Tiered Accountability and Elements of an Effective Compliance Program Within High Reliability Organizations

Tiered accountability and the seven elements of an effective compliance program provide a scalable framework for enterprise risk management within high reliability healthcare organizations (HROs). However, these elements do not self-assemble into a mature system. They must be intentionally built into an effective compliance program that assesses, controls, and manages risks at an ongoing enterprise level. This starts with good governance from the governing body and passes through the organization's chief executive officer into a psychologically safe, fair, and just culture that embraces imperfections as teaching moments. In an HRO, detected deviances from desired practices are seen as opportunities to embark on short excursions of self-improvement on the longer journey toward zero events of preventable harm.The Centers for Medicare & Medicaid Services (CMS) and the US Department of Justice (DOJ) have published regulations and guidance that require and encourage organizations to proactively manage risk, with tiered accountability written into the CMS hospital conditions of participation (COP) and strongly encouraged in the DOJ newly revised Compliance Program Guidance containing its seven essential elements of an effective compliance program. Both CMS and the DOJ utilize a mixture of incentives and consequences to incentivize proactive risk management and compel reactive risk reduction. In these toolboxes of incentives and consequences, proactive healthcare executives can find the standards and rules to engineer and build highly reliable enterprise risk management systems with tiered accountability and risk-based talent management that focus available resources on high-risk, high-volume, and problem-prone areas.