Organizational compliance and regulatory mandates
Healthcare in the United States benefits from extraordinary technological advances,well-trained and motivated professionals, and well-supplied facilities. Yet few would disagree that the system has been broken. Patient injury statistics have been high; too many have been uninsured and without access to care; unnecessary procedures are demanded and provided; and too much costly testing is done within a lawsuit-fearful medical environment.
The U.S. spends more per capita on healthcare than any country in the world but consistently ranks low in the quality of care those dollars purchase. The issue of quality in healthcare is not new but its slow evolution to the spotlight has recently been spurred by widely disseminated Institute of Medicine (IOM) reports; subsequent regulatory mandates; organizational advocacy and involvement; and sweeping legislation that remains continually challenged. This volatile environment is a challenge for healthcare administrators responsible for organizational compliance with regulatory mandates.
For this Assessment, you will respond to authentic scenarios focusing on organizational compliance with regulatory mandates for healthcare quality and safety.
Competency Statement: Evaluate organizational compliance with regulatory mandates for healthcare quality and safety.
Type of Assessment: Performance Task
Prerequisites: None
Overview
This Performance Task Assessment includes a series of prompts focused on organizational compliance with regulatory mandates for healthcare quality and safety. The prompts are based on a brief scenario provided. Respond to each prompt as instructed.
To complete this Assessment:
Download the Academic Writing Expectations Checklist to use as a guide when completing your Assessment. Responses that do not meet the expectations of scholarly writing will be returned without scoring. Properly formatted APA citations and references must be provided, where appropriate.
Be sure to use scholarly academic resources as specified in the rubric. This means using Walden Library databases to obtain peer reviewed articles.
Additionally, .gov (government expert sources) are a quality resource option. Note: Internet and .com sources do not meet this requirement. Contact your coach or SME for guidance on using Library Databases.
Carefully review the rubric for the Assessment as part of your preparation to complete your Assessment work.
This Assessment requires submission of four (4) files. Save your files as follows:
For Part 1, save your slide presentation as OM002_Presentation_firstinitial_lastname (for example, OM002_Presentation_J_Smith).
For Part 2, record an audio or video file and save it as OM002_2_firstinitial_lastname (for example, OM002_2_J_Smith).
For Parts 3-4, save your file as OM002_ 3-4_firstinitial_lastname (for example, OM002_3-4_J_Smith).
For Part 5, save your completed Organization Assessment Worksheet as OM002_Worksheet_ firstinitial_lastname (for example, OM002_Worksheet_J_Smith).
When you are ready to upload your completed Assessment, use the Assessment tab on the top navigation menu.
Instructions
Before submitting your Assessment, carefully review the rubric. This is the same rubric the assessor will use to evaluate your submission and it provides detailed criteria describing how to achieve or master the Competency. Many students find that understanding the requirements of the Assessment and the rubric criteria help them direct their focus and use their time most productively.
Rubric
Click each of the items below to complete this assessment.
To begin, review:
Kohn, L.T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. National Academy Press. https://www.nap.edu/
National Academy of Sciences. (2001). Crossing the quality chasm: A new health system for the 21st century. https://www.nasonline.org
Note that you first read these resources in OM001.
Scenario
Imagine that you are an executive with a healthcare consultancy that helps hospitals improve patient experiences by creating and implementing sustainable quality improvement programs. Consider your role as you answer the questions in this Assessment.
Part One: History of the Quality-Management Movement in Healthcare
An important part of your role at the consulting firm is to lead training sessions at hospitals nationwide. At the training sessions, you educate hospital administrators on the history of the quality-management movement in healthcare. Many of the individuals you train have little or no background in quality management, and you have found that leadership is more receptive to changes if they understand the history of the quality-management movement in healthcare.
Create a slide presentation to communicate the following information to your audience. (5 – 7 slides)
Briefly summarize the history of the quality movement, in general, to set the context for this presentation.
Explain the history and influence of Deming and Donabedian (referenced in Chapter 2, 12, and 14 of the Nash text, respectively) in the healthcare quality-management movement.
Describe the impact that the two reports, To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, had on quality management in the healthcare system.
Describe the role of the Centers for Medicare & Medicaid Services (CMS) in the healthcare quality-management movement.
Summarize the impact of The Joint Commission accreditation in the quality-improvement process of participating hospitals.
Part Two: Response to Syndicated News Show Interview
As a result of your success as a healthcare-quality consultant, you have been invited to appear as a guest on a nationally syndicated news show. The show explores the topic of quality in healthcare. The interviewer asks you, “Why is a hospital different than a nuclear power plant or a commercial airline? Why can’t hospitals achieve the same quality levels as high-reliability organizations?” Create an audio or video response to the questions by explaining the challenges related to ensuring quality and safety standards in hospitals. In addition, explain how hospitals can achieve the same quality levels as high-reliability organizations. (2-minute audio or video)
Part Three: Summary of the Differences and Similarities Between the JC and DNV surveys
In your role as a healthcare consultant, administrators and executives often ask you about the differences and similarities between the major accrediting agencies. Many want to know about the DNV surveys and how they compare to The Joint Commission (JC) surveys. Prepare a 1-page document that summarizes the differences and similarities between the JC and DNV surveys. Also, explain why accreditation may or may not equate to quality healthcare (1 page)
Part Four: Transparency in the Health Care System
The dean of the Master of Healthcare Administration (MHA) program at your alma mater has asked you to participate in a debate on transparency in the healthcare system. As part of your preparation for the debate, prepare a 1- to 2-page paper in which you:
Address your definition of the concept of transparency in the healthcare system.
