Healthcare Regulations

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Standards of Practice

Whether receiving care from a small-town hospital or a nationally owned health system, government agencies maintain strict oversight of the healthcare industry and all associated organizations. Likewise, each healthcare profession maintains standards of practice by which they expect healthcare professionals practicing under their job titles to follow. While each state may vary, basic principles are the same. Professionals must either pass examinations in each state to obtain a license to practice in that state, demonstrating they know the applicable standards in that state, or participate in a compact among states accepting similar standards. 

Quality Performance

For healthcare agencies, a similar process exists. In contrast, third-party payors (i.e., insurance companies who pay medical expenses on your behalf) establish expectations for performance that the agency must meet before they willingly provide full payment for services provided. Federal contractors like the Army or Medicare won’t do business with a hospital that does not meet the expectations of performance they establish for them. Furthermore, many of these agencies make unannounced visits to survey the facilities to see that the hospitals, nursing homes, or doctor’s offices are doing as expected to receive payments. All these standards, surveys, expectations, etc. exist for two primary purposes:

  1. To control costs to make sure the agency gets its money’s worth.
  2. For quality control to ensure that the consumer (you) gets the best product.  

An additional result of standardization allows healthcare professionals to travel from state to state, working in multiple places throughout their professional careers without relearning multiple ways to do the same procedures from one location to another.

All healthcare professions have established standards of practice, and each state has laws and regulations governing professional practice. Each professional has a list of “dos” and “don’ts” related to job assignments. They can’t go there if you ask them to do anything outside that list of acceptable duties. Performing duties outside what is allowed under their professional licenses could result in the loss of their license forever or at least for an extended time frame. When harm comes to a patient due to performing duties outside of the scope of practice, criminal charges may also accompany the loss of licensure.   

Regulatory Agencies

The following regulatory agencies conduct scheduled and unannounced surveys of healthcare facilities to ensure their compliance with regulatory requirements.

  • The Joint Commission accredits all healthcare systems that receive Medicare reimbursement or contract for their services.
  • State Professional Boards license all healthcare professionals like doctors, nurses, pharmacists, dentists, etc.
  • The Drug Enforcement Administration, the Occupational Safety and Health Administration, and the Centers for Medicare and Medicaid Services (CMS) monitor all pharmacies.
  • CMS (Centers for Medicare and Medicaid Services) and the Office of the Inspector General (OIG) regulate any facility that accepts Medicare, Medicaid, or CHIP.
  • OSHA (Occupational Safety and Health Administration) monitors all workplaces, including hospitals, for workplace violations related to safety and working conditions for employees.

Each agency has a book of regulations explaining how they think the organization must be compliant. The regulatory book for that agency then has books interpreting that book. In addition, each agency provides training on their standards and produces literature to teach their standards. It’s a big deal!

Nearly every month, some department in the hospital stands ready to spring into action to present their area to a surveyor at the last minute. The constant state of “readiness” that hung over the heads of staff for years led to a state of readiness burnout. As a result, standards started back-sliding, and quality care suffered. 

With Covid following quickly on the heels of “constant readiness,” staff morale crashed, leading to significant staffing shortages. As a result, doctors began discharging patients home sooner because care and attention at home may be better than at the hospital. Studies show less infection and better healing once the patient returns home, where personalized care allows for faster healing and promotes as quickly possible to get better care at home because the care in the hospital isn’t what it used to be.

https://www.jointcommission.org/
 
Healthcare Highly Regulated

As a consumer of healthcare, you have certain rights and responsibilities. All accredited hospitals have accepted these patient rights and must make them available for their patients to view either on their website, premises, or both. As a caregiver or if you are the patient receiving care, you have a right to the following and should speak up if you have concerns about the following.

Right to be Treated with Dignity

As a consumer of healthcare services, caregivers always have a right to be treated with respect, as does the family member under their care.

