Healthcare Governance Glossary.

AAAHC is important because it helps ensure that ambulatory healthcare organizations meet recognized standards for safe, high-quality care outside of traditional hospital environments. Its standards support consistent clinical practices, effective leadership oversight, and ongoing quality improvement in outpatient settings where care is delivered efficiently and often on a same-day basis. 

An ambulatory surgery center pursuing AAAHC accreditation conducts ongoing reviews of clinical protocols and patient safety measures. Staff participate in routine assessments to confirm care processes meet established standards, helping the center consistently deliver high-quality outpatient services.

ASCs play a critical role in expanding access to high-quality surgical care while reducing costs for patients and payers. Because they operate outside of traditional hospital settings, ASCs must carefully manage contracts, policies, and compliance documentation to meet federal, state, and accreditation requirements. 

An ambulatory surgery center coordinates care among surgeons, anesthesia teams, and clinical staff to deliver same-day procedures efficiently. Clear processes and documentation help the ASC maintain patient safety, meet regulatory requirements, and ensure procedures run smoothly from pre-op through discharge.

This law matters because patient care should be based on what is best for the patient, not on financial rewards. The AKS helps prevent fraud, protects fair competition among vendors, and ensures healthcare decisions remain ethical and transparent.

A medical device company offers a physician free travel and expensive gifts in exchange for choosing its products. The hospital reviews the arrangement, identifies a compliance risk, and stops the practice to ensure purchasing decisions stay focused on patient care rather than financial incentives.

BAAs are important because healthcare organizations often depend on outside companies for services like billing, IT, or data storage. These agreements make sure vendors follow the same privacy rules as the healthcare organization and clearly state who is responsible if patient data is exposed or misused.

A healthcare organization uses a cloud-based software company to store patient records. A BAA ensures the vendor follows strict privacy and security rules and explains what actions must be taken if a data breach occurs.

CMS plays a critical role in healthcare oversight by setting Conditions of Participation, payment rules, and quality standards that directly impact patient safety, care delivery, and reimbursement. Compliance with CMS requirements is essential for healthcare organizations to maintain funding, avoid penalties, and continue operating.

A hospital prepares for a CMS survey by reviewing its policies, staff training records, and clinical workflows to ensure compliance with Conditions of Participation. During the survey, the organization demonstrates adherence to CMS standards through documented procedures, staff education, and consistent operational practices.

CARF is important because it promotes high standards of care for individuals receiving rehabilitation and human services. Its accreditation process emphasizes measurable outcomes, continuous improvement, and services that are responsive to the needs of the individuals served, helping organizations deliver consistent and effective care.

A rehabilitation facility seeking CARF accreditation evaluates its treatment programs, service delivery methods, and patient outcome measures. Care teams review practices to ensure services align with CARF standards and support individualized care plans. This ongoing focus helps the organization improve outcomes and maintain high-quality rehabilitation services.

CoPs directly impact an organization’s ability to receive Medicare and Medicaid reimbursement. Compliance helps ensure patient safety, quality of care, and operational accountability, while noncompliance can result in penalties or loss of funding.

A hospital reviews its policies, medical staff bylaws, and care delivery processes to ensure alignment with CMS CoPs. During a CMS survey, leadership is able to demonstrate compliance through documented procedures, training records, and consistent workflows.

In healthcare, contracts sit at the center of relationships that power care- between providers, payers, vendors, and partners. CLM helps organizations manage complex agreements with confidence, ensuring contracts align with regulatory requirements, governance policies, and operational realities. By improving visibility and accountability, CLM reduces risk while supporting stronger, more transparent relationships.

A healthcare organization uses a CLM platform to manage physician and vendor contracts in one centralized system. Teams use standardized templates, automated approval workflows, and expiration tracking to avoid missed renewals and compliance gaps. This approach reduces risk, improves visibility, and helps contracts move forward without delays or disruptions to operations.

Healthcare organizations manage a high volume of vendor, payer, and service agreements that are subject to regulatory, financial, and operational oversight. A centralized contract repository improves visibility, supports compliance, reduces risk, and helps ensure contracts are accessible during audits, surveys, and reviews.

A healthcare organization uses a contract repository to store vendor agreements, service contracts, and amendments in one centralized system. When preparing for an audit or regulatory review, leadership is able to quickly locate contracts, review key terms, and verify compliance with contractual and regulatory requirements.

CIAs are designed to strengthen an organization’s compliance program and prevent future violations. They often require enhanced policies and procedures, employee training, internal monitoring, independent audits, and regular reporting to the OIG. CIAs also increase accountability at the leadership and board level. Failure to comply with the terms of a CIA can result in significant financial penalties or exclusion from participation in Medicare, Medicaid, and other federal healthcare programs.

