Create a 3–4-page executive summary of tools and best practices for quality improvement, risk management, and learning guidelines. Include a summary table that describes the status of an organization’s compliance with regulatory requirements.

GRADING RUBRIC MUST BE FOLLOWED

Questions to Consider:

The Regulatory Environment:

• Which regulatory bodies oversee the subsector of the health care industry in which you currently work or would like to work?
• How would you figure out which organizations oversee the subsector?
• How would you determine which laws apply to your setting and what type of data you need to collect and examine?
• What are the standards of care?
• How would you locate these standards?
• How would you know if your organization exceeded those standards and might be in a position to apply for accreditation?

Establishing a Culture of Patient Safety:

• What is an example of a best practice for establishing a systems-based culture of patient safety?
• How will you know if your organization was identified as an example of success when best practices are used?

Benchmarking:

• What types of processes exist for collecting and analyzing data to identify trends in the performance of your health care setting?
• Who are some of the health care industry’s best performers in terms of risk management?
• What types of benchmarking data are important to consider?
• What roles within your own organization need to be involved in a proactive risk-management program?
• What are some critical success factors for the establishment of a systems-based risk-management program?
• What types of considerations or cautions are important to keep in mind when interpreting internal and external benchmarking data?

Preparation

Scenario

Assume you have taken on a new role as the chief operating officer. You are charged with leading system-wide risk-management efforts to identify risk and minimize HACs. Your organization’s financial viability depends on receiving proper reimbursement for services delivered. As the chief operating officer, you must create an executive summary that describes your organization’s compliance with the regulatory requirement, to promptly identify conditions that are POAs and proactively assess and manage risk.

Instructions

Step One: Executive Summary Table

Select a risk-management issue within a specific health care setting or organization. You will use this issue as a starting point for your work on this assessment. Use the Executive Summary Table from the Required Resources to complete this step.

• Issue: Write a brief description of the risk-management issue you selected. Explain why this risk-management issue is important to your organization.
• Regulatory Requirements: Compile a list of the applicable regulatory requirements and an explanation of what they mean to your chosen risk-management issue.
• Risk-Management Implications: Identify the associated risk-management implications. For example, HACs result in no reimbursement, and poor quality ratings. Also, there is a risk of losing repeat admissions, a risk of losing Joint Commission and Magnet accreditation or excellence, or other negative implications.
• Environmental Assessment: Assess the internal versus external environment relative to the risks associated with your chosen risk-management issue. You may use strengths, weaknesses, opportunities, and threats (SWOT) analysis or another suitable tool. Be sure to cite the source.
• Resources to Address Issue: Describe any resources or strengths your organization possesses that could aid in addressing the risk-management issue.
• Philosophy or Culture Statement: Summarize your organization’s philosophy or culture as it relates to patient safety and error reporting.
• Measuring and Monitoring:
  • Identify metrics for measuring or monitoring the risk-management issue.
  • Propose how you will make use of the outcome data for organizational improvement.
• Organizational Improvement: State how you will encourage voluntary reporting.
• Ethics Considerations: Describe legal and ethical implications related to the handling of this risk-management issue.

Utilize established sources of information. Some sources that may be useful to you include the federal register, statutes, discipline-specific peer-reviewed journals, and government agency references.

Step Two: Executive Summary

Using the information assembled in Step One, prepare a 3–4-page executive summary for a written presentation to the management team. Select a format for your summary based on your chosen organization’s standards for executive summaries. (Examples of these types of documents can also be found using an Internet search.) Include the following:

• A proactive assessment of your organization’s compliance with the regulatory requirement to promptly identify POAs and proactively assess and manage risk based on existing regulations and requirements.
• Your identification of tools and best practices for monitoring parameters and reducing risk, including organizational structure needed for risk reeducation, as supported by the literature.
• Your recommendations for quality improvement and organization-specific risk management and learning guidelines.

You must include the completed table from Step One as an appendix to this executive summary.

Resources:

Accountable Care Organizations

This article discusses how a health care facility transitioned into an Accountable Care Organization successfully.

• O’Connor, J. (2016). An ACO success story. McKnight’s Long-Term Care News, 37(1), 27.

This article discusses how ACOs have achieved cost savings while improving care for their patients.

• Perez, K. (2014). ACOs and the quest to reduce costs. Healthcare Financial Management, 68(9), 118–122.

Quality Improvement Strategies

This article examines the revised nursing home quality measures endorsed by the National Quality Forum which could best represent the improving quality of care in nursing homes.

