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Collaborating on Quality-Issue Analysis and Leadership Action Plan

Collaborating on Quality-Issue Analysis and Leadership Action Plan

Collaborating on Quality-Issue Analysis and Leadership Action Plan

Issue Summary

A HIPAA privacy violation occurred when two surgeons discussed their first successful surgery. These two surgeons shared the patient information with the local media. This violated HIPAA privacy since protected health information (PHI) should not be shared without prior authorization or consent from the patient. The key issue from this event is that the organization does not have standard operating procedures concerning using and sharing PHI. The second key issue is that the organization does not have a risk management strategy to mitigate risks when patient privacy violations occur.

My goal in addressing this patient safety issue is to educate the hospital staff on the regulations governing the privacy and confidentiality of PHI and the healthcare risks associated with breaches in patient privacy. The second goal is to develop a standard operating procedure that will minimize the occurrence of patient privacy violations and prevent financial lawsuits to the organization due to the fines related to HIPAA violations. The first issue to focus on is to create a safety culture in the organization that will help the staff anticipate, identify, and acknowledge risks associated with HIPAA violations and promote a coordinated approach to patient safety. The second key issue is to create a standard way of addressing HIPAA violations to reduce the occurrences of breaches in patient privacy.


Organizational culture is the collection of expectations, values, and principles that guide the actions of employees and leaders of a healthcare organization (Mohammed et al., 2021). Creating a culture of safety in a healthcare organization needs the commitment of all stakeholders in the organization. Nurturing a safe culture requires the active participation of healthcare leaders, employees, and patients. Creating a safe environment should be a priority for healthcare organizations. This is because it is the legal and ethical duty of healthcare organizations to ensure the safety of patients. All healthcare industry stakeholders should prioritize healthcare organizations’ quality and safety. A healthcare organization with policies and operation standards can use these strategies to solve issues and adapt to scenarios that promote patient safety (Mohammed et al., 2021). This organization does not have a culture that supports patient safety.

Evidence-based programs implemented by healthcare organizations should be sustainable and effective to ensure effective compliance with HIPAA regulations to protect the privacy of patient information. Implementing staff training and conducting safety competence assessments for healthcare professionals effectively ensures they comprehend organizational policies and procedures. Healthcare professionals knowledgeable of corporate policies and procedures have the confidence to evaluate issues and provide creative solutions by correctly guaranteeing the privacy of patient information (Rothenberg, 2017).

The second strategy is promoting Accountability among healthcare professionals. This will allow them to evaluate situations that compromise patient safety proactively. Accountability enforces a safety culture since all healthcare employees must abide by it (Rothenberg, 2017). Accountability also establishes a culture of transparency in reporting errors and allowing learning opportunities to implement solutions to promote patient safety (Rothenberg, 2017).

IHI Triple Aim

The IHI developed the Triple Aim framework to optimize the performance of healthcare systems. The three aims of this framework are to enhance patient experience and satisfaction, improve population health, and reduce healthcare costs (Institute of Healthcare Improvement, 2022). The United States healthcare system is the most expensive globally (IHI, 2022). In many healthcare organizations, no one can be accountable for all three frameworks of the Triple Aim. However, it is essential to address all three frameworks simultaneously. The Triple Aim focuses on improving the healthcare system by advocating for a systematic approach to implementing change. The change process involves identifying target populations, defining strategy aims and measures, developing a portfolio, and rapid testing (IHI, 2022). For the Triple Aim to succeed, it is critical to determine the social determinants of health, empower individuals, and broaden the role of primary healthcare services (IHI, 2022).

Many aspects of the healthcare system can be strengthened by implementing innovative care delivery models such as bundled payments, accountable care organizations, innovative reimbursement models, integration of information technology, and implementing patient-centered care (IHI, 2022). The IHI has components necessary to fulfill the Triple Aim framework. They include focusing on individuals and families, redesigning primary care delivery, managing population health, cost control, and system incorporation (IHI, 2022). The benefits of the Triple Aim include a healthy population, less complex care, coordinated care, decreased disease burden, reduced healthcare costs, and improved population well-being (IHI, 2022).

Violations of patient privacy negatively impact the provision of safe and quality healthcare. A mistake of allowing a breach of HIPAA regulations can result in adverse effects, resulting in patients losing trust in healthcare organizations due to poor patient satisfaction. The aspect of Triple Aim that applies to this situation is improving patient experience and satisfaction. Violations of HIPAA privacy regulations can reduce patient experience, resulting in poor patient satisfaction.

Sharing patient information without consent can result in investigations by the US Department of Health (, n.d.). Consequently, this can lead to fines and criminal penalties. Healthcare organizations should thus take HIPAA regulations seriously to ensure they do not face penalties and reduce patient experience and satisfaction.

