7/30/2019 23843533
1/3Journal of Health Care Compliance November December 2006
4
John Falcetano, CHC, CIA, is the chief
audit & compliance officer at University
Health System of Eastern Carolina.
Examples of Tools that May Prove Beneficial for
Compliance Professionals
In todays day and age, when someone talks about qual-
ity in a health care setting, most people think of the
quality of care a patient has received from a provider.The
general public may not realize all the processes that
must be performed correctly in order for a patient to have
a good outcome.
The same is true for compliance. When we think about
compliance, the general public may only think about if an
individual or organization complied with a particular law
or regulation. They may not be aware of the many process-
es that have to be performed correctly to meet the regula-
tory requirement.
As you can see, both quality and compliance deal with
process management. On the quality side, there has
beensignificant work to improve the quality of services
provided.
Individuals like Deming and Juran1 have helped guide the
quality improvement revolution in the health care industry.
Numerous quality assessment methodologies were used
to achieve a successful outcome. Organizations implement
quality programs to provide the best care to their patients,
to meet professional standards, and to enhance the image
and perceptions within the organization and the public.
Quality management staff uses many quality improve-
ment tools in order to improve the care and services they
provide to patients. Because quality management focuseson
process improvements, compliance professionals can
learn much from their quality management counterparts.
Many of the quality tools can be used to improve com-
pliance processes. I will spend the rest of this article
just
touching on a few of the ones that may be of value to com-
pliance professionals.
Lets start with a flow chart. A flow chart provides a pic-
ture of the steps in a process. It is an excellent tool to
look
JOHN FALCETANO
QUALITY
Quality Tools Can Be Used to
Improve Compliance Processes
7/30/2019 23843533
2/3
Journal of Health Care Compliance November December 200642
at a complex compliance process by using
symbols to understand each step in a pro-
cess. It can help a compliance professional
identify problems in the process, analyze the
actual steps in a process to the ideal steps in
order to identify variation, and identify un-
necessary steps in a compliance process.A second tool that can
benefit compliance
professionals is a cause-and-effect diagram.
The compliance professional can use this
tool to identify possible causes of noncom-
pliance. The cause-and-effect diagram helps
to identify possible causes of variation in the
process and identifies positive and negative
relationships. The toll can be used to deter-
mine why sometimes an organization may
comply with a particular regulation while
other times it may not.A third tool that may help a
compliance
professional identify patterns of noncom-
pliance is a check sheet. The check sheet
is used when the compliance professional
wants to count the symptoms of noncompli-
ance. The data is gathered based on sample
observations. It is important that the check
sheet be designed to determine symptoms
you want to observe and the time period for
observation.
The final tool I will mention today is onethat can be of great
benefit to the compli-
ance professional. That tool is a Combination
Interrelationship Digraph Matrix. This tool is
used to identify the cause and influence re-
lationships and strength of influence among
items. The tool helps the compliance profes-
sional determine if there is a relationship be-
tween processes. It helps identify critical pro-
cesses by determining what processes affect
other processes and what processes other
processes affect.
This is important because by identifying
critical processes the compliance profession-
al can identify what process an organizationneeds to focus its
improvement efforts on in
order to improve compliance. A critical pro-
cess will have the most effect on other pro-
cesses. If the compliance professional can
focus organizational improvement efforts
on the one critical compliance process and
improve it, all the other processes that are
affected by that critical process are also im-
proved.
Compliance does not just happen. An or-
ganization creates a culture of compliance byperforming many
compliance processes cor-
rectly. Compliance professionals have a lot
of tools at their disposal that they can use
to identify and improve critical compliance
processes to improve the overall compliance
of their organizations. Learning how to con-
struct and use these tools improves the com-
pliance professionals skill sets and increases
their value to their organization.
Endnotes:
1. William Edwards Deming lived from October 14,
1900 to December 20, 1993. He was a college
professor, author, lecturer, and consultant and was
well known in the areas of improving design and
product quality, among other things. Joseph Moses
Juran was born on December 24, 1904 and is well
known for his work in the area of business and
industrial quality.
Quality