Following a government investigation into improper billing practices, a healthcare organization enters into a CIA. As part of the agreement, the organization implements new compliance policies, conducts regular audits of billing and contracting practices, provides mandatory compliance training for employees, and submits annual reports to the OIG demonstrating ongoing adherence to the agreement’s requirements.

CVOs streamline the credentialing process, reduce administrative burden, and help healthcare organizations maintain accurate and up-to-date provider records. They support compliance with regulatory and accreditation requirements.

A multi-hospital health system partners with a CVO to verify physician licenses, board certifications, and work history. This centralized approach helps standardize credentialing across facilities, speeds up onboarding, and ensures providers meet regulatory and accreditation standards before seeing patients.

DNV helps healthcare organizations demonstrate compliance with recognized quality and safety standards while promoting a culture of continuous improvement. Its accreditation model encourages organizations to maintain ongoing readiness rather than preparing only for periodic surveys, supporting consistent performance and patient safety over time. 

A hospital accredited by DNV conducts routine internal assessments to review clinical practices, patient safety protocols, and quality improvement initiatives. Leadership and care teams regularly evaluate performance data, identify areas for improvement, and implement corrective actions as part of daily operations. This ongoing approach helps the organization maintain alignment with DNV standards, strengthen patient safety practices, and remain continuously prepared for accreditation surveys rather than relying on last-minute preparation.

Healthcare organizations manage time-sensitive contracts that often involve multiple stakeholders. DocuSign helps accelerate contract execution, reduce administrative burden, and maintain compliance by providing secure, legally recognized electronic signatures. When used alongside contract management solutions like Ntracts CLM, DocuSign supports seamless workflows for executing everything from contract addendums to full agreements.

A healthcare organization uses DocuSign within its contract management process to route an agreement for electronic signature. Legal, compliance, and the vendor review and sign remotely, allowing the contract to be finalized quickly while maintaining a clear audit trail.

An EHR is important in healthcare because it allows patient information to follow individuals across different providers and settings. By improving access to accurate, up-to-date health data, EHRs support safer care, reduce duplication, and enhance communication among healthcare teams. 

A patient receives care from a primary care provider, a specialist, and a hospital within the same health system. Each provider accesses the patient’s EHR to review medical history, medications, and test results, enabling coordinated care and more informed treatment decisions.

An EMR is important in healthcare because it improves efficiency and accuracy within individual care settings. By replacing paper charts, EMRs help clinicians document care more effectively, access patient information quickly, and support day-to-day clinical workflows within their organization. 

A primary care clinic uses an EMR to document patient visits, track medications, and record test results. Providers rely on the EMR during appointments to review medical history and update treatment plans, supporting timely and informed patient care.

FMV is critical to healthcare compliance, particularly under laws such as the Stark Law and the Anti-Kickback Statute. Physician compensation that exceeds FMV may raise concerns about improper financial incentives tied to referrals. Establishing and documenting FMV helps healthcare organizations structure contracts that are compliant, defensible, and aligned with regulatory expectations.

Before finalizing a medical directorship agreement, a health system conducts an FMV analysis to confirm the proposed physician compensation aligns with industry benchmarks. The organization documents the analysis and retains it with the contract to support compliance and audit readiness. 

The GSA impacts healthcare organizations and vendors that sell products or services to the federal government, including hospitals, health systems, and suppliers involved in federally funded programs. Compliance with GSA and SAM requirements is essential to maintain eligibility for government contracts and to avoid penalties, suspension, or debarment.

A medical device supplier is found to have violated federal contracting requirements, leading to its suspension in the System for Award Management (SAM). As a result, federal agencies and healthcare organizations receiving federal funds are prohibited from awarding new contracts to the supplier until the issue is resolved, reinforcing accountability and protecting taxpayer-funded healthcare programs.

Healthcare organizations operate under intense regulatory scrutiny and constant operational pressure. Governance, Risk and Compliance (GRC) helps leaders maintain confidence across governance and compliance lifecycles by centralizing policies, controls, risk assessments, and regulatory requirements. With the right GRC approach, teams can proactively manage financial, operational, clinical, and cybersecurity risks while maintaining ethical standards and regulatory alignment.

A health system uses a Governance, Risk and Compliance (GRC) solution to track regulatory requirements, ensure policies are being followed, manage vendor risk, and stay prepared for audits. This visibility helps leaders make informed decisions and build trust with internal teams, vendors, and regulators.

