Risk Management Program Analysis – Part Two

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1

The purpose of this assignment is to analyze how an organization’s quality and improvement processes contribute to its risk management program.

This assignment builds on the Risk Management Program Analysis – Part One assignment you completed in Topic 1 of this course.

Assume that the sample risk management program you analyzed in Topic 1 was implemented and is now currently in use by your health care employer/organization. Further assume that your supervisor has asked you to create a high‐level summary brief of this new risk management program to share with a group of administrative personnel from a newly created community health organization in your state who has enlisted your organization’s assistance in developing their own risk management policies and procedures.

Compose a 1,250‐1,500 word summary brief that expands upon the elements you first addressed in the Topic 1 assignment. In this summary brief, address the following points regarding your health care organization and its risk management program:

1. Explain the role of your organization’s MIPPA-approved accreditation body (e.g., JC, ACR, IAC) in the evaluation of your institution’s quality improvement and risk management processes.

2. Describe the roles that different levels of administrative personnel play in healthcare ethics and establishing or sustaining employer/employee-focused organizational risk management strategies and operational policies.

3. Illustrate how your organization’s risk management and compliance programs support ethical standards, patient consent, and patient rights and responsibilities.

4. Explain the legal and ethical responsibilities health care professionals face in upholding risk management policies and administering safe health care at your organization.

5. Relate how your organization’s quality improvement processes support and contribute to its overall journey to excellence.

Risk Management Program Analysis (Part 2)

Grand Canyon University

11/27/2021

The Role of Joint Commission in evaluating organizational risk.

The joint commission plays a significant role in evaluating the organization’s risk management program. The JC stresses the connection between risk management and performance activities (MIPAA, 2019). The provision calls the hospital to analyze various activities for any potential risks. By allowing the organization to connect preference activities to risk management, it facilitates risk analysis in every job to help in the identification of risk. The measures also enable risk management professionals to identify risks that cannot be identified through ordinary procedures.

The JC recommends measures to allow organizations to target loss prevention actions. The commission suggests measures such as Root Cause Analysis (RCA), a systematic approach for identifying the causes of accidents and the measures to overcome the causes (MIPAA, 2019). The RCA is significant for fall prevention because it enables the organization to identify and analyze the causes of falls and the possible solutions. The JC also recommends Failure Mode and Effects Analysis (FMEA) which is crucial for identifying weakness within the clinical services and high-risk procedures (MIPAA, 2019). The FMEA measures and recommendations also enable the hospital to identify risks based on various procedures and how weaknesses of the various services can lead to fall risks. The JC recommends special resources and expertise such as the patient safety officer (PSO), whose role is to ensure excellent patient care and services. The PSO can help the hospital identify various risks related to patients that can increase the chances of falling.

Administrative personnel and their roles in enforcing risk management protocols

Managers play a significant role in risk management in the hospital. Their main duty is to oversee the risk analysis and prevention measures to ensure they are updated and effectively accomplish the desired objectives. The procurement and risk management managers and departments ensure the hospital has the necessary resources to mitigate the risk (Hendrich, 2018). They ensure the hospital has special facilities such as movement-assisted devices, which are crucial for achieving safety and quality standards set by the Joint Commission.

The risk manager and his team are responsible for organizational risk identification and analysis. They analyze all the processes and services to identify potential sources of risks. They also collaborate with other members from various departments to ensure the hospital can identify factors contributing to the rising risks in the hospital (Hendrich, 2018). The risk management department, led by the various managers, oversees risk evaluation to ensure the organization takes instant measures to deal with the risks. The risk manager also files a risk assessment report and presents it to the organization’s management board to seek instant action.

The human resources department ensures the hospital has the right personnel to enforce risk management procedures. This includes employing competent and enough nurses and other medical personnel to improve medical care serves delivered to patients. The measure also increases the patient-nurse ratio, reducing risks due to lack of adequate nursing care and assistance (Hendrich, 2018). The human resources department is also responsible for training the medical personnel to ensure they have the necessary skills to implement and enforce various risk prevention standards set by the hospital.

