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Create a Culture of Compliance

posted by SamK on November 7, 2012

Sam Kiehl, Executive VP, Accel Anesthesia, LLC

November 7, 2012


In today’s regulatory-intense environment, compliance should be an ever-present consideration for anesthesia practices.  At the heart of compliance is a sound compliance program that is reviewed and updated regularly, widely publicized throughout the practice, and enforced without exception.  A compliance program is absolutely essential, and it is most effective when reviewed and updated through a regularly-held compliance meeting.  A current plan that is well-publicized and enforced is your main line of defense when the day comes that your group is the focus of an audit. Do not put yourself at risk of fines and other penalties (even jail time) by letting your compliance plan grow stale.  Consider the following guidelines when creating, updating and implementing your compliance program, so that you may rest easy knowing you are taking appropriate measures to protect yourself, your practice, and your patients.


Guidelines for Compliance


There should be a clearly written and well communicated compliance program and practice standards.  Specifically address areas of concern where there is the greatest potential for issues.  Establish policies related to anesthesia documentation, recording anesthesia start and end times, concurrency, medical direction, clock synchronization, electronic signatures, as well as billing and coding policies.  Continue to remain educated regarding changes in compliance requirements and new compliance emphases.


Internal monitoring and auditing needs to be performed on an ongoing basis.  Compliance plans grow stale quickly.  Review your plan to insure it is being followed.  Evaluate whether changes need to be made to the plan.


Maintain a high quality training and education program for all staff members.  Regular and proper training of all staff members is a key to success for any compliance program.  Training should especially focus on those areas of greatest risk or concern.


Designate a compliance officer to oversee and monitor the implementation of a compliance program.  The compliance officer facilitates creation and revision of the compliance program, as well as training and implementation of the plan, including ongoing training.  He or she can assist in auditing / monitoring, and investigations into potentially improper practices.


Encourage candid communication from staff members.  Assure them that they may speak freely.  Train staff members to report conduct that they believe to be improper or fraudulent.  Staff members need to understand that failure to report fraud and other misconduct is a violation of the compliance program.


Enforce the compliance plan without exception.  If a problem is identified, have a plan of action to investigate and remediate issues if required.  And be sure to document your investigations and remediation efforts.


Accel Anesthesia can assist you in your efforts to create a culture of compliance at your practice.  We can help you formalize and improve upon your current compliance program, as well as any audits or related investigations into compliance.  Please contact us at Accel Anesthesia with any questions or requests.  We are happy to help you with the challenges you face!