Hospital compliance codes are commonplace. Ones that work with medical staff documents
are positively exotic.
For the most part, compliance codes are painted with a very
broad brush—or are downloaded from a very generic website-- and filed away in a
drawer, to be pulled out when the feds are at the gate. The author/consultant and often the
compliance officer has no idea how many provisions conflict with medical staff
bylaws, rules and regulations—adopted by the very same board of directors that
signed off on the compliance plan.
The hospital compliance
code is supposed to address legal requirements for hospital and how to comply
with them. But medical staff bylaws,
rules and regulations do too—at least the legal requirements pertaining to
medical staffs, which are numerous. (EMTALA,
sexual harassment, financial conflicts of interest, to toss off a few). Creating a compliance code without consulting
the medical staff bylaws, rules and regulations in place that bind a major part
of the hospital workforce should be unthinkable. So-think about your hospital’s—and compare
the documents. Get rid of the
inconsistencies. Note particularly the effect of violations and adjust the
hospital compliance code to clearly state that medical staff member discipline
is carried out under the medical staff process.
