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Six Steps to Improve Your Medical Office's Compliance in 2018

Kevin Webber - Jan 16, 2018 6:14:00 AM

Medical-Compliance-Graphics-Overlayed-on-Doctor.jpgCompliance is a vital part of running a medical practice, but how do you manage it successfully in the rush of daily operations?

While it’s true that compliance management could easily justify several full-time employees in many medical facilities, that’s only an option for the largest practices. More typically, you’re asked to wear many hats at once so how do you ensure your compliance is handled properly while juggling all of your other important tasks?

Fortunately, many of the most common compliance errors can be mitigated with robust training programs, smart use of vendors and support contractors, and diligent review of your paperwork habits.

Here’s what you need to know to avoid some of the most common medical practice compliance violations:

Develop a Hazardous Communication Program

Hazardous communication violations are the second most common reason for OSHA citations across every industry, including the medical field. More than 4,000 such related citations were issued in 2017 alone, and the average in most years is well over 5,000.

The good news is these violations are relatively easy to avoid, as long as you manage your compliance consistently.

If your medical facility handles hazardous chemicals, you’re required to train all relevant employees as well as draft a written hazardous communication program guiding your operations. You must also provide safety data sheets for each type of hazardous chemical you handle and clearly label all hazardous chemical containers. 

Conduct Annual Bloodborne Pathogens Training

The Bloodborne Pathogens (BBP) standard is used to define safety and training requirements for exposure to bloodborne pathogens. BBP standard training is required for any employee who might come into contact with such a pathogen. In most medical facilities, that applies to everyone including administration and part-time staff.

You’re required to provide annual OSHA-approved BBP training to every employee, and it’s critical to clearly document all training activity. This includes recording each training date, the materials covered, the names and positions of each attending employee, and the names and qualifications of all trainers and teachers.

Use Proper Business Associate Agreements

HIPAA and other Private Health Information (PHI) regulations are frequent culprits for compliance violations. Many practices forget that most of their partners, vendors and other business associates must also comply with HIPAA regulations if their work involves any type of contact with patient information. Failure to do so can be costly, as in the case of a $31,000 fine levied for failure to maintain Business Associate Agreement (BAA) documentation for a single partnership.

To stay compliant, you must ensure that all business associates are covered by an officially drafted Business Associate Agreement (BAA). The specific stipulations will vary, but the goal is to have a legally binding agreement with your partners guaranteeing their HIPAA and PHI compliance while working with your medical facility and its data.

Note that medical waste is not currently classified as PHI, so you're not required to sign a BAA with your waste management provider.

Train Staff on HIPAA Compliance

When it comes to HIPAA, the most common source of violations stems from employees who are inadequately trained in HIPAA compliance. Most medical facilities ensure their medical staff, administrators and managers receive proper training; however, they may forget the law requires that any employee or representative with proximity to PHI be properly trained. This includes part-timer employees, interns and volunteers.

To stay compliant, your facility should conduct regular reviews to ensure all training material and documentation is current. You should also conduct regular training sessions for all relevant employees and representatives. If you’re concerned about the cost of maintaining proper training, it’s a good idea to work with a medical waste service provider who includes compliance training as part of its service offerings.

Create a Written Medical Waste Management Plan

The Alabama Department of Environmental Management (ADEM) requires you to have a written plan for managing your medical waste.

Always ensure your waste management plan is up-to-date and properly managed.

Your written medical waste management plan should include the names and contact information for the managing authority in your medical facility, as well as relevant positions for all waste management business associates. It should also include the type of waste generated by your facility, how often the waste is removed, and how the waste complies with regulations for segregation, packaging and disposal.

Finally, your plan must list the ADEM permit numbers for your facility and all medical waste service providers. Training information, including the steps your facility takes to reduce employee risk, should also be documented in your medical waste management plan.

Request Proper Waste Provider Documentation

Remember, your medical facility is responsible for the proper disposal of its waste even when the disposal is handled by a professional medical waste provider. With this in mind, your facility must ensure your waste provider always furnishes written certification stating that all handling and treatment requirements are satisfied. The documentation should include a signed manifest for pick-up of the waste and a certificate of destruction once the process is complete. By obtaining documentation, your facility will be better prepared to prove their compliance with the proper disposal of its medical waste.

Managing compliance concerns can be overwhelming especially when you are focused on the many other important responsibilities of your job. The most common sources of compliance violations tend to revolve around appropriate training, proper documentation and good partnerships with business associates. However, if you keep a vigilant eye on your in-house training programs and partner with a waste management provider and business associates who share your dedication to compliance, you can ensure your medical facility avoids the most common sources of violations—now and in the future.

Want to further improve your waste-related compliance?

Download our free compliance checklist to help you ensure your office is meeting regulations for medical waste disposal for your staff, process and more. Click the "Download Now" button below to learn more and get your free copy.

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Topics: Compliance

Kevin Webber

Kevin Webber

Kevin Webber is a partner at TriHaz Solutions and actively involved in the day-to-day business from a strategic and operational standpoint. He has a successful background in business/investment management and entrepreneurship, including recognition by Inc. Magazine’s 5000 list of fastest-growing private companies.

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This compliance checklist helps you:

  • Make sure your office is meeting OSHA and DOT training requirements.
  • Ensure you are properly storing medical waste.
  • Establish the correct processes for your medical practice.
  • Obtain the correct documentation from your medical waste provider.
  • Organize your compliance related tasks in one location.
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