Other managers and departments such as IT can enforce various security protocols to track and monitor patient movement within the hospital to reduce falling risks. The department can also integrate various technologies necessary to enforce organizational safety standards and protocols necessary for managing the risks of falling.

How organization’s risk management and compliance programs support ethical standards, patient consent, and patient rights and responsibilities.

The organization has implemented various fall prevention programs to reduce risks occurring. The use of Total Quality Management ensures that various processes, services, and procedures comply with the JC and CDC risk management standards (Sarmiento & Lee, 2017). The program investigates every process and activity to ensure potential weaknesses are resolved and complies with the JC standards to establish risk assessment protocols. The protocols also increase organizational alert and safety standards to prevent the risks.

Secondly, the organization has also implemented alert warnings and structural changes such as bed heights to ensure patients are safe. The measure complies with the FMEA standards, requiring the organization to identify structures and processes that may cause or mitigate significant risks. Other measures such as integrating other departments such as IT improve joint effort and partnerships recommended by CDC and JC to improve risk management programs.

The legal department in the organization ensures that the organization’s measures do not violate patient privacy standards and ethical concerns. The department ensures measures such as patient tracking and movement monitoring do not violate patient privacy and comply with measures by accredited bodies and other agencies.

Challenges faced by professionals when enforcing risk management policies.

One of the main challenges professionals face when enforcing risk management measures is upholding patient privacy. Measure such as patient tracking exposes the organization to ethical and privacy challenges such as data security and safety (Hendrich, 2018).. The managers may also face compliance challenges because the risk management measures must comply with the measures set by accredited bodies. Compliance measures become a challenge when the hospital has unique conditions requiring changes and deviation from the regulatory measures and standards. These measures and standards may also acquire additional resources to improve the services.

The measure enforced by the organization can also be subject to resistance from various employees. Employees may not be comfortable with some measures, and they may feel the measures require additional effort, time and may violate their privacy (Goh, 2016). The resistance has an impact on the ability of the organization to manage the risks successfully. The resistance can also affect subsequent measures such as risk evaluation to identify the measure’s performance.

The organization and the management are also likely to experience additional costs incurred when implementing various measures and protocols. The costs may include training expenses which should be conducted regularly to ensure nurses and staff are updated. The hospital also requires expert help to implement various risk management measures; these measures may also require special services and investigations which may also be cost demanding. Finally, the resources and the equipment installed to improve safety may be capital intensive.

How quality improvement processes support contribute to the program’s excellence.

The quality standards by the hospital ensure the company complies with various regulatory measures hence reducing the conflicts with the various regulatory bodies. This improves organizational reputation hence boosting organization image.

The quality measures and standards also ensure the organization gains positive and genuine reviews from patients, enabling the organization to identify potential areas of improvement and potential sources of challenges that require improvements (Sarmiento & Lee, 2017). The quality measures and standards also improve employee commitment to the organization’s safety and risk management protocols. The inclusion of all stakeholders enables the organization to improve the services and identify errors and challenges that may affect progress.

References

MIPAA. (2019, January 17). The risk management standards proclaimed by the Joint Commission research paper for students. Campuscrosswalk. https://campuscrosswalk.org/the-risk-management-standards-proclaimed-by-the-joint-commission/

Sarmiento, K., & Lee, R. (2017). STEADI: CDC’s approach to make older adult fall prevention part of every primary care practice. Journal of safety research, 63, 105-109.

Hendrich, A. L. (2018). An effective unit-based fall prevention plan. Journal of Nursing Care Quality, 3(1), 28-36.

Goh, Y. M. (2016). Investigating the effectiveness of fall prevention plan and success factors for program-based safety interventions. Safety science, 87, 186-194.

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