Written by Laura Wakelam
28 Jul 2023

6 Strategies To Promote Regulatory Compliance at Your Hospital

The Canadian regulatory environment for hospitals is constantly evolving. In recent years, these changes have come more rapidly than ever before. Due to the costly consequences that can result from regulatory missteps, compliance is of even greater concern.

Hospitals in Canada are tasked with staying ahead of these regulatory changes to ensure uniform compliance and a consistent experience for patients. Here are some of the best tips and practices to promote regulatory compliance at your hospital.


1 / Appoint a Compliance Officer

2 / Establish Medical Waste Processes

3 / Protect Patient Privacy in Observance of PIPEDA

4 / Establish Workplace Violence Prevention Policies

5 / Ensure all Fees Charged are Legal Under the Canada Health Act

6 / Train Staff on Compliance Policies

7 / Compliance is an Ever-Evolving Process to be Continually Monitored & Updated 

Appoint a Compliance Officer

The regulatory requirements for a healthcare facility are filled with continuously evolving local, provincial, and federal requirements. Additionally, they are continuously evolving, and it is crucial for hospitals to grow with them. It is next to impossible to do this without a centralised effort, and this is where a compliance officer comes in.

A compliance officer is a healthcare professional with knowledge and experience, both in the healthcare industry and in the laws and regulations that govern the healthcare industry. It is crucial to ensure that compliance is not an afterthought. Instead, it needs to be an intentional goal that is kept in mind during every workday. By employing a compliance officer, these professionals can coordinate with every department to review operations and procedures to ensure compliance with regulatory parameters.

Whether it is ensuring safety and staff training is in line with Canadian Centre for Occupational Health and Safety requirements, guaranteeing patient privacy is protected in line with PIPEDA, or seeing that medical waste is being disposed of in line with the many national and provincial requirements, a compliance officer can help. This is why employing these professionals is a must for every medical facility.  

Establish Medical Waste Processes

Waste management is an integral component of any hospital’s compliance program. This includes both the policies and procedures related to the disposal, collection, and disposal of medical waste. Unfortunately, this is also one of the most challenging aspects of compliance due to the wide breadth of regulations governing the management of the many types of medical waste that hospitals handle each and every day.

Compliance rules for hospitals can be found in the Guidelines for the Management of Biomedical Waste in Canada from the Canadian Council of Ministers of the Environment. But, it’s important to note that although many provincial and territorial regulations are similar to those found in the national guidelines, they are often more strict.

This is why it’s crucial to review local, provincial, and national regulations when developing a sound medical waste management program that handles waste from generation to its final disposition. A key part of this is partnering with an experienced, professional waste disposal provider like Daniels. They can help to guarantee a compliant, environmentally sound destruction process, providing sound advice for the entire disposal process. 

Protect Patient Privacy in Observance of PIPEDA

The Personal Information Protection and Electronic Documents Act, or PIPEDA, is the primary national-level regulation governing the collection, use and disclosure of personal information, which includes health information. This regulation requires that hospitals be transparent during the collection process for obtaining personal information and how it will be stored and used, as well as when it will be disclosed.

Hospitals need to ensure that they have suitable procedures in place for addressing all of these points. Once collected from patients, the security of patient data is the medical provider's responsibility. This of course means that hospitals need to limit access of this information to only personnel who are required to view it. Additionally, once this data is no longer needed, it will need to be destroyed in a secure manner. 

Establish Workplace Violence Prevention Policies

Workplace violence has never been more of a threat than it has been in recent years. In response, every employer, including hospitals, must take steps to prevent violent acts from occurring. The regulations related to the prevention of harassment and violence in hospitals are primarily provincial.

The federal legislation Workplace Harassment and Violence Prevention Regulations applies to federally regulated workplaces such as banking, telecommunications and interprovincial industries. In most cases, hospitals will be subject to provincial regulations such as Ontario’s Occupational Health and Safety Act (OHSA). This shows the importance of being aware of what regulations an organisation is subject to.

In general regulations require that hospitals maintain a workplace violence and harassment prevention plan and provide training to all staff members on the elements of this plan. It is crucial that all stakeholders be properly educated on expectations under the plan. They must also know how to recognise warning signs and address incidents in the workplace. 

Ensure All Fees Charged Are Legal Under the Canada Health Act

The Canada Health Act clearly guarantees the public equitable access to medically necessary care based on their needs regardless of their ability to pay for it. However, though this requirement is clear, how it is carried out may be a little more opaque. In many cases, the Act is somewhat vague on how it is to be carried out. This includes what fees are permissible. Common issues include charging facility fees for services that are deemed to be medically necessary or fees to move to the front of queues. These regulations are primarily enforced by the provinces. Therefore, it is crucial to keep abreast of the latest interpretations of the Canada Health Act by local authorities. These developments can provide critical guidance for avoiding violations. 

Train Staff on Compliance Policies

Any policy is only as effective as it is applied. Noncompliance begins when staff strays from policies. That is why it is crucial to train employees on hospital policies, why they exist, and how they can be followed. Develop a training program that dives into all major regulatory concepts that affect employees’ work. Or partner with an organisation capable of supplying that training.

Compliance training should occur immediately for new hires and frequently for existing employees. This will ensure the info is not forgotten and any updates to policy can be communicated. Mandatory annual training sessions are the most common way to achieve this.

Addressing topics like patient privacy and workplace safety may seem obvious. However, do not forget day-to-day tasks like medical waste disposal procedures and violence prevention measures. Training modules should cover all topics employees will come across in their job or anywhere within the facility. When staff is well-educated on policies, compliance follows.  

Compliance Is an Ever-Evolving Process to Be Continuously Monitored & Updated

Compliance is never easy in the fast-paced, complex world of healthcare. But, the potential costs of mistakes can be more than any hospital should be willing to risk. Healthcare compliance is no accident and can only come from intentional efforts on the part of hospital leaders and staff. By following the tips and best practices described above, it is possible to help build a culture of compliance that can help to prevent violations and ensure facility operations remain compliant.





Header Style: 
Laura Wakelam

Laura Wakelam

Chief Marketing Officer

Brand and Communications Curator of Daniels Health global group of companies, Laura is a strong believer in cause-driven brand identity and honest storytelling