Explain the primary benefits and drawbacks of transparency in the healthcare system. Express your opinion on whether the benefits of transparency in the healthcare system outweigh the drawbacks? Will transparency create more informed healthcare consumers, lead to more questions, or both? Explain your answer.
Part Five: Organization Assessment Worksheet
Review the National Patient Safety Goals (NPSG) at http://www.jointcommission.org/standards_information/npsgs.aspx. Then, read the scenarios presented on the Organization Assessment Worksheet provided*, and evaluate whether a violation had occurred. Based on your evaluation, complete the worksheet as follows:
If a compliance issue has occurred, identify and classify the issue in the second column of the worksheet.
If no compliance issue occurred, explain why not (in the second column of the worksheet).
For each scenario, provide a recommended course of action in the third column of the worksheet.
*Examples have been provided in the first two rows of the worksheet.
Take the time to read each of the chapters listed. Make notes to inform the slide presentation that you will create for Part 1 of the Assessment for this Competency. Be sure to refer to your notes when creating your presentation.
Chapter 6, “Physician Profiling and Provider Registries”Chapter 9, “The Patient Experience”
Chapter 10, “Safety Science and High Reliability Organizing”
Chapter 12, “Creating Alignment: Quality Measures and Leadership”
Chapter 13, “Governance for Quality”
Chapter 14, “Ambulatory Quality and Safety”
Joshi, M.S., Ransom, E.R., Nash, D.B., Ransom, S.B. (2019). The Healthcare Quality Book: Vision, Strategy, and Tools. (4th ed.). Health Administration Press, https://www.ache.org
Understanding Quality Measurement
Agency for Healthcare Research and Quality (AHRQ). (2020). Understanding quality measurement. AHRQ. https://www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/understand/index.html
Chapter 14, “Ambulatory Quality and Safety”
Chapter 17, “Value-Based Purchasing: The Increasing Importance of Quality Considerations in Funding the Healthcare System”
Chapter 19, “Population Health Safety and Quality”
Joshi, M.S., Ransom, E.R., Nash, D.B., Ransom, S.B. (2019). The Healthcare Quality Book: Vision, Strategy, and Tools. (4th ed.). Health Administration Press, https://www.ache.org
Practical Application of High-Reliability Principles in Healthcare to Optimize Quality and Safety Outcomes
Oster, C. A., & Deakins, S. (2018). Practical application of high-reliability principles in healthcare to optimize quality and safety outcomes. JONA: The Journal of Nursing Administration, 48(1), 50 – 55. https://www.doi.org/10.1097/NNA.0000000000000570
Walden University. (2010). Quality assessment and improvement: Strategies and techniques to improve patient safety and quality [Video]. Walden University Brightspace. https://mytempo.waldenu.edu
The Joint Commission
The Joint Commission. (2021). The Joint Commission. https://www.jointcommission.org/
Centers for Medicare and Medicaid Services
Centers for Medicare and Medicaid Services. (n.d.). CMS. https://www.cms.gov/
DNV GL Healthcare
DNV GL Healthcare. (n.d.). DNV GL Healthcare. DNV GL. https://www.dnvgl.us/assurance/healthcare/ac.html
Improving Electronic Health Record Usability and Safety Requires Transparency
Ratwani, R.M., Hodgkins, M., & Bates, D. W. (2018). Improving electronic health record usability and safety requires. JAMA, 320(24), 2533 – 2534. https://www.doi.org/10.1001/jama.2018.14079
Medication Errors in Community Pharmacies: The Need For Commitment, Transparency, and Research
Hong, K., Hong, Y.D., & Cooke, C.E. (2019). Medication errors in community pharmacies: The need for commitment, transparency, and research. Research in Social and Administrative Pharmacy, 15(7), 823 – 826.https://www.doi.org/ 10.1016/j.sapharm.2018.11.014
Evaluation of a Peer-to-Peer Data Transparency Intervention for Mohs Micrographic Surgery Overuse
Albertini, J. G., Wang, P., & Fahim, C., et al. (2019). Evaluation of a peer-to-peer data transparency intervention for Mohs micrographic surgery overuse. JAMA Dermatology, 155(8), 906–913. https://www.doi.org/10.1001/jamadermatol.2019.1259
Transparency: Friend or Foe? How Price Transparency May Impact Competition in The Health Care Industry
Lomas, D., & Sun, S. (2020). Price transparency: Friend or foe? How price transparency may impact competition in the health care industry. Affiliated
Monitors. https://www.affiliatedmonitors.com/wp-content/uploads/2020/06/CPI-Lomax-Sun.pdf
Ethics and Learning Health Care: The Essential Roles of Engagement, Transparency, and Accountability
Kass, N. E., & Faden, R. R. (2018). Ethics and learning health care: The essential roles of engagement, transparency, and accountability. Learning Health Systems, 2(4), e10066. https://www.doi.org/10.1002/lrh2.10066
Provider Responses to Online Price Transparency
Whaley, C. M. (2019). Provider responses to online price transparency. Journal of Health Economics, 66, 241–259. https://www.doi.org/10.1016/j.jhealeco.2019.06.001.
Click on the 2021 NPSG Program Link and take time to become familiar with National Patient Safety Goals. Consider actions in the workplace that would reflect compliance or non-compliance with various goals. You will access this website when completing Prompt 6 of the Assessment for this Competency.
2021 National Patient Safety Goals
The Joint Commission. (2019). 2021 National Patient Safety Goals (NPSGs). The Joint Commission. https://www.jointcommission.org/standards/national-patient-safety-goals/
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