Improving patient experience is a critical aspect of the Triple Aim. This can be achieved by protecting the privacy and safety of patient information. Subsequently, this can be a result of educating and training healthcare organizations. It is crucial to educate and train healthcare professionals on HIPAA regulations. This training should focus on HIPAA’s regulatory background and objective and organization policies implemented to ensure HIPAA regulations are adhered to (Edemekong et al., 2021). Improved patient experience can be achieved through administrative safeguards. In addition, the Triple Aim framework requires the optimization of healthcare systems. This can be achieved by adopting written privacy procedures and employing a privacy security officer to develop and implement the policies (Edemekong et al., 2021). Furthermore, the set design should identify healthcare professionals authorized to access protected health information (Edemekong et al., 2021). Healthcare organizations should conduct regular training and risk management audits to identify system gaps (Edemekong et al., 2021).

Evidence-Based Leadership and Collaboration Strategies

The primary objective of a quality improvement team is planning, designing, studying, and acting on opportunities to determine areas that require improvement to promote patient safety and quality. The quality improvement team reviews and analyzes healthcare information to improve service delivery and healthcare outcomes (Agency for Healthcare Research and Quality (AHRQ), n.d.). To be effective, the team should be multidisciplinary and include healthcare leaders from different disciplines. Patients should also be included in the collaboration process. The leadership and collaboration team should regularly meet to review performance data, identify critical efforts that require improvement, and implement and monitor quality improvement initiatives to reduce patient safety issues (AHRQ, n.d.). The leadership and collaboration team should have a champion committed to the improvement process. The team champion should build capacity by gathering data and engaging the perspectives of different stakeholders (AHRQ, n.d.). The winner’s role is to ensure the multidisciplinary leadership team functions effectively. The key departments involved in the corrective action are the nursing, medical, risk management, and information technology departments.

The nursing department has been selected since they interact with most patients. Hence, training nurses is essential to ensure they understand organizational procedures regarding the privacy and confidentiality of patient information. The medical department has been included since physicians are involved in treating patients. They also have access to patients’ medical records. The risk management department will be tasked with developing a risk management strategy in case any breaches in the privacy of PHI occur. The information technology department has been comprised since technology is crucial in healthcare. They will be tasked with educating healthcare professionals on safely and effectively using technology to protect healthcare information privacy. They will also implement technological safeguards to ensure no breaches occur in electronic healthcare records.

The clinical expert included in the team is the senior nurse informaticist. Nurse informaticists offer information on new workflows, guide the implementation of new technology, and assess data quality to ensure patient safety (Kassam et al., 2017). The nurse informaticist will be in charge of guiding the implementation of new technology to protect the security of patient information. The senior leader included in this corrective action is the chief executive officer of the healthcare organization. He will be in charge of liaising between the board and the implementation team. The CEO will also be responsible for implementing the budget needed for the corrective action.

It is essential to involve all departments in implementing corrective actions since different departments will have different perspectives on the implementation plan. It is expected that there will be differences in opinion. Failure to include all departments in the plan will hinder implementing the corrective action since the implementation team will not solicit feedback and get the support needed to achieve the process. It will also result in reduced buy-in of the departments excluded.

The best way to involve other departments in addressing the issue is by conducting surveys and interviews to gain their perspective on patient information privacy. This will promote shared decision-making in the development of corrective action. The leaders that will help address this issue include the risk manager, chief quality officer, nurse manager, patient access manager, and a patient representative. These individuals will comprise the patient safety committee responsible for implementing the corrective action.

The chief quality officer will guide the quality improvement process and ensure that the patient safety committee adheres to the HIPAA regulations on protecting the safety of PHI. The risk manager will help ensure the implementation of risk management strategies to identify potential vulnerabilities that may lead to a breach in HIPAA violations. In addition, the patient safety officer will develop a policy that will protect patient medical information. Furthermore, the patient will be valuable to the quality improvement process. They will provide feedback and ensure that the corrective action is patient-centered and respects patients’ values, preferences, and needs. A patient representative will offer a different perspective to ensure a culturally competent disciplinary action. The strategy I will use to enlist the leaders’ help to develop a four-point proposal addressing patient safety, HIPAA regulations, risk of breaches of HIPAA regulations, and strategies to implement the corrective action.

Leadership Action Plan

The first strategy that will be used to solve the incident is to educate the surgeons involved and other healthcare professionals on the importance of adhering to HIPAA regulations. This training should focus on HIPAA’s regulatory background and objective and organization policies implemented to ensure HIPAA regulations are adhered to (Edemekong et al., 2021). The second strategy is developing privacy policies and procedures to guide the practices that ensure patient safety. These policies should be formed by a privacy officer who will also ensure they are correctly implemented (Edemekong et al., 2021). The third evidence-based strategy is the set of procedures and policies to respond to patient privacy breaches (Edemekong et al., 2021). This will include notification procedures for HIPAA violations.

The first evidence-based strategy to address the issue at the organizational level is to conduct regular internal audits. Regular audits will allow the healthcare organization to review its operations and procedures to identify violations and vulnerabilities in the system (Edemekong et al., 2021). The second strategy is to implement risk management strategies. Risk management will involve identifying, evaluating, and mitigating risks associated with HIPAA violations (Edemekong et al., 2021). The third evidence-based strategy is developing procedures for employees authorized to access protected health information (Edemekong et al., 2021)

Opportunities to Enlist Governing Board

The organization’s governing board is essential in reviewing policies and approving policies and budgets for the correction action plan. The decision that the governing board makes determines the direction of the organization. Any decision this board makes thus affects the safety and quality of patient care. The best way to enlist the organization is to prepare a PowerPoint presentation detailing the need for a corrective action plan. This PowerPoint presentation will define the patient safety issues identified in the organization, the effect of the patient safety issue on patients and the healthcare organization, the importance of preventing the healthcare safety issue, and the dangers associated with not solving the problem. The proposal will also include the budget, teams to help implement the correction plan, and the responsibility of each team member. Evidence-based literature will be used to support the need for a corrective action plan.


