Regulatory Environment -Executive Summary

Regulatory Environment -Executive Summary

Executive Summary

Patient safety is one of the critical areas in the healthcare setting. It is important for healthcare organizations to develop a range of practices that enhance patient safety. Healthcare organization administrators must thus determine various risks that can reduce patient’s safety. Besides, various government authorities stipulates certain rules and guidelines that foster high quality patient care and safety. This paper provides a summary of various tools and practices that permit quality improvement in healthcare organizations while managing risks and demonstrating compliance to the set regulations. In this regard, this document explicates the various regulations relating to data breaches and patient information security risk management procedures and compliance practices. Although realization of effective quality improvement is engaging, quality improvement is highly inevitable towards meeting today’s healthcare demands. In order to realize this, an organization can use a range of quality improvement tools.

One of the most effective tools for quality improvement is the “cause and effect diagram.” For a healthcare organization to be successful, it must demonstrate high level of information organization. Cause and effect diagrams help the nurses, physicians and other healthcare workers to determine the cause and effects of certain occurrences in an organization. This tool allows the administrators and other employees to examine why something happen or might occur by clearly organizing all possible causes into lesser categories. The tool is also helpful in showing associations between the contributing factors. Another helpful tool for quality improvement is the flow diagrams. Like many other organizations with critical procedures and processes, healthcare organizations should use flow diagrams to enhance processes and systems. Besides, forms are effective quality improvement tools as they help to collect credible information from different sources. Other effective tools include the run charts for determining the variations in special and common causes of event, and Gantt charts for successful project management.

While using the above tools, a healthcare organization can achieve the best quality improvement practices. Some of these practices include “adaptive leadership, culture and governance,” effective analytics, consensus and evidence-based practices as well as financial alignment. Usually, Healthcare administrators must understand the best practices to ensure that they develop effective quality improvement programs. Effective quality improvement initiatives demand enhanced senior leadership support in addition to adaptive learning culture emphasizing on quality improvement based on credible data. As such, adaptive leadership and culture serve the best interest of the organization, employees and the patient.

Analytics culture is one of the most effective practices toward sustainable quality improvement. Notably, analytics play critical roles in all phases in the quality improvement lifecycle- including planning, doing, studying and acting. Analytics enhance processes involved in measuring and understanding various challenges as well as to determine whether the outcomes promote quality improvement. Notably, it is not obvious that an organization has quality improvement because it have measurements. Of importance, evidence-based practices permit quality improvement and patient safety among other healthcare benefits (Schwappach, Frank,  Buschmann & Babst, 2013). However, quality improvement efforts are meaningless without adoption. As such, making adequate plans and implementing the best practices is essential for healthcare organizations.

Also, an organization that implements the best practices must not only recognize by also comply with the set rules and regulations.  Some of the most fundamental regulations that every health provider must comply with are the HIPAA rules (Harman, Flite & Bond, 2012). For instance, government HIPAA Security Rule requires the organizations to conduct frequent audit trails to understand the users using certain information, data or processes in the system at a particular time (American College of Healthcare Executives, 2007). Besides, organizations must also ensure that they have the right software and hardware while adhering to right procedures recording and examining activities in systems containing protected health information. Hospitals and other healthcare facilities should comply with the HITECH Act (2009) requirements (Morello et al., 2013). For instance, the law requires hospitals and other healthcare facilities to watch for personal health information breaches from both external and internal intrusions. As such, facilities must protect the patients and the workers at all times in addition to providing high quality health services. Compliance to these regulations allow organizations to limit any data breaches (Okuyama, Wagner & Bijnen, 2014).

While implementing the best practices, healthcare organization realizes the potential risks to the entire organization including the patient, employees, data and information as well as processes and procedures. Risk management is thus very crucial towards quality improvement. In the contemporary world, various organizations are putting emphasis on risk management to allow continuity in case any risk occurs but more importantly to ensure that risks do not occur. Risk management practices help to mitigate against risks or reduce the impacts from the risks and permit continuity.

In light of this, healthcare administrators must understand various risk management techniques including avoidance and retention as well as reduction and sharing strategies. Understanding risk management process is also important for the administrators and the risk managers. Notably, risk management process involves a rage of phases including identification of the risk, assessment of the possible impacts from the risk and the control of the risk as well as effective review of the process to ensure efficiency.

References

American College of Healthcare Executives. (2007). ACHE code of ethics.

Harman, L. B., Flite, C. A., & Bond, K. (2012). Electronic health records: privacy, confidentiality, and security. AMA Journal of Ethics, 14(9), 712-719. Retrieved from https://journalofethics.ama-assn.org/article/electronic-health-records-privacy-confidentiality-and-security/2012-09

Morello, R. T., Lowthian, J. A., Barker, A. L., McGinnes, R., Dunt, D., & Brand, C. (2013). Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf, 22(1), 11-18.

Okuyama, A., Wagner, C., & Bijnen, B. (2014). Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC health services research, 14(1), 61.

Schwappach, D. L., Frank, O., Buschmann, U., & Babst, R. (2013). Effects of an educational patient safety campaign on patients’ safety behaviours and adverse events. Journal of Evaluation in Clinical Practice, 19(2), 285-291.

Appendix

Executive Summary Table