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By Frank Ruelas
Facility Compliance Professional, St. Joseph’s Hospital
and Medical Center/Dignity Health
Let’s be frank (sorry, couldn’t resist). I am going to make some very overarching assumptions which may or may not hold true 100% of the time. However, I feel they are correct much more than not. Some of these assumptions include:
- People generally have a good sense as to what is right and wrong;
- People tend to know when they are doing something they should not be doing; and
- Every day types of compliance related decisions are usually the type that don’t require a meeting of the compliance committee or a special task force to analyze.
That being said, I think for the most part, when people wonder if they are in “compliance” given whatever that may mean at any given moment, the answer to that question is much closer than they are willing to admit.
Let me explain.
The last time you walked down the hall and saw some trash on the floor there was probably a little voice that said you should pick it up. Now whether you did or didn’t pick up that trash is truly only known for certain by you. Now the connection of sensing what one should do and what action one ultimately takes is a very good topic and worth of its own discussion, but back to my main thought.
Now imagine a nurse on the unit who is entering a patient room and asks if he or she should follow the hospital’s policy on “foaming in” and “foaming out” in the practice of hand hygiene. What do you think that little voice in the nurse’s head is telling him or her what to do? I am guessing that the little voice is telling the nurse to follow the hospital’s hand hygiene practices and foam in when they enter the room and foam out when exiting the patient’s room.
Think about the physician who knows that the hospital’s policy is to avoid using verbal orders except in an emergency who decides to call a patient unit from another part of the hospital to phone in a non-emergent verbal order. What do you think that little voice in the physician’s head is telling him or her to do? I am guessing that little voice is telling the physician to go over to the unit and give the order personally or to enter it directly into the Electronic Health Record for that patient.
Lastly, think about a hospital compliance officer who knows that he or she should not park in a nearby parking space to the hospital because the hospital’s policy is that employees park along the perimeter of the parking lot so as to leave the closer spots available for patients. What do you think that compliance officer’s little voice is telling him or her what to do? I am guessing that the little voice is telling the compliance officer to park along the perimeter of the parking lot.
My point is this. I truly believe that after getting adequate training from our organizations on such things as its code of conduct, training on department specific procedures, or getting information on what is expected of us from other educational or training opportunities, we then probably pretty much know when we are either in or out of compliance.
After all, isn’t that little voice, as much as we may not want to admit, really ourselves reminding us what we should be doing? Of course it is. The same holds true, I believe when it comes to many of our everyday work related practices and processes. So try this little experiment.
The next time someone asks you if they are in compliance, ask that person, “What do you think and why?” I am going to go out on a limb and say that often these people do know when they are in or out of compliance and one of the main reasons they are asking you may be to get confirmation or validation of something they already know and they just need that little extra push to action
Do I think for the most part that people need to go to and read a number of policies to decide if they are in compliance? No. Do I think that they have to call their manager or supervisor to ask if they are in compliance? No. I do think for the most part they only have to listen to that little voice in their head. Sometimes that voice is so soft we can easily decide to ignore it. Sometimes we can hear it loud and clear. But in either case, we can hear it. All we need to do is just listen.
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