Communication And Reporting Mechanisms In Compliance

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Select a healthcare facility or service (e.g., hospital, physician practice, long-term care facility, ambulance service, pharmacy, or skilled nursing facility).

1. Create an outline for a policies and procedures manual appropriate to the facility you select.

Include the following sections in your outline, what are the sub-sections?

Organizational structure
Compliance reporting structure
Code of conduct
Risk analysis
Medical necessity
Billing
Compliance with federal regulation
Marketing
Retention of records
Compliance as an element of performance appraisal
Violations
2. Write a brief description of each policy and procedure outlined.

Include the following components for each policy/procedure brief you write:

Policy number (fictional)
Effective and revised dates (fictional)
Policy title
Purpose statement
List of statutes, regulations, state board policies, executive orders, or other relevant authorities governing the policy
To whom or what does the policy apply
Policy statement
Procedure steps
Cite 3 reputable references to support your assignment (e.g., trade or industry publications, government or agency websites, scholarly works, or other sources of similar quality).

 

Sample Solution

Policies and Procedures Manual Outline for an Ambulance Service

I. Organizational Structure

  • A. Organizational chart
  • B. Job descriptions and reporting lines
  • C. Delegation of authority

II. Compliance Reporting Structure

  • A. Incident reporting protocol
  • B. Quality improvement processes
  • C. Regulatory agency reporting requirements

III. Code of Conduct

  • A. Professional ethics and standards
  • B. Conflict of interest policy
  • C. Workplace harassment and discrimination policy

IV. Risk Analysis

  • A. Hazard identification and assessment
  • B. Mitigation strategies and emergency response plans
  • C. Equipment maintenance and safety protocols

V. Medical Necessity

  • A. Criteria for transport based on clinical guidelines
  • B. Documentation requirements for justification of transport
  • C. Refusal of transport procedures

VI. Billing

  • A. Accurate coding and claims submission procedures
  • B. Patient billing practices and collections policy
  • C. Third-party payer contracts and reimbursement guidelines

VII. Compliance with Federal Regulations

  • A. HIPAA privacy and security rules
  • B. EMTALA patient anti-dumping regulations
  • C. DOT safety regulations for commercial motor vehicles

VIII. Marketing

  • A. Ethical marketing practices and advertising guidelines
  • B. Community outreach and education programs
  • C. Use of social media and online platforms

IX. Retention of Records

  • A. Recordkeeping requirements for patient care documentation
  • B. Archiving and destruction of records according to legal and regulatory mandates
  • C. Data security and confidentiality measures

X. Compliance as an Element of Performance Appraisal

  • A. Integration of compliance into performance evaluations
  • B. Training and development opportunities for improving compliance
  • C. Recognition and rewards for consistent adherence to policies

XI. Violations

  • A. Disciplinary procedures for policy violations
  • B. Reporting and investigation processes
  • C. Corrective action and remediation strategies

XII. Appendices

  • A. Emergency contact information
  • B. Standard operating procedures for specific interventions
  • C. Regulatory agency resources and contact information

Example Policy/Procedure Brief:

Policy Number: AMB-001

Effective Date: 01/01/2024

Revised Date: 12/31/2023

Policy Title: Medical Necessity Criteria for Patient Transport

Purpose Statement:

This policy establishes the criteria used by ambulance service personnel to determine the medical necessity for transport of a patient to a healthcare facility. Following this policy ensures appropriate utilization of ambulance resources and adherence to federal regulations.

Statutes and Regulations:

  • Emergency Medical Treatment and Labor Act (EMTALA)
  • State Department of Health ambulance service regulations
  • American College of Emergency Physicians (ACEP) clinical practice guidelines

Applies to:

All ambulance service personnel, including paramedics, EMTs, dispatchers, and supervisors.

Policy Statement:

Ambulance service personnel will transport patients to a healthcare facility only when there is a reasonable belief that:

  • The patient has a condition that poses an immediate threat to life or limb.
  • The patient has a condition that would significantly worsen without immediate medical intervention.
  • The patient is unable to transport themselves to a healthcare facility due to their medical condition.

Procedure Steps:

  1. Dispatchers will gather information about the patient’s condition and location.
  2. Responding EMTs will conduct a patient assessment to determine the severity of the condition.
  3. Based on the assessment and consultation with medical control, if necessary, a decision will be made regarding transport.
  4. Documentation of the patient’s condition, assessment findings, and justification for transport will be completed in accordance with departmental policies.

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