Q&A: Ongoing compliance success: Creating your action plan

Q: How should I approach monitoring and addressing compliance issues?

A: You will need to develop and implement action plans, measure progress, and monitor compliance with the goal of achieving improvements once deficiencies are identified. The first step is to prioritize your noncompliant findings in terms of how they can be addressed.

• Easy to resolve: Involves minor modifications needed in one patient care area, which do not require multiple committee approvals. Short resolution time.
• Moderate effort to resolve: Involves document and practice changes in multiple patient care areas, which may involve research to obtain consensus. Education or training will be required through communication vehicles and department staff meetings.
• Major effort to resolve: Involves the medical staff as well as employees. Policy or procedure requires significant revisions to meet the EPs. A plan must be developed and implementation involves multiple steps. Additional staff training to achieve competency may be warranted.

Categorization and prioritization allows you to identify what you can easily fix. It also allows you to prioritize follow-up based on the impact on quality and patient safety in your organization. It is important to pay attention to the impact of the EPs. Direct-impact EPs are linked to high-risk and critical issues. These are also likely to have a direct link to CMS CoPs; therefore, their priority would be higher, and the time frame to correction will be shorter than those that have indirect impact or are not linked to the CMS CoP.