Healthcare organizations should be committed to promoting a safe culture. This will ensure the delivery and safety of quality healthcare. All patients deserve to receive care in a safe clinical environment. The leadership action plan is essential since it ensures that the privacy and confidentiality of patient information are maintained and protects the organization from financial losses and civil and criminal penalties. The leadership action plan will provide a framework that healthcare organization employees will apply to protect the privacy of patient information. This action plan aligns with the Triple Framework of redesigning healthcare delivery to improve the patient experience. Mistakes and errors occur in healthcare organizations. However, healthcare organizations should learn from these errors and implement strategies to prevent their occurrence.


Agency for Healthcare Research and Quality (AHRQ). (n.d.). Module 14. Creating quality improvement teams and QI plans. Agency for Healthcare Research and Quality.

Edemekong, P. F., Annamaraju, P., & Haydel, M. J. (2021, February 4). Health Insurance Portability and Accountability Act – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. (n.d.). Summary of the HIPAA Privacy Rule

Institute of Healthcare Improvement. (2022). The IHI Triple Aim | IHI – Institute for healthcare improvement. Improving Health and Health Care Worldwide | IHI – Institute for Healthcare Improvement.

Kassam, I., Nagle, L., & Strudwick, G. (2017). Informatics competencies for nurse leaders: Protocol for a scoping review. BMJ Open7(12), e018855.

Mohammed, F., Taddele, M., & Gualu, T. (2021). Patient safety culture and associated factors among health care professionals at public hospitals in Dessie town, northeast Ethiopia, 2019. PLOS ONE16(2), e0245966.

Rothenberg, I. Z. (2017). Achieving a culture of safety with competency and commitment. Medical Laboratory Observer.


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Write an analysis and leadership action plan for the issue you selected that will enable you to address the issue on an organization-wide basis. Please include the following headings and answer all the questions underneath each title.

Collaborating on Quality-Issue Analysis and Leadership Action Plan

Collaborating on Quality-Issue Analysis and Leadership Action Plan

Introduction: Issue Summary
Address the following:
• How would you summarize the key elements of the incident that occurred?
• What is your goal in addressing the issue?
• Which 2-3 essential items will be your focus? For example, you may elect to focus on nursing staffing levels if being short-staffed in nursing is contributing to compromises to patient safety.
Address the following:
• What is culture?
• Why is culture a critical organizational priority for safety and quality?
• What do you know about the existing organizational culture based on your knowledge about the selected issue?
What are some of the evidence-based strategies you are considering that could be employed to cultivate a culture of safety?
IHI Triple Aim
Address the following:
• What is the IHI Triple AIM?
• How does the IHI Triple Aim apply to this specific incident?
• What IHI Triple Aim elements will you incorporate into your organizational improvement strategy?

Leadership and Collaboration
Address the following:
• Which key departments must be directly involved with the corrective action process?
• What is your rationale for selecting these departments? For example, you may want to involve nursing because many errors involve nurses, and obtaining their buy-in is critical to achieving the organizational priority.
• Which specific senior leader, front-line staff member, and clinical expert will you include in your action plan and hold accountable for implementation?
• What are the implications of not engaging with all departments toward making safety and quality top of mind?
• How might you involve other departments in addressing the specific and cultural issues?
• Which specific leaders within the organization could assist you in addressing this issue and in making patient safety and quality top of mind
throughout the organization? Examples for you to consider include the chief nursing officer, medical officer, patient safety officer, et
• What role do you expect these leaders to play in addressing the specific issue and the issue of culture?
• What best practices would you employ to enlist their aid in the improvement effort?
Leadership Action Plan
Address the following:
• What are three evidence-based actions you recommend that would help to solve the incident that occurred?
• What are three evidence-based best practices you recommend to address the issue on an organizational level?
Opportunities to Enlist Governing Board
Address the following:
• What role does the organization’s governing board have in quality and safety?
• How could you enlist the governing board’s aid in your improvement initiative?
What additional information could you provide them to increase their involvement in the organization’s safety and quality improvement efforts?

How will you summarize your analysis of the incident and your leadership action plan?
Remember that health care is an evidence-based field. You must cite at least two credible references to support your analysis and action-planning process.
In addition, your assignment needs to conform to current APA style and format guidelines. Ensure it is clear, persuasive, concise, organized, and without grammar, punctuation, and spelling errors. Do provide citations and title and reference pages in the current APA format. Other leaders in your organization will want to know what sources you relied on to prepare your analysis and action plan.
Please review the Collaborating on Quality: Issue Analysis and Leadership Action Plan Scoring Guide to ensure you understand the grading requirements for this assignment.

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