Healthcare organizations rely on accurate and secure health information to deliver care, support billing, and meet regulatory requirements. HIM plays a critical role in protecting patient privacy, maintaining data integrity, and ensuring compliance with laws such as HIPAA. Strong HIM practices also support effective decision-making and operational efficiency.

An HIM department reviews access logs and data-sharing agreements to ensure only authorized staff and vendors can view patient records. This oversight helps the organization maintain compliance, protect patient privacy, and reduce the risk of unauthorized data access.

HIPAA matters because patient trust depends on data privacy. Healthcare organizations handle large volumes of sensitive information, and HIPAA establishes clear expectations for confidentiality, security, and accountability. Noncompliance can result in fines, reputational damage, and loss of patient confidence.

A hospital switches to a new electronic system to store patient medical records. To comply with HIPAA, the hospital limits who can access patient data, tracks system access, and ensures the technology provider meets strict privacy and security standards.

By operating as a connected network, IDNs can better manage costs, improve patient outcomes, and deliver a more consistent care experience. At the same time, managing an IDN increases the number of contracts, vendors, and regulatory requirements, making strong governance and clear visibility critical to maintaining control and compliance.

A health system owns multiple hospitals, clinics, and urgent care centers. By managing contracts and policies centrally, leadership ensures all locations follow the same rules and provide consistent patient care. 

Accreditation by The Joint Commission is a key indicator of quality and compliance for healthcare organizations. Many hospitals and health systems must maintain accreditation to participate in Medicare and Medicaid programs. The Joint Commission’s standards influence policies, procedures, contracts, and vendor relationships, making ongoing readiness and documentation critical.

During a Joint Commission survey, trained surveyors conduct on-site reviews, follow patient care processes using tracer methodology, and examine policies, contracts, and vendor documentation. Because the hospital maintains centralized, up-to-date records, staff can quickly respond to survey requests, address findings, and demonstrate continuous compliance with accreditation standards. 

Healthcare organizations must ensure staff are properly trained to deliver safe patient care and meet regulatory and accreditation requirements. An LMS provides documented proof of required training, supports audit and survey readiness, and helps reduce risk by ensuring staff understand policies, procedures, and safety standards. 

A healthcare organization uses an LMS to deliver required training tied directly to approved policies and procedures. When a policy is updated, related training is assigned through the LMS, and completion records are maintained to demonstrate staff awareness and compliance during regulatory or accreditation surveys.

LEIE checks matter because healthcare organizations receive government funding and must follow strict rules about who they work with. If an organization unknowingly hires or contracts with someone on the exclusion list, it can face fines, repayment demands, and legal trouble. Regular checks help organizations avoid these risks and maintain trust with regulators and patients.

A hospital reviews a staffing agency before signing a contract. As part of the review, the hospital runs an LEIE check to ensure the agency and its employees are approved to work in healthcare and are not prohibited from participating in federally funded programs.

LEIE checks matter because healthcare organizations receive government funding and must follow strict rules about who they work with. If an organization unknowingly hires or contracts with someone on the exclusion list, it can face fines, repayment demands, and legal trouble. Regular checks help organizations avoid these risks and maintain trust with regulators and patients.

A hospital reviews a staffing agency before signing a contract. As part of the review, the hospital runs an LEIE check to ensure the agency and its employees are approved to work in healthcare and are not prohibited from participating in federally funded programs.

Long-term care plays an essential role in supporting individuals with chronic illnesses, disabilities, or age-related conditions. By providing consistent care and supervision, LTC settings help maintain quality of life, promote safety, and reduce unnecessary hospitalizations. LTC services also support families and caregivers by ensuring individuals receive appropriate care in a structured environment.

An elderly individual with mobility limitations and multiple chronic conditions moves into a long-term care facility where they receive daily assistance, ongoing medical monitoring, and access to rehabilitation services. This ongoing support helps the individual remain safe, stable, and as independent as possible over time.

LEIE checks matter because healthcare organizations receive government funding and must follow strict rules about who they work with. If an organization unknowingly hires or contracts with someone on the exclusion list, it can face fines, repayment demands, and legal trouble. Regular checks help organizations avoid these risks and maintain trust with regulators and patients.

A hospital reviews a staffing agency before signing a contract. As part of the review, the hospital runs an LEIE check to ensure the agency and its employees are approved to work in healthcare and are not prohibited from participating in federally funded programs.

NPSGs guide healthcare organizations in implementing evidence-based practices that improve patient safety and quality of care. Compliance with NPSGs is evaluated during accreditation surveys and helps organizations reduce errors, improve outcomes, and maintain accreditation status. 

