Risk Management Program Analysis
The use of digitalized healthcare systems such as electronic health records (EHRs) has opened my organization to a new variety of risks that have the potential to affect the safety of the patients and the hospital’s operations. The increased use of aggregated patient information, the Internet of Medical Things, health information systems, and healthcare cloud services has made data privacy and confidentiality a serious issue of consideration within healthcare organizations (Hussain Seh et al., 2020). The facility is responsible for ensuring the safety of the EHRs and other digital systems to maintain the privacy and confidentiality of patient’s health and medical information.
My organization has implemented a cyber risk management plan to protect against all cyber-related risks and achieve accreditation. This paper presents the role of The Joint Commission (TJC) as a MIPAA-Approved accreditation body, the administrative roles in ensuring employee-focused organizational risk management strategies and operational policies, and how the organization’s risk management and compliance programs support ethical standards, patient consent, and patient rights and responsibilities. It will also discuss the legal and ethical responsibilities of health care professionals in upholding risk management policies and delivering safe patient care and how the health organization’s quality improvement processes support its journey toward excellence.
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Role of the Joint Commission (TJC) as a MIPPA-Approved Accreditation Body
The Joint Commission (TJC) is an MIPAA-approved, non-profit organization that accredits healthcare organizations and other healthcare organizations within the United States. TJC aims to collaborate closely with various stakeholders within the healthcare industry to ensure the continued improvement of healthcare interventions, systems, programs, medical devices, and other healthcare-related practices. TJC is mandated to utilize various actionable health care standards and Acts such as the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to establish a culture of safety and quality in health patient systems.
The Joint Commission utilizes the standards and guidelines set by the regulations and the law to critically evaluate healthcare organizations and the programs provided by the organization to ensure that the healthcare organizations provide healthcare services that are safe, of the highest quality, and provide value to the patients and other consumers (Ibrahim et al., 2022). The healthcare organizations evaluated by TJC must meet the set standards to gain accreditation. The TJC also provides feedback after evaluation that can assist organizations in improving their systems and services to meet the basic compliance requirements for accreditation. Therefore, The Joint Commission ensures that health care organization conduct all their activities and services in ways that meet the professional, legal, and ethical requirements and operate within the principles of safety and quality. Getting accredited by The Joint Commission can help the health facility achieve meaningful use and easily qualify for Medicaid and Medicare programs.
Administrative Roles in Employee-Focused Organizational Risk Management Strategies and Operational Policies
The different levels of administration and personnel play various significant roles in healthcare ethics and sustaining employee-focused organizational risk management strategies and operational policies. The administrative roles of the risk manager are critical to establishing and sustaining employee-focused risk management strategies within the organization. The risk managers establish the methodologies within the organization to detect, identify, and analyze risks to the cyber-physical infrastructure and their impact on the operations of the health care organization (Kure et al., 2018). The risk manager also develops cost-effective risk management strategies that are tailored to meet the identified risks. The risk manager also educates the employees on cyber security risks and threats and how to remain safe when interacting with interconnected systems.
Cybersecurity risk management and healthcare ethics are the responsibility of all members of the hospital staff. Successful management of cybersecurity challenges within an organization requires the adoption of collaborative strategies to support the management in dealing with related issues (Lezzi et al., 2018). All levels of administration have a role to play in ensuring that the employees adopt the best practices that guarantee cyber hygiene, maintenance of practice ethics, and an understanding of risk management strategies. This includes collaboration with other departmental managers, including operations managers and human resources managers. This collaboration ensures a facility-wide commitment by all employees to ensuring the system’s safety. The operations and HR managers also contribute to establishing a safe and ethical culture by educating the employees on the set standards of quality, safety, and ethical practices. Therefore, all levels of administration have a role in reducing risks related to the operations of the facility.
How the Organization’s Risk Management and Compliance Programs Support Ethical Standards, Patient Consent, and Patient Rights and Responsibilities
Compliance with healthcare security strategies and data security regulations by healthcare organizations shows the ability of the organization to harness information technology resources, the organization’s functional capacity, and managerial capabilities. Adopting risk management and compliance programs helps health organizations achieve accreditation. Accreditation is viewed as an internationally recognized tool that facilitates healthcare organizations to improve decision-making and the quality and safety of practices with notable patient outcomes (Al-Alawy et al., 2021).
My hospital’s risk management and compliance programs have been developed and implemented based on the guidelines of approved MIPAA accreditation organizations. The programs ensure that the employees observe the set practice standards when delivering care and interacting with the patients. The risk management and compliance programs also educate the employees on the various regulations and laws, such as HIPAA and HITECH, and their requirements for using EHRs and maintaining the privacy and confidentiality of aggregated patient data. The programs also educate the employees on the ethics of practice within hospital settings, the rights of the patients to health care services and their health information, and the need to include the patient in the development of their treatment plans. The risk management programs also educate the employees on the need to ensure patient privacy and confidentiality, the basics of the cyber-physical infrastructure, the related threats and risks, and how to ensure the safety of the cyber and physical systems.
