Module 5- Course Project- Procedures for Compliance

Medical facilities have to and need to uphold the highest standards of hygiene, patient care, and thoroughness in neatness and other things that could be taken for granted. In the previous modules, there have been procedures of compliance that have been outlined to ensure the facility is doing the right thing as per the law (Ly, 2013). However, to carry out these procedures and ensure that they are working as per the requirement, there has to be an auditing and monitoring process for the compliance plan (Ly, 2013). These processes enable the compliance officer to confirm the viability of the procedure itself and to have and gain knowledge of whether the plan is working.

The auditing and monitoring process in any healthcare organization or facility assists that facility to stay in check regarding the compliance of the federal and state rules and regulations by enabling the implementation of internal audits and reviews of compliance program operations. This is an essential element bearing in mind that most of these facilities are bound by law either under federal or under state jurisdiction (Pappas, 2017). These facilities can know which laws they are subject to, but some rules cut across all the authorities, and it does not matter whether or not they are state or federal facilities.

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The monitoring tools involve checks and assurances that enable verification of procedures to know if they are functioning as they ought to within the compliance program and to also check on the quality control. These are the critical area that is typically sought after by the relevant authorities and to an extent, the compliance officer of a facility (Pappas, 2017). While the monitoring of a compliance program is ongoing, it is typically conducted by the Compliance Department Staff. However, if there are any deficiencies discovered during the monitoring process, there is a need to have additional auditing, which is administered by the Internal Audit Department of that organization. 

In most of these organizations, an external audit is more recommended, and this is because there are more formal reviews that involve several critical areas. These areas revolve around identifying risk areas, validating information, testing processes, assessing internal controls, corrective actions for improving a compliance program to management and the board of directors and formally communicating recommendations (Turetken, 2012). This idea is the same as having an external examiner in a school set up they can assess the children impartially, and this yields more results in the future, but of all, it gives honesty to a higher degree.

The main reason why these facilities go for an external audit is due to objectivity and independence being realized. It is imperative for health care facilities to conduct and have auditing and monitoring plans. This enables an operational success because it provides in-depth reviews of the compliance program from both inside and outside the compliance department. By having these review processes, it ensures that there are necessary procedures, safeguards, and policies that are in place to avoid high compliance risks and to run an effective compliance program (Tyl, 2009). This compliance plan also verifies that work members in the organization are aware of and adequately trained on required state and federal laws as well as ensuring the internal conduct and procedures are upheld. 

It is important to note that all these facilities have to ensure that they are compliant with these laws. In this, there is an assurance to the people needing these services that there is a safe environment that they can visit to make sure that they can be able to have the right services according to them (Turetken, 2012). It is also suitable for the facilities to uphold these standards as per the law to avoid any unnecessary tussle with the relevant authorities.

The Key Health Care Auditing and Monitoring Tools

There are several essential health care monitoring tools that are typically used to ensure that there is compliance in a facility. These tools are used to make sure that several set initiatives are met, for example, quality control, which is very important in a health care center (Fdhila, 2016). Every compliance auditing and monitoring plan is often tailored to an organization, and this is based on its current risks, procedures, and operations. Despite this being the case, some standard monitoring and auditing tools are meant to help ensure that the compliance program is running effectively (Fdhila, 2016). This enables the facility to be aware of the areas of weakness and how they can be mended.

The first monitoring and auditing tool is the risk assessment and evaluation procedure that is used by the compliance officer. This tool has been used to determine how many and what types of risks are existent in an organization. By having this type of analysis, the organization can decide on the critical areas of focus while auditing and monitoring efforts to identify the most severe risks (Ly, 2015). This is important since it allows the facility to know the areas that need mending at times; some of these areas are usually being neglected, and they need more focus. This could be contributed by some things such as lack of funding, lack of enough personnel and facilities. 

These facility needs to be reliable in every department. If they are unable to allow all the departments to thrive, then it would be best to do away with the under-utilized department. It is best to acknowledge that there are departments that are unable to meet the standards, and there could be many issues that contribute to these factors, as mentioned above (Ly, 2015). The aim of having such a facility is not to turn a profit but to offer quality services.

As per the standard process, conducting a comprehensive risk assessment is recognized as one of the critical elements of an effective compliance and ethics program. It is paramount that also the ethics aspect of the organization is factored in to enable to shed light on service delivery. In perspective, regulators or compliance officers have emphasized on the importance of having an effective risk management program (Dufour, 2017). To add to this, management and board teams have increased their focus on the concept of risk, and there has been an observation of a paradigm shift in this area at their organizations. An organization is enabled to understand the nature and impact of the risks they face by having better design programs.

This is why an external audit is vital to these organizations because there would be no compromise in this process. The external audit firms work hand in hand with the compliance officer of the organization who assists them by giving precise information about the compliance plan of the facility (Dufour, 2017). As we indicated, different organizations have a separate compliance plan that is tailored to their facility, and this is because of specializing in various areas of medicine such as chest hospitals, cancer centers, and other individual facilities. 

