adavis_finalsubmission_12623

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Rasmussen College, Florida *

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3422

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Information Systems

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Jan 9, 2024

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docx

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Module 6: Final Submission Ariel Davis Rasmussen University H340/HSA3422: Regulation and Compliance in Healthcare Rebecca Mangali 12/6/2023

Overview of Compliance Plans Compliance efforts are designed to establish a culture within an organization that promotes prevention, detection, and resolution of instances of conduct that do not conform to federal and state law, and federal, state, and private payer healthcare program requirements, as well as the provider's ethical and business policies (Merritt, 2015). Compliance plans are important in preventing fraud, abuse, and other liability areas within a healthcare practice. There are two compliance plans that our company is currently working on. The first compliance plan we are working on is making sure that clinical staff is washing their hands between patients. The purpose of this compliance plan is to prevent the spread of germs throughout the facility. Setting guidelines to practice better hygiene will help keep patients and staff from getting sick. By incorporating proper hand hygiene techniques, this will also create a much cleaner workplace. The second compliance plan we are working on is to make staff more knowledgeable in the use of fire extinguishers. The purpose of this compliance plan is to help educate staff on the importance of fire safety. When staff is knowledgeable on the use of fire extinguishers, they can keep themselves and patients safe in the event of a fire. This compliance plan can also help prevent any damage to the facility. The new compliance officer must put the two new compliance plans in affect. The officer must have good communication skills to demonstrate the new regulations to staff members. It’s important for the compliance officer to assist in developing and implementing new compliance plans that protect the patients and staff members of this hospital. Every employee will benefit from these compliance plans because they are developed in the employee’s best interest.

Policies and Procedures Clinical Staff Members Must Wash Their Hands Between Patients Hand hygiene is extremely important within the work environment. For the hand washing compliance program to be effective, I have established written guidelines on the hand washing procedures. Every member of this hospital is expected to follow the new procedures regarding washing hands between patients. Hand Washing Procedure Handwashing offers great rewards in terms of preventing illness. Adopting this habit can play a major role in protecting your health (Mayo Clinic, 2020). Follow these six steps every time: 1. Wet your hands with clean, running water. Either warm or cold water is fine. 2. Apply a generous amount of soap. 3. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. 4. Scrub your hands for at least 20 seconds. 5. Rinse your hands well under clean, running water. 6. Dry your hands using a clean towel. When to Wash Hands Knowing when to wash your hands will prevent the spread of germs. The main goal of this compliance plan is to make sure that employees wash their hands between patients. Employees should be washing their hands more frequently, rather than just in between patients. All

employees should be washing their hands after they use the restroom, after throwing away garbage, after blowing their nose/sneezing/coughing, after preparing food, and before and after time with a patient. Who Will Make Sure It’s Done? The supervisors are expected to continually model appropriate hand washing practices for employees. Supervisors shall monitor employee hand washing and make sure that everyone is washing their hands correctly. Supervisors will also be monitoring the hand sinks at least once every few hours to assure that each sink has the necessary supplies. Who Must Wash Their Hands Every single employee must abide by these hand washing procedures. If for Some Reason you Cannot Wash Your Hands If an employee does not have access to a sink, or if soap and paper towels are limited, they must use antibacterial hand sanitizer. It is important to remember that hand sanitizer works best when there’s enough to lightly coat the entirety of both hands and it must dry completely to be effective. To make sure both hands are completely covered, rubbing the hands together while wet and interlacing the fingers to coat the inside each individual finger is best (Whitlock, 2020). Hand sanitizers do not get rid of all types of germs so it’s important to make sure the resources to wash your hands are readily available. Monitoring Tools for Compliance Clinical Staff Members Must Wash Their Hands Between Patients

A crucial part of a compliance program is to monitor the effectiveness of the procedures set in place. Monitoring tools allow staff to find any errors in the compliance plan and actively work to fix them. I have put several different monitoring tools into action regarding the hand washing policy. Sign-Off Sheet To keep track of whether people are washing their hands, I have administered a sign-off sheet that is located at every hand washing station. The sign-off sheet would consist of writing the time the employee washed their hands, answering yes/no if they followed the required hand washing guidelines and whether the wash station needs to be restocked. The sheet will need to be signed by the employees each time they wash their hands throughout their shift. At the end of the day the supervisor will sign off and make sure that each employee has washed their hands before and after every patient. The sign-off sheet will help keep employees on top of their responsibilities and will also help keep supplies stocked. Hand hygiene compliance increases dramatically when these observers, who are usually well known to the staff, are circulating in the unit (Infectious Disease News, 2014). Having supervisors check off on the sign-off sheets will allow for more compliance from staff. Electronic Monitoring Systems Use of electronic monitoring can be a valuable tool for educating healthcare workers on their hand hygiene performance, and tracking hand hygiene performance improvements (Infection Control, 2013). Electronic monitoring systems can have a great impact on hand hygiene compliance. An electronic monitoring system can help improve workflow because it does not require healthcare workers to record information. Although a sign-off sheet requires employee

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