HLT308V GCU Joint Commission in Evaluating Quality Management Process Paper

HLT308V GCU Joint Commission in Evaluating Quality Management Process Paper

HLT308V GCU Joint Commission in Evaluating Quality Management Process Paper

This assignment builds on the Risk Management Program Analysis Part One assignment you completed in Topic 1 of this course.

Assume that the example risk management program you analyzed in Topic 1 was developed by and is now currently implemented by your health care employer/organization. Further assume that your supervisor has asked you to present a high-level summary brief of this new risk management program to a group of administrative personnel from a newly created community health organization in your state who has enlisted your organization’s assistance in developing their own risk management policies and procedures.


Compose a 1,250 word summary brief that expands upon the elements you addressed in the Risk Management Program Analysis Part One assignment. In addition, analyze the following:

  1. Explain the Joint Commission’s role in the evaluation of an organization’s quality management processes.
  2. 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.
  3. Explain the relationship of risk management programs and compliance with ethical standards.

You are required to support your analysis with a minimum of three peer-reviewed references.

Part one completed assignment is attached.

Risk Management Plan Sample Paper

Question One

Healthcare facilities have a role to play in the society which should make people have access to quality services. However, hospitals also face risks which challenge the way in which they assist patients in recovering as expected (McAlister, Stewart, Ferrua & McMurray, 2004). Some risks have more impacts while others have fewer results in hospitals. However, there is the need to implement risk management plans that will take care of the different types of risks in the hospitals. Below is a risk management plan addressing the dangers which arise from ineffective communication in a hospital:

Risk and consequences Probability Impact (1-5) Priority Mitigation Response
Wrong medication to patients 50 4 150 Enhancing communication between the doctors and the nurses
Delay in delivery of services to patients 35 2 70 Support by the management in communicating about the urgency of services in patients
Increased death rate during surgeries 10 3 100 Enhancing teamwork among the care providers in the hospital


The risk management plan addresses the issue of poor communication in a hospital and some of the impacts which it will have on patients and the management. The program identifies some of the risks and the consequences which affect patients as they receive medical attention. Ineffective communication makes it hard for doctors and nurses to participate well when providing medical care to the patients (Kasper et al. 2002). Patients are at the receiving end since they suffer from instances of wrong medication and delayed services. The hospital also is at risk of poor performance as teamwork may not work for the care providers. The example provides a clear picture of how one challenge might cause risks in healthcare facilities. The probability of the risks indicates the number of times when the risks might occur. The impact also identifies the extent to which it affects the patients. The priority, on the other hand, indicates the amount of attention that should be given to each of the risks.

Question Two

The implementation of the risk plan will require the administration to take some steps that will make the activity successful. The following steps will assist in identification of the best risk management plan in the healthcare facilities;

Risk identification

The administration should state the risk affecting operations through some failures taking place in the center. This will only take place where the hospital recognizes mistakes and failures arising from some of the working methods and styles applied by the care providers. Uncovering and understanding the risk will make it possible to describe its impact (Capomolla et al. 2002). On the other hand, it will make it easy to identify the impacts which it might have on the outcomes of various operations in the hospital.

Risk analysis

The step will include determining the likelihood of occurrence of the risk and the consequences which it might have on the operations of the healthcare (McAlister, Stewart, Ferrua & McMurray, 2004). The step will help the administration in understanding the nature of the risk and the way in which it will affect the journey to achieving goals and objectives of the healthcare facility. The information acquired during this stage should be put in the Project Risk Register.

Evaluation and ranking risk

The stage will involve ranking the risks based on the impact that each will have on organizational operations. The administration will have to identify the likelihood and the consequences of the risks (Kasper et al. 2002). The stage will also recognize some of the acceptable risks and those that need immediate attention.

Treating the risk

The step will involve all activities related to planning for ways in which mitigating the threat will take place. The set of plans that will assist in eliminating the risk will assist in dealing with the challenges which affect the hospital (Capomolla et al. 2002). The preventive strategies and the contingency plan will be developed at this stage.

Monitoring and reviewing the risk

The step will include taking the Project Risk Register and using it to track, monitor and evaluate the risks.

Question Three

Administration of safe health is a requirement in all hospitals. The agencies liable for the activity include;

The Department of Health and Human Services Office for Civil Rights- the body is responsible for enforcement of HIPAA. In this case, the body audits the healthcare providers as well as their business associates (McAlister, Stewart, Ferrua & McMurray, 2004). The body also handles fines for noncompliance with the regulations.

The Centers for Medicare and Medicaid Services, (CMS)- The body ensures that there is compliance of resources and regulators for meaningful use of the Medicare and Medicaid programs in their facilities (Kasper et al. 2002).

The Office of the National Coordinator for Health IT- The health care resources and regulators should comply with the requirements of the healthcare programs which should benefit all people in the society.

The Food and Drug Administration- The agency helps in managing the IT applied in the provision of healthcare services (McAlister, Stewart, Ferrua & McMurray, 2004). The FDA, therefore, evaluates the medical devices and classifies them according to the level of risks which they could expose their users.

Question Four

The selected risk management plan complies with the requirements American Society of Healthcare Risk Management standards. For instance, it contains the various matrices that define the components of the risk management plan. The priorities and the impacts as well as the probabilities meet the standards of ASHRM and ensure patient safety (Capomolla et al. 2002). Also, it calls for the cooperation of the various stakeholders so that they can work together to ensure that the facility provides a healthy working environment for all. The compliance with the standards also makes it clear that the hospital has its management determined to provide quality products and services to the patient.

Question Five

Using the above plan, I would make changes related to the probability of the occurrence of the different risks based on the extent to which they affect patients in the hospitals. I would raise the chances to show the seriousness of the risks and how they have a negative impact on patients (Kasper et al. 2002). This will ensure that the management becomes concerned and pays the right amount of attention to avoid them from happening. I would also add the number of mitigation methods to give a variety which will fit the various hospitals where one method does not work. Providing alternatives will thus leave no room for the occurrence of the risks.


Capomolla, S., Febo, O., Ceresa, M., Caporotondi, A., Guazzotti, G., La Rovere, M. T., … & Gnemmi, M. (2002). Cost/utility ratio in chronic heart failure: comparison between heart failure management program delivered by day-hospital and usual care. Journal of the American College of Cardiology40(7), 1259-1266. Retrieved from http://www.sciencedirect.com/science/article/pii/S073510970202140X

Kasper, E. K., Gerstenblith, G., Hefter, G., Van Anden, E., Brinker, J. A., Thiemann, D. R., … & Gottlieb, S. H. (2002). A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission. Journal of the American College of Cardiology39(3), 471-480. Retrieved from http://www.sciencedirect.com/science/article/pii/S0735109701017612

McAlister, F. A., Stewart, S., Ferrua, S., & McMurray, J. J. (2004). Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. Journal of the American College of Cardiology44(4), 810-819. Retrieved from http://www.sciencedirect.com/science/article/pii/S0735109704011234

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