Most employers conduct pre-hire background checks, but in industries such as healthcare, background screening must go a step further to include continuous monitoring for employment sanctions, licenses, and other professional credentials. Within a healthcare environment where employees work with the elderly, children, and the ill and injured, there’s an invaluable benefit in having a workforce monitoring process in place. 

Monitoring helps you know when there’s an issue with an employee’s medical license status, employment sanctions or exclusions, or even criminal activity precluding their employment in healthcare. Knowing about any of those issues beforehand is always better than finding out after an accident or other incident occurs. 

Conducting an employee’s background check only once causes possible risk to patient safety, employer reputation, and the bottom line, and healthcare employers can’t afford to conduct background screening solely at the point of hire. Doing so invites the risk of regulatory fines, loss of accreditation, and even lawsuits. Approaching background screening as a talent management process spanning the entire employee lifecycle can help any healthcare organization confidently approach and manage compliance risks

The Benefits of Auditing Your Healthcare Workforce Monitoring Process

An audit of the monitoring process can deliver insights about specific areas of your program in need of updating or reworking to remain in regulatory compliance. For example, both CMS (U.S. Centers for Medicare and Medicaid Services) and The Joint Commission have guidelines for checking employee exclusion lists and licensing. The workforce monitoring process you have in place will need to be evaluated for optimal alignment with the guidelines of those organizations.

Whether you engage in self-monitoring or monitoring with the help of experienced partners, the feedback from an audit can uncover risks, opportunities for efficiency, and possible cost savings. When done routinely, auditing your workforce monitoring process is an important step in managing hiring and talent management risks.  Here are five tips to guide your audit as you get started:

Tip 1: Set a Foundation for Items to Monitor

Workforce monitoring doesn’t mean following an employee’s every move or eroding trust by collecting privacy-violating data. After all, the point of workforce monitoring is not to make employees feel uneasy or worry that every action, on- or off-duty, is being tracked. However, you can implement a monitoring process to capture information pertinent to the healthcare workforce, including:

  • Criminal activity: Know when employees are convicted of crimes making them ineligible for ongoing healthcare employment
  • Driving records: For employees who transport patients, get current updates about violations on motor vehicle records, accidents, or other driver misconduct
  • Healthcare sanctions and exclusions: Scan a range of sanctions and exclusions lists to identify individuals barred from healthcare employment such as:
    • The Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE)
    • General Services Administration’s (GSA) System for Award Management (SAM) database
    • National Practitioner Data Bank (NPDB)
    • Healthcare Fraud and Abuse sanction histories
    • State-specific exclusion lists
  • Medical license status: Continuously monitor license expirations, revocations, or medical board actions so that you can take timely action

Tip 2: Identify Potential Risks with the Current Monitoring Process

There can be many possible areas of risk associated with your existing workforce monitoring process, and an effective audit will seek to identify and mitigate any weak spots or vulnerabilities. For example, areas of risk can include:

  • Timing intervals of medical license status checks: Does the current process monitor all licenses regularly, or have some licenses lapsed in the intervening time between checks?
  • Disclosure and authorization forms: Do forms include proper disclosure language to cover continuous monitoring?
  • Consistency of application: Is continuous monitoring conducted consistently across all individuals within a particular job category?

How you answer those questions will help to determine not only the level of risk associated with your current monitoring process, but also the actions you can take to mitigate those risks.

Here are 10 ways healthcare organizations can ensure accurate and efficient  background screening programs.

Tip 3: Assess Employee Communications

A well-communicated policy allows employees to understand the actions taken by the organization to protect both employees and patients. Therefore, an audit of the workforce monitoring process should also include a review of how monitoring activities are communicated to employees. 

Employees should have a clear understanding of what will be monitored and what won’t, when monitoring will take place, and any actions the organization will take when certain information is discovered—for example, criminal activity or an expired license. With clarity, there’s more opportunity for trust and transparency to grow in the workplace. Some of the important areas to cover in your monitoring program communications include:

  • Where employees can go to get information and updates about the organization’s background screening programs
  • How adverse action decisions are made and communicated to affected employees
  • Key internal contacts for employees to share information and ask questions

Tip 4: Use Available Monitoring and Auditing Tools 

Monitoring tools include a range of federal and state databases, but they can also include technology to automate medical license tracking and deliver reminders to key internal stakeholders. A real-time continuous monitoring platform gives organizations the ability to upload and manage employee rosters with perpetual monitoring. With this kind of protection, HR, compliance, and legal teams can be informed of credentialing or other issues instead of finding out later, or not at all.

Another useful tool to guide an audit of your workforce monitoring program is the OIG’s Work Plan, which includes resources, guidelines, and suggested audits to prevent fraud, abuse, and bad actors in the healthcare work environment. 

Tip 5: Partner with Trusted Advisors

A successful audit involves the right partners to support a thorough and timely process review and delivery of findings. Working with trusted partners offers the benefit of expert advice and a regular flow of information about best practices. One important partner is your background screening provider. Background screening and workforce monitoring experts can leverage their broad regulatory knowledge and experience working with other healthcare organizations to help you improve your existing workforce monitoring process.

Working with a background screening provider doesn’t guarantee a successful audit on its own, but having a knowledgeable and committed partner can help you ask the right questions and implement policies to support a compliant and effective workforce monitoring program. Other advisors to consult include internal compliance departments and legal counsel, who can provide guidance on the correct use of background screening information, disclosure forms, and related processes.

Regular Audits Support Compliance

Auditing your healthcare workforce monitoring process benefits employees and ultimately supports better patient care. By reviewing potential risks, communication plans, and available monitoring tools, you can keep your monitoring program in compliance and stay informed of activities impacting the safety of the workplace. With trusted partners as your guide, you can conduct regular audits of your workforce monitoring program and keep it healthy, safe, and strong. 


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