  • To be treated with courtesy and respect by everyone who represents the organization and to not suffer denial of services or be mistreated based on any discriminatory reason, including but not limited to race, color, gender, age, disability, sexual preference, nationality, political affiliation, marital status, religion, or genetic information.
  • To practice your religious or spiritual beliefs and discuss those beliefs with those willing to do so.
  • To know the names of the people who provide your care.
  • To have your healthcare information remain private and confidential unless you authorize its release.
  • To limit the use of any pictures or videos taken of you to what you approve or to assist in your care.
  • To have an advocate with them during their care
Rights to have Effective Communication
  • To be informed about your care
  • To have your healthcare team listen to you regarding how you feel about your medical needs.
  • To be allowed to make your own decisions regarding your treatment choices, including the right to refuse all or any part of any treatment you do not want to do
  • To have the information provided to you in a way that meets your needs (such as if you are hearing impaired, they need to provide you with an interpreter, or if you cannot see to read, you need to have information provided orally)
  • To receive copies of test results and medical records (which includes the patient chart during the hospital stay or afterward)

If you feel the healthcare agency violated your rights, you must provide them with a way to complain and attempt to resolve any legitimate problem. If you cannot resolve the situation, you can take the complaint to the agency that oversees the violated regulation. Below is information about patient rights and whom you should contact if you wish to file a complaint with someone other than the agency in conflict

Process for Filing Complaints about Healthcare Concerns

All hospitals are licensed by the Department of Health and accredited by the Joint Commission. If you have a complaint or concern, contact the Patient Relations or Guest Services office first to see if they can help you resolve the issue. If your attempt to resolve an issue internally is unsuccessful, you have several options for addressing your complaints outside the organization.

The Joint Commission

The Joint Commission investigates issues related to patient safety and quality of care. Go to their website at  https://www.jointcommission.org/resources/patient-safety-topics/report-a-patient-safety-event/  to get the form you need to fill out and to find out more about filing the report.

The Virginia Department of Health

The Office of Licensure and Certification (OLC) investigates consumer complaints regarding the health care services received at the facilities and services it licenses or certifies. The OLC is responsible for nursing facilities, inpatient and outpatient hospitals, abortion facilities, home care organizations, hospice programs, dialysis facilities, clinical laboratories, and managed care organizations. To file a complaint, go to http://www.vdh.virginia.gov/licensure-and-certification/complaint-unit/.

The Center for Medicare and Medicaid Services (CMS)

You can file a complaint if you have concerns about the quality of care or other services you get from a Medicare or Medicaid provider. To submit a complaint to CMS, go to their website at https://www.medicare.gov/claims-appeals/how-to-file-a-complaint-grievance.

Board of Health Professions – Virginia

The Department of Health Professions receives complaints about Virginia healthcare practitioners who may have violated a regulation or law. In addition, claims for all thirteen licensing and regulatory Boards are received and investigated by the agency’s Enforcement Division. For more information, their website is https://www.dhp.virginia.gov/PractitionerResources/Enforcement/FileaComplaint/.

Your Responsibilities as a Caregiver

As a caregiver, the more you know about how the healthcare system works, the easier it is to find your way around and get what you need from it. It’s also easier to understand what’s happening around you and ensure that your family receives safe care. For example, when you enter a healthcare facility to receive treatment for an illness or injury, you voluntarily come to that facility for help, which implies that you agree (consent) to treatment. It establishes an agreement between you and them for services. It’s called “implied consent.”

With implied consent, the medical team can assume you want to accept care from them if you become unconscious and cannot speak up for yourself. The reverse is also true. The unspoken agreement also establishes an expectation of competent (skilled) care from the healthcare team and responsible behavior by you. Therefore, you have specific responsibilities from the minute you become a patient. If you do not intend to accept the healthcare team’s help, if it’s reasonable, please do not go to that facility for care but instead go somewhere else. If you have an issue with the assistance provided, discuss your concerns with someone in authority at that location respectfully. If you cannot address the issue with the person directly to your satisfaction, ask for a supervisor. If you cannot reach a supervisor, ask for an administrator.

Most healthcare professionals are genuinely in the profession to help people and to do the best they can every day in difficult circumstances. If you talk through an issue with them respectfully, attempting to clarify rather than accuse, you can work something out most of the time.

As a consumer of healthcare services, you are responsible for the following:
  • Complete your admission and billing paperwork accurately.
  • Ask questions if you do not understand something and let your doctor know if you do not want to follow a plan of care offered.
  • If you have one, give your doctor and the hospital a copy of your advanced directive (i.e., wishes regarding what to do if your heart stops beating)
  • Once you go home, your plan of care includes buying the supplies, medications, and other items you need to take care of yourself.
  • Leave your valuables at home so they do not get lost at the hospital.
  • Being respectful to everyone, following the rules, and being safe.
  • Paying your bills as agreed.

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