Regulatory Compliance And The Auditing Process - 1323 Words

Situation The purpose of this SBAR request is to help the Regulatory Compliance and Privacy Team standardize the auditing process, perform more comprehensive auditing, better assist internal and external customers , and make appropriate recommendations to Executive Management, Hospital Departmental Managers, Physician Practice Administrators, Human Resources professionals, Finance, Administration, Nursing and Medical Staff professionals regarding privacy and compliance incidents and incident investigations that result in employee disciplinary actions and recommended employee terminations. We are getting significantly more regulatory, privacy, information security and compliance requests from nursing, risk management, legal services,†¦show more content†¦As of June 21, 2016, the Compliance and Privacy Department auditors have investigated over 9600 investigations pertaining to regulatory compliance and privacy incidents from June 2015 to June 2016. And thousands more went un-investigated because of insufficient access to the appropriate EPIC modules and systems audit trail viewers. Background The Compliance and Privacy Department is a complex unit whose job functions and duties crosses every department in the hospital, from clinical to housekeeping, to administration to finance, and to patient access to information technology, just to name a few. We are required to look at each discipline’s EPIC modules and audit trail viewers to make incident determinations, chart access appropriateness or inappropriateness, and employee disciplinary and termination recommendations to managers, regional medical directors, medical directors, hospital and nursing executive staff members, and human resources professionals. The Compliance and Privacy Department answers request for assistance from every department, to include: ambulatory care, physician practice, hospital administration, allied health, nursing, transplant, imaging, health information management, pathology, transcription, coding, scheduling, finance, surgery, nurse triage, call management, revenue cycle, patient access, patient finance, pharmacy and information technology. Currently, the Compliance and