A hospital implements policies and staff training to support NPSGs related to patient identification and medication safety. During a Joint Commission survey, the organization demonstrates compliance by showing consistent practices, staff education, and documented adherence to patient safety standards.

The OIG plays a critical role in healthcare compliance by enforcing federal laws and regulations related to Medicare, Medicaid, and other federally funded healthcare programs. Its audits, investigations, exclusions, and compliance guidance help healthcare organizations understand regulatory expectations, avoid violations, and reduce legal and financial risk.

The OIG investigates a healthcare organization suspected of submitting false Medicare claims. After confirming the violations, the OIG imposes civil monetary penalties and excludes the responsible provider from participating in federal healthcare programs. As a result, other healthcare organizations must screen against the OIG Exclusion List to ensure they are not employing or contracting with the excluded provider, helping them avoid fines, repayments, and enforcement actions.

The OIG Exclusion List is hugely important because healthcare organizations must ensure they do not employ or do business with excluded individuals or companies. Working with an excluded party can lead to fines, repayment of funds, and legal consequences. Regular screening helps organizations avoid these risks and maintain compliance.

Before hiring a new physician or contracting with a service provider, a healthcare organization checks the OIG Exclusion List to confirm the individual or company is approved to participate in federally funded healthcare programs.

This screening matters because healthcare organizations often rely on federal funding and must follow strict rules about who they work with. Screening helps confirm that vendors, contractors, and employees are eligible to do business, reducing the risk of penalties, financial loss, and compliance violations.

Before signing a contract with a new vendor, a health system completes OIG and GSA screening to verify the vendor is eligible to work with government-funded healthcare programs.

Healthcare organizations rely on policies to ensure consistent, compliant and ethical operations across clinical, administrative and operational functions. Clear policies reduce ambiguity, support regulatory compliance and help teams act with confidence in high-pressure environments where accuracy and accountability matter. 

Healthcare organizations develop and maintain policies to address regulatory requirements, patient safety, workforce conduct, vendor relationships and risk management. Effective policy governance includes regular review, version control, approval workflows and alignment with contracts and regulatory obligations.

A healthcare organization uses a centralized policy management solution to maintain current policies, track approvals, manage attestations and demonstrate compliance during audits. This approach provides visibility, reduces risk and supports consistent practices across the organization.

PSV is essential for patient safety and regulatory compliance, as it ensures providers are qualified and authorized to deliver care. Accrediting and regulatory bodies require PSV as part of credentialing and privileging processes, and failure to complete PSV can result in compliance findings or accreditation risk.

A hospital completes primary source verification of a physician’s medical license, board certification, and education before granting clinical privileges. Documentation of PSV is maintained to demonstrate compliance during accreditation or regulatory surveys.

Protected Health Information (PHI) is important because it contains highly sensitive personal information. Healthcare organizations must protect it to maintain patient trust, comply with privacy laws like HIPAA, and prevent data misuse or breaches.

A clinic sends patient appointment reminders through a third-party messaging service. Before sharing patient names and appointment details, the clinic confirms the vendor has proper safeguards in place to protect that information.

Healthcare regulations protect patient safety, data privacy, and ethical business practices. Maintaining compliance helps organizations avoid fines and penalties, stay prepared for audits, and build trust with regulators, patients, and partners.

A healthcare organization tracks regulatory requirements alongside its policies and contracts. When regulations change or an audit occurs, teams can quickly confirm compliance, update documentation, and respond with confidence.

An RFI is important because it helps healthcare organizations identify and correct gaps that may affect patient safety, quality of care, or regulatory compliance. Addressing an RFI supports continuous improvement and helps prevent similar issues from recurring in the future. 

During a routine accreditation review, a healthcare organization receives an RFI related to incomplete policy documentation. The organization updates the affected policies, clarifies responsibilities, and implements regular reviews to ensure documentation remains accurate and current.

Healthcare organizations operate in highly regulated environments where failures can affect patient safety, accreditation, and reimbursement. Effective risk mitigation helps reduce the likelihood of adverse events, regulatory findings, and financial loss by proactively addressing vulnerabilities through clear policies and consistent practices.

A healthcare organization identifies gaps in its infection prevention practices during an internal audit. To mitigate risk, leadership updates related policies, provides staff training, and implements ongoing monitoring. These actions help reduce the risk of patient harm and support compliance during future regulatory or accreditation surveys.

Healthcare organizations rely on third-party vendors for critical services that can directly impact patient care, safety, and compliance. SLAs help ensure vendors meet required performance standards, support regulatory requirements, and reduce operational risk by clearly defining expectations and consequences for nonperformance.

