[solved]-Risk Management Program Analysis
Question
Compose a 1,250-1,500 word summary brief that expands upon the elements you addressed in the Risk Management Program Analysis Part One assignment. In addition, analyze the following:
Explain the Joint Commission’s role in the evaluation of an organization’s quality management processes.
Describe the roles that different levels of administrative personnel play in establishing or sustaining operational policies that are focused on employer-employee organizational risk management policies.
Explain the relationship of risk management programs and compliance with ethical standards.
Sample Response
The Joint Commission plays a critical role in the evaluation of risk management process in healthcare organizations. Essentially, the formation of the Joint Commissions on Accreditation of Healthcare Organization originated from concerns about the quality of healthcare services delivered by United States’ healthcare organizations and the need to address outcome measures against the standards of care. The mission of the Joint Commission is to promote continuous improvement of the safety and quality of healthcare services delivered to the patients by accrediting healthcare and other associated services, which enhance improvement of performance in healthcare institutions. The three main roles of the joint commission include evaluation of the risk management providing performance improvement support and facilitator of quality improvement in health care system (The Joint Commission, 2018).
Currently, the Joint Commission accredits over 25,000 hospitals, ambulatory care, home care, long-term care facilities, behavioral healthcare providers, medical laboratories and healthcare networks (The Joint Commission, 2018). A survey in the United States healthcare organizations indicates that over 96% of hospitals beds are located in the accredited healthcare facilities (The Joint Commission, 2018). Accreditation is one of the main roles that Joint Commission applies in evaluating the quality of healthcare services offered in hospitals. The accreditation model was developed by the American College of Surgeons, which later became the Joint Commission in 1951 (Ali, 2016).
Initially, the accreditation of healthcare institutions in the country was undertaken independently by the Joint Commission without government’s involvement. However, changes policies in the healthcare system including healthcare reform shave increased government involvement in the accreditation process. For instance, enacting legislation on Medicare program for older American citizens has highlighted the importance of accreditation of healthcare facilities. In this case, healthcare institutions accredited by the Joint Commission are considered eligible for enrollment in the Medicare program (The Joint Commission, 2018). Therefore although accreditation is managed by healthcare professionals, the government is an important user of the process.
Since the introduction of the accreditation, the main objective has been to enable healthcare institutions improve the quality of care delivered to the patients by developing standards, evaluating the performance against the set standards and accreditation of clinical decision making. The objectives of the Joint Commission’s accreditation process in risk management are to promote continuous improvement of the set quality standards in healthcare facilities, promoting organizational ownership and enabling its adoption as a quality improvement tool (The Joint Commission, 2018).
Through accreditation process, the Joint Commission evaluates the quality of management process in various ways. They includes reviewing the performance periodically, initiating priority focused procedures, survey development and application of tracer methodologies. The quality management process focus on various areas of healthcare delivery such as prevention and control of infections, management of medications, enhancing preparedness for emergencies and effective use of data to enhance continuous quality improvement.
To ensure the healthcare organizations enforce and undertake the required healthcare safety standards, the Joint Commission undertakes various actions which include conducting unannounced visitations and surveys, intensifying healthcare organization’s compliance to the life safety code and undertaking random validation surveys in addition to periodic monitoring assessments using collected data on various quality management indicators. Another role of Joint commission in evaluating the quality management processes in healthcare organizations includes developing policies on sentinel events and how healthcare organizations should respond to them, collaborating with the government and other agencies involved in healthcare quality management in exploring effective approaches of reducing and preventing errors and other adverse events in healthcare settings (The Joint Commission, 2018).
To monitor and evaluate the quality of management process in healthcare organizations, the Joint Commission applies a process which involves ten critical steps. The steps include assigning responsibilities to the appropriate professionals, defining the scope of services, identifying critical elements of care and then development of key indicators. The other steps includes establishing standards or thresholds for evaluation, collection and organization of data, evaluation of the collected data and the eight step entails taking action to enhance patient care. The ninth step involves assessing the effects of the actions taken in the previous step and finally communication of critical information through the quality improvement plan (The Joint Commission, 2018).
In the risk management plan for new employees in the healthcare organization, various administrative personnel would be involved in establishing and sustaining operational policies focused on employer-employee management policies. They include unit manager, unit director and the employees in the various healthcare departments or units within the healthcare organizations. The role of unit manager is to approve the quality risk management plan of the organization involving the new employees and implementation of the plan as envisaged. The unit director undertakes various roles, which includes being accountable for the quality assurance procedures that offer adequate guarantee and confidence that the established areas of quality improvement are satisfied or met.
The second role is ascertaining that all employees within the organization are adequately prepared to undertake the various assigned roles. To achieve this, the unit director should ensure that all the new employees are adequately trained have requisite educational level, equipped with appropriate quality improvement tools and resources in addition to ensuring that the employees participate fully in the quality improvement process. The unit director is also accountable for undertaking the role of quality improvement director and coordinating the implementation of the quality improvement plan with other professionals within the healthcare organization.
Another role of the unit director is setting the priority areas for surveillance goals and setting up measurable indicators for the quality improvement program which are compatible with the available resources within the organization set up. Other roles of unit director includes evaluation of data related to the quality improvement plan, making recommendations on the actions required while assigning responsibilities to the new employees and other members of the staff in addition to evaluating the impacts of the various actions taken in the quality improvement plans . The employees’ role includes following the established and approved operational procedures and policies for the department, collecting and organizing data, participating in quality control by undertaking the specified activities for ensuring that the anticipated stands of quality are met. Additionally, employees are responsible for communicating appropriately by transmitting pertinent information regarding quality improvement within the organization and also participating in enacting and implementation of the particular actions identified after evaluation of the collected data.
In the risk management plan for new employees in the organization, it is important to acknowledge the critical role that the staff play in influencing the quality of healthcare services provided to the patients in the facility. Failure to provide appropriate support to new employees undermine their ability to provide competent and quality services as envisaged in the quality improvement plan. This could result to inadvertent errors and serious adverse events within the healthcare setting (Reason, 2010). Thus is it is the responsibility of the healthcare organization to ensure that the new employees are provided with adequate support in terms of training and education in addition to other appropriate resources (Guo, 2015). This could be achieved by providing an appropriate institutional framework to facilitate seamless integration of the new employee into the organizational setup as outlined in the quality improvement plan.
The risk management plan should be compliant with the ethical standards defining the operation of the healthcare organization. Some of the common ethical principles governing healthcare organizations include autonomy, beneficence and non-maleficence. This implies that the risk management programs should safeguard the best interest of the patients, employees and other stakeholders involved in the healthcare system. This could be achieved by promoting safety of all stakeholders involved by minimizing and preventing harm. The efficacy of risk management plan is based on its ability to comply with the established ethical standards.
References
Ali, Y. (2016). Steps in the Process of Risk Management in Healthcare. Journal of Epidemiology and Preventive Medicine 2(2): 118.
Guo, L.(2015). Implementation of a risk management plan in a hospital operating room. The International Journal of Nursing Sciences, 2: 348-354.
Reason, J. (2010). Human errors: models and management. British Medical Journal, 320:768–770.
The Joint Commission.(2018). What is accreditation? Accessed from https://www.jointcommission.org/accreditation/accreditation_main.aspx
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