Center for Improvement in Healthcare Quality Newsletter
June 2022

CIHQ-ARS Article

Healthcare Compliance vs. Non-Compliance Defined

An article provided by Christie Hutchinson
What exactly is COMPLIANCE? According to Cambridge Dictionary: a) the act of obeying an order, rule, or request; b) the fact of obeying a particular law or rule, or of acting according to an agreement. Still, in healthcare, compliance can mean so many things, such as compliance with accreditation organizations (CIHQ, DNV, TJC, AAAHC); compliance with local, state, and federal laws; compliance with insurance companies; compliance with OSHA, CDC, Board of Pharmacy, Board of Nursing, and Medical Board; and compliance with your company’s policies and procedures…. the list goes on and on. All of these are in place to support our mission of providing safe and effective medical care.
Many of these regulations, such as EMTALA, infection control practices, and privacy rules, are in place because healthcare made a huge blunder in the past. Thankfully we no longer turn away ER patients, we don’t stick used needles into the cushions of our stretchers, and we have stopped writing the patient’s full name on our scheduling boards.
Healthcare organizations by now should have moved from a provider-centered model to patient-centered care. This allows hospitals and physician offices to be hyper-focused on quality and outcomes (value-based care) as opposed to fee-for-service. While these improvements have created positive changes, they have simultaneously inflated the number of “rules” we must comply with within healthcare.
So, what is non-compliance? We have all seen it and are probably guilty of it to some degree. I’ll call it “defiance.” It takes many forms. Surely you have observed sarcasm, eye-rolling, laughing, passive-aggressive behaviors, complaining, criticizing, blaming, hostile reactions, and even extremely disrespectful encounters. And we all know the “we don’t / won’t do it that way in my department” leader.
In my experience, I find that explaining the intent of the standard, rule, or regulation will buy you some buy-in. It’s when our colleagues think it’s another rule for the sake of another rule that they dismiss the importance. So next time you’re rounding or doing spot checks, take the extra minute to clarify the “why” behind the standard. You’ll be amazed at how many people will tell you, “If I had known that I would have made sure we were COMPLIANT.”