NABIDH integration is only the first step in the journey of enhancing healthcare delivery. Once you’ve successfully hopped onboard the NABIDH bandwagon, it’s important to emphasize that adhering to NABIDH policies and standards will remain an ongoing priority for your healthcare facility- which makes NABIDH compliance auditing an essential responsibility. Compliance audits are an inherent part of regulated industries such as healthcare owing to their stringent security prerequisites. Because of their complexity, NABIDH compliance audits can be overwhelming in a number of ways. The only solution is to adopt the right auditing tools and best practices to simplify the process and avoid mistakes. So, what are the best practices for an effective NABIDH compliance audit? Before answering that question, here are some fundamental questions that need to be answered:
What are NABIDH Compliance Audits?
NABIDH compliance audit refers to a formal review or an independent assessment of your healthcare facility’s adherence to the policies and standards prescribed under Dubai Health Authority’s NABIDH Program. The NABIDH policies and standards are a set of rules and guidelines that all healthcare providers in Dubai are expected to comply with. The NABIDH compliance audit helps determine whether your facility meets these regulatory guidelines appropriately.
What purpose does the NABIDH compliance audit serve?
Just like any other compliance audit, the NABIDH compliance audit is necessary to ensure that your organization meets all legal and regulatory standards and requirements under NABIDH. Besides this, it also helps:
- Determine whether your internal policies are in accordance with the NABIDH prescribed guidelines.
- Evaluate how effective your internal controls and processes are with regard to fulfilling NABIDH requirements.
- Spot probable compliance-related issues that need to be addressed and fixed.
- Maintain integrity, transparency, and accountability of processes in your facility.
NABIDH Audit Policy
NABIDH policies prescribe the guidelines for compliance audits in your healthcare facility. Therefore, the first step is to understand what the NABIDH Audit Policy entails:
- It clearly defines the compliance and audit requirements for the NABIDH platform.
- It provides the guidance for identifying and preventing unauthorized access to Patient Health Information (PHI) within the NABIDH system, and for complying with the relevant privacy standards.
- It defines the roles and responsibilities of all the participants in the NABIDH system.
- It recommends an effective auditing process to ensure confidentiality of PHI.
- It defines the frequency of audits and specifies the requirements for maintaining audit logs for documenting access to PHI through NABIDH.
Best Practices for NABIDH Compliance Auditing
Compliance audits share common elements across industries. But they also possess unique aspects that are specific to each sector. It’s therefore essential that you recognize the significance of both general best practices and industry-specific audit requirements and give them equal consideration. Below are the compliance auditing best practices accepted and applied across sectors:
- Understanding the basic elements of a compliance audit: Compliance audits are complex. To successfully implement a compliance audit, you should understand and clearly determine the fundamental aspects of your audit, including:
a. The context of your compliance audit
b. The rules, regulations, guidelines, acts, and other legal or regulatory standards that your facility has to comply with
c. The criteria or benchmarks that your facility has to be evaluated for
d. The subject matter of the compliance audit, or in other words what you are examining for compliance. For example, your healthcare information, the processes and activities in relation to the use of health information, etc.
e. The standard and prescribed procedures and processes to be used to minimize errors in the audit, so that the results of the audit are completely reliable and credible.
2. Establishing the aim of the audit: Every compliance audit begins with the goal to evaluate the degree of compliance of your entity with the relevant laws, policies, rules, standards, or guidelines. Defining them in a detailed manner can help navigate the audit in the right direction and make the process much more focused and efficient.
3. Adopting a methodical approach: The only way to simplify a highly complex task is to approach it one step at a time. Compliance audits are no exception. Determining the steps of the audit, and preparing well to take these steps methodically, is crucial. A well-planned audit can be carried out in an economic, efficient, effective, and timely manner. Listing out the requirements, and planning on allocating your resources efficiently can come a long way in simplifying the process. So, make sure you assess:
a. The availability of all required information for your audit and ensure seamless access to it at any point in time.
b. The competency of your audit teams to determine whether they possess the knowledge, skill sets, and expertise necessary to carry out the audit.
c. The availability of other resources based on your needs including time, and personnel.
4. Considering audit risk: Audit risks could be classified as inherent risk, control risk, and detection risk.
a. Inherent risk is one that exists inherently within your entity’s processes or operations, and are associated with the specific regulations of your industry.
b. Control risk refers to the possibility that the controls you have in place may not be effective in preventing non-compliance.
c. Detection risk is associated with the possibility that your audit procedures and sampling methods may not be adequate or effective.
You have to consider these risks throughout the audit process and manage, or mitigate them to the extent possible.
5. Gathering & evaluating audit evidence: Audit evidence refers to the information you use to arrive at conclusions about the findings of your audit. Once you move into the audit execution phase you have to gather and evaluate audit evidence to substantiate the results of your compliance audit. Based on the evaluation you should be able to arrive at a final conclusion.
6. Documenting & reporting findings: Compliance audits don’t end with the completion of an audit. You need to prepare an audit documentation with details about the purpose, resources, methods used, processes followed, and conclusions of your compliance audit. Your audit report is the most important product of your compliance audit. So, organize all details in your report in a logical and systematic manner, and also provide links to key issues or findings. It should not only detail the degree of compliance but also provide scope and suggestions for corrective action.
Compliance Audit Best Practices as Recommended by NABIDH
While the previous section details the common best practices for compliance audits, here are some specific ‘must-dos’ in relation to NABIDH compliance:
- Ensure all activities in relation to Patient Health Information, including access, creation, modification, disclosure, and deletion are accurately recorded and stored for auditing purposes.
- Conduct audit testing for all applications used by NABIDH users on a regular basis to address audit requirements proactively.
- Log all clinical data transactions on NABIDH to support periodic audits, and maintain these logs securely.
- Prevent unauthorized alterations to log files to maintain a complete record of activities and thwart potential attacks.
- Create and maintain an audit log for user logins on the NABIDH platform, recording both successful and failed login attempts.
- Document requests to access health information over NABIDH, and record the date, location, reason, description of requests, data changes made and whether there was an emergency access involved.
- Identify requests for sensitive health information and privileged accounts in the audit log.
- Record IDs of individuals or systems making requests for patient health information.
- Collaborate with NABIDH to address the finding of your audit and implementing corrective actions.
- Follow additional recommendations from the privacy and security committee for continuous improvement.
NABIDH Compliance audits are not just a regulatory requirement, they are more importantly a means to determine how successful your NABIDH integration efforts have been, and how effective are your controls surrounding the privacy and security of patient health information. Periodic NABIDH compliance audits are therefore a prerequisite for a secure and robust system of health information exchange, and these best practices can serve as a guiding light, providing you much-needed direction and support through the audit process.