HCS 235 UoPX Organizational Performance Management Paper

Assignment Content

1. As a team, discuss and compare your chosen organizations selected in this week’s individual assignment, Organizational Management Performance Table, to complete this presentation.As a team, create an 8- to 10-slide Microsoft® PowerPoint® presentation (not counting the title or reference slides) with detailed speaker notes of at least 100 words per slide in which you compare and contrast the organizations selected by each learning team member.Your presentation should:Describe ways each organization will communicate with leadership to ensure alignment of organizational goals and gain buy-in from staff to achieve compliance with the standards and requirements issued by regulatory and accreditation bodies.Include each team member’s completed table as an appendix to your presentation.Cite at least 3 peer-reviewed, scholarly, or similar references and your textbook to support your assignment.

HCS/456 v5
Organizational Performance Management
Table
Choose a health care organization and research it to complete this table, and then share it with your
learning team as you collaborate to complete your presentation. Include your tables as appendices in
your presentation.
1. Provide a name of or link to a specific health care organization. Summarize the key products or
services provided by the organization and identify the primary customers it serves.
Organization Overview
Cleveland Clinic
Link: https://my.clevelandclinic.org/
Key services provided: Some of the key services provided and diseases managed by the Cleveland
clinic include primary care services, cancer management, dermatology care, plastic surgery,
gastrointestinal diseases management, neurological diseases care, endocrinology and metabolism,
urology, ophthalmology, pediatrics, health and wellness promotion, and respiratory disease treatment.
Primary Customers: The primary customers served at the facility includes patients from different age
groups and their family members, physicians and other healthcare staff, investors, researchers, and
medical equipment suppliers.
2. Outline the overall content of the major regulations, accreditation requirements, and other
standards that affect the organization. Provide the title, section, parts, or subparts, or the
numbering system, etc. of the specific regulations or accreditation requirements. Responses
should be at least 100 words.
For example: Use of electronic signatures in electronic medical records is equivalent to
handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200
Electronic Signature
Organization Regulations, Accreditation, and Standards
1. Major regulations:
A. Regulation bodies include:
a) Federal regulation bodies like U.S. Food and Drug Administration (FDA), Centers for Medicare
and Medicaid Services (CMS), Department of Health and Human Services, and HealthIT.
b) State regulation bodies include Ohio Department of Health and the Ohio Department of
Insurance.
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c) Industry related regulation bodies include: American Medical Association
B. Regulations provided by the bodies
Federal: Regulations associated with the Affordable Care Act (ACA), HIPPA for patient and health
information privacy protection, and adherence to health insurance reforms
State: Regulations found at http://codes.ohio.gov/oac/ (Ohio department of insurance and Ohio
administrative code)
2. Accreditation Requirements
a. The Joint Commission
b. Ohio Department of Health (ODH)
c. Accreditation Council for Graduate Medical Education (ACGME)
d. Centers for Medicare and Medicaid Services (CMS)
e. National Committee for Quality Assurance (NCQA)
Other accreditation bodies (https://my.clevelandclinic.org/departments/patientexperience/depts/quality-patient-safety/accreditation):
i American Association of Blood Banks (AABB)
ii American Association of Tissue Banks (AATB)
iii American Board for Certification Orthotics and Prosthetics (ABC)
iii American Society for Bariatric Surgery (ASBS)
iv American Standards of Histocompatibility & Immunogenetics (ASHI)
v College of American Pathologists (CAP)
Other standards that affect the organization
Departments, accreditation, clinical risk management, environmental safety, quality control, quality
data registries, quality improvement, environmental safety, bioethics, and infection control.
3. Highlight the effect the organization’s regulations, accreditation requirements, and other
standards have on risk management functions and activities. Responses should be at least 100
words.
Effects on Risk Management
Regulations use by the organization: HIPPA, Patient Rights, Informed Consent, and Pension
Protection Act of 2006
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Accreditation and Licensure: The Joint Commission, Ohio Department of Health, Centers for Medicaid
and Medicare, American Association of Blood Banks, American Association of Tissue Banks, College
