laws, or the repeal of laws and provisions contained within that may potentially impact the business. It is important to remember, the regulatory agencies (DHHS in this LearnScape) create regulations that are designed to operationalize and enforce the laws. There are often changes to external reporting requirements associated with regulations and financial penalties for those providers and provider organizations that fail to comply. 

Whenever new laws are passed and in anticipation that regulations will be forthcoming the organization’s leadership team needs to examine the impact on the business, and then develop internal policies and procedures to ensure compliance. This LearnScape does a good job illustrating the typical process that organizations undertake when faced with new regulatory requirements. In this case, there are new Medicare requirements that will require the organization to track and report additional metrics to the Department of Health and Human Services (DHHS). These changes are prompting a reexamination of existing policies and procedures to ensure alignment with the new Medicare requirements. This is standard practice in the healthcare industry. 

More specifically, the system will be required to monitor and report medical errors as well as perform a root cause analysis to determine what caused the errors, so that measures can be instituted to prevent similar issues from occurring in the future; track and report patient outcomes and the five health care professional competencies (apply quality improvement, provide patient-centered care, use evidence-based practice, utilize informatics, and inter-professional teams); and then establish a non-blame culture. One final thought, all policies should be presented through the executive team to the Board of Directors or Trustees. Only the Board can approve policies. It is the job of the Chief Executive Officer and his or her team to ensure they are enforced.