Saturday, April 13

Hospital Compliance Essentials: Ensuring Patient Safety and Quality Care

The Hospital Operating License permits an agency or facility to provide medical therapies and diagnostics under the supervision of an organized medical staff. An official state license is required before providing medical services to patients.

This tool helps healthcare organizations to manage compliance by identifying any gaps in procedures and policies, then making a plan to address them. It comes with a personalized Hospital Standards Compliance Assessment Workbook which includes a clear set of questions that are correlated with the EPs in each.


The hospital license requires that the hospital adhere to certain rules. The hospital, among other things, has to have a procedure for recording and indexing medical records to allow them to be easily retrieved through diagnosis or procedure. Also, the hospital should maintain patient records in a secure manner and only allow access for authorized personnel. In giay phep hoat dong benh vien rare instances the hospital might be required to release information about patients to law enforcement officials.

Lastly, the hospital must ensure that their physicians have current licensure and a legitimate medical board accreditation. Also, the hospital needs an accreditation committee that can act quickly and expeditiously in the event of applications for the privileges of a licensed physician or podiatrist.

The hospital should also include an procedure for changing or removing the privileges of clinical practice of an advanced practice nurse or physician assistant. This procedure must also include procedures for the advanced practitioner health professional or doctor like a hearing, and a in writing notice of the hospital’s decision.


State licensure’s purpose is to protect the general public through the establishment of minimum standards for competence. Licensing boards generally accomplish this by demanding education, assessing character and testing through examinations.

Health professionals often seek independently-certified certifications to prove their knowledge and expertise in specific subject areas. Additionally, they work for institutions subject to organizational accreditation. These tools, together with licensure, play a significant role in shaping how the educational establishments and employers support the cultivation of lifelong skills for learning.

The committee thinks that geographic licensing and scope of practice laws require an additional look to make sure that they don’t hinder in the realization of the promise of top-quality health care offered by inter-disciplinary teams and the use of informatics. The need for further research and coordination among professional boards.


The law prohibits any person, firm, partnership, association, corporate or other legal entity may establish, operate, conduct and maintain a hospital for the treatment and care of humans in this State without obtaining first permission from the Department for the purpose. This is a case for a general, critical access hospital or psychiatric facility.

Prior to the commencement of construction, hospitals must make plans and specifications available to the department. This must include an architect’s endorsement that the plans have been prepared conforming to the state’s and local ordinances, codes of zoning and building regulations.

The department reviews all CON applications, including those for changes in ownership and new construction/additions. Proposals that qualify for a limited review need not be apposed by the PHHPC and can be found in proposals that have projects with a total budget of less six million dollars ($15 millions for hospital projects) with certain requests.


Hospitals must be compliant with the numerous regulatory bodies which oversee healthcare. Infractions can result in sanctions, fines, and penalties that can affect the image of an organization. It also puts patients at risk of not receiving top-quality care. This can impact their wellbeing.

The Department is required to inform the hospital as well as any health care system of any findings that could require the Commissioner to decide to revoke or suspend hospital’s operating license. The notice must specify why it is necessary and provide a time frame for a public hearing.

The hospital needs to have an efficient medical staff and governing body that is accountable for the quality of medical care provided to patients. Additionally, the hospital has to provide assessment of the patients’ discharge plans who are in the beginning of their hospitalization or at the request by a patient or a someone acting on their behalf or their physician.


Hospitals should ensure that their state licenses are current. They also need to perform background checks that are specially designed for the healthcare industry. These include criminal checks identification verification, sex offender status checks and further. Utilizing background checks that are specifically designed specifically for the health industry can help ensure that your hospital’s employees adhere to strict standards and offer high levels of care.

Top-of-the-line staffing benefits healthcare organizations and employees. If CNAs, nurses, MAs, and RNs are working in the top tier of their certifications, hospitals enjoy more employee engagement, lower delays in care, higher quality patient outcomes and lower labor expenses.

Each hospital’s operating Certificate provides information regarding the amount of beds with licenses as well as the facilities that are available to patients at the location. The certificate also lists extension clinics operated by the clinc or hospital.