Managing healthcare policies without compliance theatre

Compliance and risk are critical in the healthcare sector. They heavily influence everything from patient care to the systems and applications in place. Compliance and quality teams face a challenging regulatory landscape and a demanding administrative burden. The specific regulations in scope depend on jurisdiction. 

In the US, key frameworks include HIPAA (data privacy for covered entities), 21 CFR Part 11 (FDA rules for electronic records in regulated life sciences), and Joint Commission accreditation standards. In England, the Care Quality Commission (CQC) sets the regulatory framework for health and social care providers. Across the EU and UK, GDPR governs the processing of personal data, including patient information. Patient safety, data privacy, and passing related inspections are all areas where there is no room for compromise.

Challenges for healthcare compliance teams

Given these demands, it’s no surprise that healthcare compliance teams can feel pressurised, overloaded and overwhelmed. A survey from Barnes & Thornburg found that only 31% of healthcare compliance and risk leaders feel that they are “very prepared” to meet future compliance challenges. Even more concerning, only 42% felt “very confident” they could maintain a high quality of care given compliance issues.

These challenges are made worse by issues familiar in healthcare. Overworked staff, high volumes of documentation, and the difficulty of reaching busy frontline staff all add to the pressure. So does the looming threat of audits. When an inspection is imminent, teams face a scramble to tick all the required boxes.

This intense activity can also lead to “compliance theatre”. This is where teams make policy changes and carry out reporting that ticks the audit paperwork boxes, but doesn’t make the bigger, more systemic changes that actually reduce risk.

What is compliance theatre?

Compliance theatre is defined by the International Compliance Association as “activities that demonstrate compliance without necessarily achieving the outcomes that the regulation is meant to deliver.”

A healthcare provider guilty of “compliance theatre” might pass an inspection. But it is not introducing the measures that actually reduce the risk of a data breach or a patient safety issue. In healthcare, compliance must be effective. It cannot be a box-ticking exercise.

What does compliance theatre look like in healthcare policy management?

Compliance theatre takes several forms, especially in healthcare policy management:

• Policies that appear to be up to date but have not actually been properly reviewed by all the experts who need to read them.
• Logs and audit records relating to policy management that have been manually updated but are not necessarily reliable and are very time-consuming to complete.
• Policy changes have been made, but employees have low awareness of the details of the actual change.
• Policy management processes are nominally in place, but then fall apart once the inspection is over.
• A pattern that keeps on repeating for each audit and inspection - box-ticking rather than real change.

What are the risks of “compliance theatre”?

Of course, the risks of compliance theatre can be serious:

• A data breach that results in a financial penalty and reputational damage.
• Patient safety was potentially compromised, again resulting in fines and a damaged reputation.

It can also lead to lower-level risks such as operational inefficiencies, while the compliance team remain hindered by manual processes and unnecessary administrative tasks, with less opportunity to provide value. Overall, employees are less aware of policies and related updates, and there is not a strong culture of compliance as there should be.

What leads to compliance theatre in the healthcare sector?

There are potentially multiple reasons why “compliance theatre” happens:

• Compliance teams do not have enough resources to set up a compliance or policy management system that actively reduces risk.
• Where policies are spread over multiple sites and multiple versions, and are difficult for employees to find and for compliance teams to keep track of.
• There are too many manual approaches for reporting that are hugely time-consuming.
• There has been underinvestment in effective technology, for example, solutions that use automation to save time or help employees access and find policies.
• High numbers of frontline healthcare workers prove very difficult to reach with ongoing compliance-based communications, especially when they are very busy, based across multiple locations, work in shifts and have a high turnover.

What does effective healthcare policy management look like?

Policy management in the healthcare sector that completely avoids compliance theatrics has several pillars that combine to establish a system that actually reduces risk:

• Easy access to policies: employees can effortlessly find the latest version of a policy at the point of need.
• Automated policy management: automation across every aspect of policy management, lifting the admin burden on compliance teams.
• Effective change management: changes and updates to policies that employees take notice of to increase awareness.
• Being audit-ready: Policies that are up to date and a system all in place that avoids the mad scramble around inspections and audits.

Need to avoid compliance theatre in your healthcare organisation? Try Xoralia

Healthcare compliance teams need to actively reduce risk and avoid compliance theatre at all costs. A solution like Xoralia supports effective healthcare policy management and supports audit-readiness. Want to experience it for yourself? Book a free demo!