Welcome back to the Compliance Blog!
We are happy to have you here for the April 2024 Compliance Blog! This month, we are talking about Variance… Let’s go!
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Let’s talk about our Variance Process:
A variance is an undesired outcome, not expected within the normal course of care or treatment. HealthPoint encourages open and honest reporting of actual or potential injuries or hazards to patients, visitors, and employees at all sites and services and at all levels of care throughout the organization as a continuing effort to promote a safe environment for all involved. You can learn more about variance reporting here.
How are we doing with Variances?
In 2023, we submitted 365 variances, the highest number since 2018. We want to make it clear that having a variance submitted by itself is not necessarily a bad thing. It can mean anything from feeling more comfortable reporting more, catching more near misses, and reporting incidents.
The top 5 categories of variances were medication, other, HIPAA, EHR documentation, and abusive patients/visitors. Within the medication subcategory, the highest variance had to do with wasted medication, with most of those being due to wrong stock being used; for another category, it was truly Other with one-offs that did not fit in any other category; for the HIPAA category, it was due to unencrypted emails. As a reminder, our internal HIPAA policies are more stringent than the law requires. Of the 51 HIPAA violations, only one was reportable by law, for which the report was timely completed. For the EHR documentation, it had to do with wrong documentation in patient charts, and for abusive patients/visitors, we revised our procedures to send timely warning letters to abusive patients.
Did we do well?
The compliance rounding for all of 2023 averaged between 97% to 100% for every location. This is amazing and you get all the kudos from the Compliance Team! If you see us rounding in the clinics, feel free to come say hello 😊 If you have suggestions, comments, or want us to write about something specific, you can always send an email to compliance@healthpoint-tx.com.
We are Here to Help!
As always, if you have any questions about this material, please reach out to either Brian Thurston (Bthurston@healthPoint-tx.com) or Katherine Hall (KHall@healthpoint-tx.com).