• Barr, P. (2011). Setting higher standards: Nursing home quality measures offer guide. Modern Healthcare, 41(18), 17–19.

This article examines the various domains associated with quality improvement in healthcare organizations.

• Brandrud, A. S., Nyen, B., Hjortdahl, P., Sandvik, L., Haldorsen, G. S. H., Bergli, M., . . . Bretthauer, M. (2017). Domains associated with successful quality improvement in healthcare – a nationwide case study. BMC Health Services Research, 17.

This article explains the key role that leadership plays in supporting and aligning staff for patient care using the Malcom Baldrige criteria as a path to quality excellence.

• Miller, R. P. (2007). Baldrige as a path to excellence. Modern Healthcare, 37, 23–24.

This article explores how hospital managers perceive lean in the context of quality improvement.

• Savage, C., Parke, L., von Knorring, M., & Mazzocato, P. (2016). Does lean muddy the quality improvement waters? A qualitative study of how a hospital management team understands lean in the context of quality improvement. BMC Health Services Research, 16.

This article discusses methods for auditing cost and quality tailored to a hospital’s specific population.

• Silber, J. H., Rosenbaum, P. R., Ross, R. N., Ludwig, J. M., Wang, W., Niknam, B. A., . . . Fleisher, L. A. (2014). A hospital–specific template for benchmarking its cost and quality. Health Services Research, 49(5), 1475–1497.

This article focuses on the factors affecting the adoption of innovative assurance technologies in nursing care.

• Storey, J. (2013). Factors affecting the adoption of quality assurance technologies in healthcare. Journal of Health Organization and Management, 27(4), 498–519.

Regulatory and Compliance

This article discusses a new regulation establishing and new safety-reporting for drugs under the investigational new drug applications.

• Behrman Sherman, R., Woodcock, J., Norden, J., Grandinetti, C., & Temple, R. J. (2011). New FDA regulation to improve safety reporting in clinical trials. The New England Journal of Medicine, 365(1), 3–5.

Additional Resources for Further Exploration

You may use the following optional resources to further explore topics related to competencies.

Process and Performance Improvement

This is the home page of the American Productivity and Quality Center that provides best practices and benchmarking tools for designing effective methods for process and performance improvement.

• APQC. (n.d.). APQC’s glossary of benchmarking terms. Retrieved from https://www.apqc.org/knowledge-base/documents/apqc…

Quality Improvement

This is a blog page on how to improve care for patients with Medicare.

• Berwick, D. (2011). Improving care for people with Medicare [Blog post]. Retrieved from http://www.whitehouse.gov/blog/2011/03/31/improvin…

This is the home page of Medicare that summarizes measures of quality shown on Hospital Compare.

• Medicare.gov. (n.d.). Hospital compare. Retrieved from https://www.medicare.gov/hospitalcompare/search.ht…

This article discusses the Affordable Care Act funding for health providers to improve patient care.

• Infection Control Today. (2011). Up to Up to $500 million in Affordable Care Act funding will help health providers improve care.00 million in Affordable Care Act funding will help health providers improve care. Retrieved from http://www.infectioncontroltoday.com/news/2011/06/…

Patient Safety

This article discusses various principles for creating a culture of safety in hospitals.

• Teal, K. (2017). What infection preventionists can do to ensure a culture of safety. Retrieved from http://www.infectioncontroltoday.com/general-hais/…

This is the home page of the National Quality Forum. It focusses on reducing preventable admission and readmissions, reducing adverse health care associated conditions, and reducing harm or unnecessary care.

• National Quality Forum. (n.d.). Retrieved from http://www.qualityforum.org/Home.aspx

This is the home page of the Joint Commission on patient safety goals and standards.

• The Joint Commission. (n.d.). Retrieved from http://www.jointcommission.org

Regulatory and Compliance

This is the home page of the Healthcare Compliance Association for compliance professionals in the healthcare provider field.

• Healthcare Compliance Association. (n.d.). The Healthcare Compliance Association. Retrieved from https://www.hcca-info.org/

This is the home page of the OIG U.S. Department of Health and Human Services. It discusses legal issues regarding ACOs participation in Medicare.

• U.S. Department of Health & Human Services. (n.d.). Accountable care organizations. Retrieved from http://oig.hhs.gov/compliance/accountable-care-org…

This is the home page of the U.S. Department of Health and Human Services laws and regulations.

• U.S. Department of Health & Human Services. (n.d.). Laws & regulations. Retrieved from http://www.hhs.gov/regulations/index.html