Risk assessment and evaluation fall under the discipline of risk management, where enhanced frameworks and techniques have been able to emerge over the years. Evaluation of risks comprises evaluation, prioritization, and identification of risks, which is followed by the coordinated and efficient use of resources used to monitor, minimize and control the probability or the impact of that risks being able to occur (Dufour, 2017). Risks can manifest themselves in many forms. They can range from operational failures, natural disasters, uncertainty in financial markets, third party risks, to reputational harm, legal liabilities, and also missed opportunities that could occur as a result of not having enough resources.

The second monitoring tool that can be used to ensure the compliance plan is in effect is the compliance training to educate the workforce on compliance policies and procedures. This is extension could also include the education of the workforce on compliance program operation protocols (Boyce, 2017). This type of training also highlights compliance issues across the organization while focusing on the problems that pose the most significant risk to the organization. The workforce ought not to be left out in such matters. More often than not, human error leads to some of the identification of these risks, which could jeopardize the operations of the whole organization (Boyce, 2017). There should be time set aside to enable the education of these issues, and it can be done at all stages of the tribe’s meaning at the high level and the low level.

The education and training of these individuals are typically done at the primary level, and at times, it is done during the first class in medical school. These procedures are often tested to enable people to understand whether they have been able to comprehend what has been taught (Aranda-Gallardo, 2013). Despite this, there needs to be further emphasis at the facility to make sure that all the personnel in the facility has been able to be taught about these policies, and it is vital for both the facility and the staff. 

During this period, persons are often educated about the ethical side of how they should conduct themselves in the organization. Perhaps this side of education is even much more emphasis than the other, which is the compliance plan. Recently, facilities have seen that neglecting the training of their personnel could lead to miscommunication and lack of understanding (Aranda-Gallardo, 2013). In most circumstances, if there is no cohesion at all these levels, there could be chaos and confusion.  

If there is a gap in this respect, then there could be severe malpractice issues in the organization, and the compliance officer will have a hard time trying to reconcile all these issues at once. In respect to this, it would be proper to set up a compliance training program just in case there needs to be one. At times even the people at the lowest level need to be made aware of the compliance plan, and this enables those people to have a layout on the standards and how they need to be perfected at such a facility (Flodgren, 2011). Training is one of the key areas that these facilities thrive on, and they are sometimes set up as teaching referral facilities. 

The main reason why these steps are being taken is to avoid significant risks that could harm the facility. As a compliance officer, it would be recommended that the policies and procedures be set up in offices and departments for emphasis since it is essential to minimize the risk exposure to the organization (Flodgren, 2011). Most facilities have these policies pinned professionally on the walls of the facility. They need not be taken for granted by those who work there because there is a need for operational success on the matter. To carry out this process successfully, the people in the facility need to have allowed themselves the need to understand these policies.

Once the person has been educated on the procedures and policies, it would be suitable if they can begin to have their templates within which they can be able to read and understand from it (Pires, 2017). This would be a sign of seriousness in enforcing the compliance plan by the facility, and it would be favorable if it is done thoroughly and by the book, as we have seen at the federal and state levels.

In all this process, there needs to be a procedure in place that needs to be carried out, and it needs to be fine-tuned by the compliance officer of the organization. The first thing that needs to be done is to provide an early warning process for detecting compliance and ethics threats and as we have seen this can be done by making a risk assessment and evaluation plan and to put into place in order to monitor how the program is being executed in that company (Pires, 2017).

The other is to identify the risk universe, and by this, one is made aware of the risks that can be subjected to their organization. This is done to know what risks can be accrued by the organization; this will eventually enable the persons to be aware of all the hazards that can be subjected to the organization (Watzlaf, 2011). This is the work of the compliance officer who can do their research on the risk universe.

This will strictly be followed by prioritizing the risks at hand, and this is done by having a list of the risk universe. After having the list of threats it becomes much easier to know what types of risks the organization is going to be subjected to and which ones are less likely to occur in the business. It makes the organization aware of what to avoid and how to avoid these risks (Pappas, 2017).

After prioritization, inventory the compliance environment and existing controls, which assists in having the necessary procedures that would help to avoid and mitigate the risks that have been indicated in the first places (Tyl, 2009). This can be done by setting up an insurance scheme in the case of fires and other disasters that might occur at the facility.

Risk evaluation and action plans are next, and in this case, it assists the facility to be proactive. This is done by having a way in which the facility can avoid being on the spot by not following the right policies and procedures (Tyl, 2009). 


The discussions about compliance have been taken seriously since 2008, and it has made organizations much more aware of the risks that they are exposed to in the long run. The issues to do with compliance are not only subject to medical facilities but to also the businesses and other firms that have these types of risks in their wake.

Aranda-Gallardo, M., Morales-Asencio, J. M., Canca-Sanchez, J. C., Barrero-Sojo, S., Perez-Jimenez, C., Morales-Fernandez, A., … & Mora-Banderas, A. M. (2013). Instruments for assessing the risk of falls in acutely hospitalized patients: a systematic review and meta-analysis. BMC health services research, 13(1), 122.

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