A hospital enters into an agreement with a medical equipment maintenance vendor that includes an SLA requiring response to critical equipment failures within a specified timeframe. The SLA helps ensure timely repairs, minimizes service disruptions, and supports compliance with regulatory and patient safety standards.

Skilled Nursing Facilities play a key role in the continuum of care by supporting patient recovery after hospitalization. They help reduce hospital readmissions by providing focused clinical care, rehabilitation services, and monitoring for patients who no longer need acute care but are not yet ready to return home. 

After a patient undergoes hip replacement surgery, they are discharged from the hospital to a skilled nursing facility for physical therapy, pain management, and nursing support. The SNF helps the patient regain mobility and strength while preparing them for a safe transition back to their home environment.

Saas is important in healthcare because it allows organizations to access technology quickly, scale systems as needs change, and receive regular updates without managing on-site infrastructure. SaaS solutions support efficiency, data accessibility, and collaboration across teams while helping organizations adapt to evolving healthcare requirements. 

A healthcare organization uses a SaaS platform like Ntracts to access contract and compliance information through a secure, web-based system. Staff members can log in from different locations to review documents, monitor updates, and stay aligned without relying on locally installed software. Using a SaaS solution allows the organization to maintain consistent access to information while benefiting from regular system updates and improvements managed by the provider. 

Healthcare organizations work with a wide range of vendors and operate under tight financial and regulatory pressures. Effective spend management helps organizations control costs, avoid unnecessary or duplicate spending, and reduce contract leakage caused by missed pricing terms or outdated agreements. It also supports compliance by ensuring purchasing decisions follow approved contracts and policies.

A health system reviews vendor invoices against contract pricing and identifies charges that no longer match negotiated terms due to expired pricing agreements. By correcting the issue and renegotiating the contract, the organization reduces costs and improves financial oversight.

SOPs help healthcare organizations deliver safe, reliable, and compliant care by standardizing processes across departments. They support regulatory and accreditation requirements, reduce variability, and provide clear guidance to staff, especially in high-risk or highly regulated activities.

A healthcare organization develops an SOP for handling patient admissions that outlines required documentation, verification steps, and staff responsibilities. During a regulatory survey, the organization uses the SOP to demonstrate consistent processes and compliance with patient safety and operational standards.

The law promotes ethical referrals and transparency. It helps prevent conflicts of interest that could drive unnecessary services or increased costs, while protecting patient trust and organizational integrity.

A health system reviews physician contracts, ownership interests, and compensation structures to confirm referrals meet Stark Law exceptions. This review helps the organization avoid compliance issues and remain prepared for regulatory audits.

The System for Award Management (SAM) is critical for healthcare organizations and vendors that participate in federally funded programs or contracts. Failing to screen against SAM can result in contracting with ineligible or excluded parties, which may lead to contract termination, loss of funding, repayment obligations, and compliance violations.

 A healthcare services vendor is debarred for violating federal contracting requirements and is listed as ineligible in the System for Award Management (SAM). When a hospital performs required vendor screening during contract review, the SAM check flags the vendor as debarred, preventing the hospital from executing the contract and helping it avoid enforcement actions and potential loss of federal funding.

Healthcare contracts often support critical services and are subject to regulatory and operational requirements. Clear termination clauses help organizations manage risk by setting expectations upfront and providing a structured path to exit agreements when performance, compliance, or business needs change. Well-defined termination terms help prevent disputes, protect patient care, and reduce legal or operational disruption.

A healthcare organization relies on a vendor for clinical support services but experiences repeated service failures. Using the termination clause, the organization provides the required 60-day notice, documents the performance issues, and transitions services to a new vendor while maintaining continuity of care and compliance. 

Healthcare organizations work with many vendors, from medical equipment suppliers to service providers. Without proper oversight, vendor access can create safety, legal, and compliance risks. Credentialing helps ensure vendors are properly trained, insured, and approved to work in healthcare environments, protecting patients, staff, and day-to-day operations. 

Before allowing a medical equipment vendor into operating rooms, a hospital reviews the vendor’s insurance coverage, training records, and background checks. This process helps ensure only qualified and approved vendors are allowed in patient care areas.

Healthcare organizations manage activities that involve multiple stakeholders, regulatory requirements, and time-sensitive decisions. Established workflows help ensure contracts, policies, and compliance activities follow approved procedures. By standardizing how work progresses, workflows reduce delays, improve accountability, and help organizations meet operational and regulatory expectations. 

A healthcare organization sets up a contract workflow that automatically routes a new vendor agreement to legal for review, then to compliance for approval, and finally to an executive for signature. Each step must be completed before the contract moves forward, helping the organization avoid missed approvals and execution delays.