BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan

Student Name

Capella University

BHA-FPX4004 Patient Safety and Quality Improvement in Health Care

Prof. Name:

Date

Issue Summary

The incident at Vila Health involving a breach of patient privacy, which violated the Health Insurance Portability and Accountability Act (HIPAA), highlights the critical need to safeguard patient information (Vila Health: Patient Safety, 2021). Enacted in 1996, HIPAA establishes standards to protect patient data (Health Insurance Portability and Accountability Act [HIPAA], 2022; HHS.gov, 2022). The HIPAA Privacy Rule regulates the use and disclosure of patients’ protected health information (PHI), emphasizing the importance of patient control over their data (HIPAA, 2022; Vila Health: Patient Safety, 2021).

To address HIPAA violations, it is essential to reeducate staff on HIPAA regulations, ensure private discussions regarding patient care, and restrict access to medical records to only those directly involved in patient care (HIPAA, 2022; Berwick et al., 2008). Implementing the Institute for Healthcare Improvement (IHI) Triple Aim framework, which focuses on enhancing patient experience, reducing costs, and improving population health, can elevate care quality and minimize errors (Institute for Healthcare Improvement [IHI], 2018).

Culture

A safety culture prioritizes the values, beliefs, and attitudes necessary to ensure patient safety (Pellegrini, 2017). Trust-based communication and learning from adverse events are vital for fostering a safety culture (Pellegrini, 2017). The Joint Commission recommends principles such as recognizing error reporting and eliminating intimidating behavior to cultivate a robust safety culture (Berry et al., 2020).

Collaboration

Collaboration between risk management and nursing departments is crucial for reducing errors and ensuring patient safety (Berry et al., 2020). By involving various departments and reinforcing patient identification protocols, hospitals can mitigate risks and enhance patient safety (Stevens, 2014).

Leadership Strategies

Effective leadership entails promptly addressing HIPAA breaches and implementing compliance programs (Denham, 2007). Training staff on HIPAA regulations and monitoring compliance are essential strategies for leadership (Denham, 2007). Gaining support from organizational leaders and utilizing educational resources can strengthen compliance efforts (Denham, 2007).

Opportunities to Enlist the Governing Board’s Aid

To promote a fair and just culture, organizations should engage the governing board in advocating for safety and reporting mechanisms (Berry et al., 2020). Leadership responsibilities include setting high standards, coaching employees, and ensuring a respectful work environment (Berry et al., 2020).

Leadership Action Plan

An effective action plan should include internal monitoring, staff training, and policy evaluation (Stevens, 2014). Collaboration between compliance officers and department leaders is essential for implementing corrective actions and ensuring ongoing compliance (Stevens, 2014).

Conclusion

Addressing HIPAA breaches necessitates a multifaceted approach that includes education, policy development, and leadership commitment (Stevens, 2014). Fostering a culture of safety and compliance is vital for protecting patient privacy and enhancing the quality of healthcare (Pellegrini, 2017).

References

Antes, A. L., English, T., Baldwin, K. A., & DuBois, J. M. (2018). The role of culture and acculturation in researchers’ perceptions of rules in science. Science and Engineering Ethics, 24(2), 361-391. https://doi.org/10.1007/s11948-017-9876-4

Berry, J. C., Davis, J. T., Bartman, T., Hafer, C. C., Lieb, L. M., Khan, N., & Brilli, R. J. (2020). Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system. Journal of Patient Safety, 16(2), 130-136. https://doi.org/10.1097/PTS.0000000000000251

Hofmann, A., & Scordis, N. A. (2018). Challenges in applying risk management concepts in practice: A perspective. Risk Management and Insurance Review, 21(2), 309-333. https://doi.org/10.1111/rmir.12106

Gillam, S., & Siriwardena, A. N. (2013). Frameworks for improvement: Clinical audit, the plan do-study-act cycle and significant event audit. Quality in Primary Care, 21(2), 123-130.

Millar, R. (2013). Framing quality improvement tools and techniques in healthcare. Journal of Health Organization and Management, 27(2), 209-224. https://doi.org/10.1108/14777261311321789