Core 4.0

C-CPE 2-3: Monitoring and Oversight of Ethical Healthcare Practices

Submited by: Tom Goddard

The Basics

Once an organization has defined ethical practices, as required by the previous standard, it must implement mechanisms to monitor for violations of its ethical standards and address those violations. Such mechanisms must spell out how it:

  • Identifies appropriate authorities to remediate particular situations involving ethical transgressions;
  • Will take action in the event of ethical issues; and
  • Will review information relevant to monitoring and addressing ethical issues.

In addition, this standard has an optional element that encourages organizations to anticipate future ethical issues through such actions as review trends in healthcare ethics.

Management Tips

Your policies will need to clearly articulate accountabilities, activities, and specific types of ethical issues that need remediation. You may even establish an ethics committee to address some or all of these activities. 

URAC recommends that your organization have an escalation matrix that details communications around ethical violations.

Accreditation Tips

Desktop Review

The minimum documentation required for this standard include policies, process documents, or other documentation that outlines the steps your organization will take to address ethics issues.

Other types of documentation to help tell the story may include bylaws, screen shots, meeting minutes, and other documents.

Validation Review


The reviewer will interview senior management about the mechanisms described in your ethics policies.

Document review

The reviewer will want to see documentation of actual instances of interventions in the event of ethical practices. Also, you should be prepared to document to the reviewer your active monitoring for unethical behavior.