Core 4.0 Pre-release

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.

  • Core 4.0 Pre-release / 10.02.2018

    C-OPIN 3-3: Formal Acknowledgment of Compliance with the Organization’s Legal Requirements and Code of Conduct

    This standard requires a formal, signed acknowledgement from each staff member and all other "relevant persons" (members of oversight bodies and committees) that they:have access to the Code of Conduct;received compliance training, including training on the Code of Conduct;they understand the consequences of failure to comply with the Code of Conduct, the organization's policies, and applicable la...

  • Core 4.0 Pre-release / 10.02.2018

    C-OPIN 3-2: Staff Training Programs

    The organization must train its staff members in the following areas:Privacy and security of information (HIPAA, HITECH, and applicable state laws and regulations);New-hire orientation and training in role performance expectations before being allowed to assume the position;Healthcare ethics;The organization's code of conduct, which defines ethical business practices dealing, at a minimum, with co...

  • Core 4.0 Pre-release / 10.02.2018

    C-OPIN 3-1: Job Descriptions and Staff Qualifications

    This standard requires that your organization hires qualified staff, and that the measure of staff's qualifications is, in part on the extent to which staff meet the qualifications required by written job descriptions. In other words, each position in the organization has a written job description, and each staff member meets the qualifications of the applicable job description.Each such job descr...