Legal and Ethical Responsibilities of Health Care Professionals
The healthcare professionals in my organization understand that they have legal and ethical responsibilities to uphold risk management policies and administer safe health care to patients and the community. The health care professionals understand that every patient within the organization is legally their responsibility. They ensure that the patients are well taken care of and that their care delivery meets their health needs. Healthcare professionals strictly follow all professional standards and ethics of care to help achieve desirable patient health outcomes and experiences. They apply evidence-based practices (EBPs) to minimize the occurrence of risks related to the care provided. EBP has been associated with an increase in the quality of care and patient safety with a positive impact on reducing the cost of care (Tang & Hudson, 2019).
The health professionals also understand that in order to provide care services that meet the preferences of the patients, they need to obtain the patient’s consent to administer the selected treatment. Besides this, the various health practitioners also understand that they are responsible for maintaining the privacy and confidentiality of all patient interactions and the data collected. The practitioners understand they have a legal and ethical responsibility for patient records and that they must obtain a patient’s consent before sharing the information with other stakeholders related to the patient’s health, such as health insurance providers and other care providers outside of the facility. They also observe cyber hygiene to reduce the risks of cyberattacks on the health information and smart devices used in health care.
How Quality Improvement Processes in a Health Care Organization Support Its Journey to Excellence
Quality improvement processes and strategies, such as creating a clinical learning environment for staff, have been linked to improved quality, safety, equity, and value of care (Arora et al., 2021). The main goals of my organization are to provide healthcare services that meet the needs of the patient, lead to excellent community health outcomes, and meet the financial goals of its shareholders. Quality improvement processes have enabled the organization to design and improve the effectiveness and efficiency of its care programs, which have assisted in providing affordable and accessible healthcare services. The use of EHRs and smart devices in care provision has improved the timeliness, safety, and quality of care for patients with excellent health outcomes. The systems are also contributing to the healthcare organization’s capacity to achieve excellence in providing patient-centered healthcare services. The implementation of risk management strategies such as the cybersecurity risk management plan has improved stakeholder confidence in the facility’s capabilities, which has improved patient satisfaction and reduced the risk of losses from cyberattack incidents. In conclusion, the implemented quality improvement processes support the organization’s journey toward excellence.
References
Al-Alawy Immanuel Azaad Moonesar Hanan Ali Mubarak Obaid Ehab Ismail Al-Abed Bawadi Reem Gaafar Health Regulation Sector, K., Health Authority, D., Administration, H., Bin, M., & Al-Alawy, K. (2021). Hospital Accreditation: A Review of Evidence, Regulatory Compliance, and Healthcare Outcome Measures. Dubai Medical Journal, 4(3), 248–255. https://doi.org/10.1159/000516483
Arora, V. M., Rosenbluth, G., O’Rourke, A., Pappas, R. M., Hamilton, A. C., Vath, R. J., & Blanchard, A. K. (2021). Pursuing Excellence: Integrating Clinical Learning Environment Staff and Learners into the Pursuit of Quality, Safety, Equity, and Value. Journal of Graduate Medical Education, 13(2), 294. https://doi.org/10.4300/JGME-D-21-00197.1
Hussain Seh, A., Zarour, M., Alenezi, M., Krishna Sarkar, A., Agrawal, A., Kumar, R., Ahmad Khan, R., Manager, S., & Gandhi Post, S. (2020). Healthcare data breaches: insights and implications. Mdpi.Com. https://doi.org/10.3390/healthcare8020133
Ibrahim, S. A., Reynolds, K. A., Poon, E., & Alam, M. (2022). The evidence base for US Joint Commission hospital accreditation standards: cross-sectional study. BMJ, 377, e063064. https://doi.org/10.1136/BMJ-2020-063064
Kure, H. I., Islam, S., & Razzaque, M. A. (2018). An Integrated Cyber Security Risk Management Approach for a Cyber-Physical System. Applied Sciences 2018, Vol. 8, Page 898, 8(6), 898. https://doi.org/10.3390/APP8060898
Lezzi, M., Lazoi, M., & Corallo, A. (2018). Cybersecurity for Industry 4.0 in the current literature: A reference framework. Computers in Industry, 103, 97–110. https://doi.org/10.1016/J.COMPIND.2018.09.004a:link {text-decoration: none;}a:visited {text-decoration: none;
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Question 
see attachment 1 for assignment guidelines. (HLT week 3 final paper)
Risk Management Program Analysis
See attachment 2 for reference to be used for the assignment.( HLT 308 week 1 Final paper) Please note it’s a continuation of the same topic submitted.