of American Pathologists, American Standards of Histocompatibility & Immunogenetics, American
Board for Certification Orthotics and Prosthetics, the Ohio Department of Mental Health, and the
American Society for Bariatric Surgery.
Risk management functions and activities: Clinical risk management, Infection control, proper handling
of patients and management of their conditions and reduction in risks of complications or errors, quality
improvement of activities conducted in the facility, ensuring that all the staff have the required training
and education qualifications, and health insurance issues management.
4. Identify specific components of performance-management systems—policies and procedures,
self-audits, benchmarking, complaint management, corrective or preventive action, education and
training, communication, and other mechanisms—to be used by the organization. Responses
should be at least 100 words.
Organizational Performance Management Systems
The performance-management systems components involves the use of strategic performance
standards and measures, progress reports, and quality improvement efforts.
Performance standards: Some of the standards include identifying relevant standards to different
departments in the organization, selecting proper indicators, setting goals and objectives, and
communicating the information and expectations.
Measures of performance: Performance measures include refining of indicators, developing
databases, and collecting data.
Process: The processes included entails use of clinical data for decision-making, using strategic
approaches to address clinical issues, and developing of a learning environment
Quality improvement efforts: These measures include use of data for clinical data in decision-making,
creating a positive organization culture that supports learning, and using feedback mechanism
Policy and procedures: The policies and procedures used by the organization are based on state and
federal guidelines and recommendations.
Complaint management: Complaints are brought forward through the human resource department or
the department affected by the issue related to the complaint
Communication: Communication is done through a top-down approach and departmental approaches,
which aims at addressing issues affecting the organization
5. Provide several links to relevant sources that will be useful as your learning team completes the
paper.
Additional Links
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Links:
Health IT Legislation. (2020, May 19). Retrieved from HealthIT.gov:
https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislation
Department of Health and Human Services. (2020, June12). Retrieved from HHS.gov: www.hhs.gov
US Department of Labor – Occupational Safety & Health Administration. (2017, January 10). Retrieved
from OSHA.gov: https://osha.gov/SLTC/healthcarefacilities/standards.html
Cleveland Clinic. (2020, June 10). Retrieved from Cleveland Clinic.org: http://my.clevelandclinic.org/
Copyright 2020 by University of Phoenix. All rights reserved.
HCS/456 v5
Organizational Management Performance Table
Brandee Spector
Risk Management/HCS235
University of Phoenix
June 22, 2020
Qiana Amos
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Organizational Performance Management Table
HCS/456 v5
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Organizational Performance Management
Table
Choose a health care organization and research it to complete this table, and then share it with your
learning team as you collaborate to complete your presentation. Include your tables as appendices in
your presentation.
1. Provide a name of or link to a specific health care organization. Summarize the key products or
services provided by the organization and identify the primary customers it serves.
Organization Overview
The Mayo Clinic is a non-profit organization that provides quality health care services to patients. The
organization has three locations that offer a wide variety of health care services such as cancer care,
gastroenterology, surgery, pediatrics, and gynecology. The organization offers health care services for
pediatric, adult, and geriatric patients.
Link: https://www.mayoclinic.org/
2. Outline the overall content of the major regulations, accreditation requirements, and other
standards that affect the organization. Provide the title, section, parts, or subparts, or the
numbering system, etc. of the specific regulations or accreditation requirements. Responses
should be at least 100 words.
For example: Use of electronic signatures in electronic medical records is equivalent to
handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200
Electronic Signature
Organization Regulations, Accreditation, and Standards
The Mayo Clinic is affected by many regulations, standards, and accreditation requirements for patient
safety and the delivery of high -quality care. The Mayo clinic received Magnet Recognition for their
nursing program from the American Nursing credentialing center. The Mayo clinic adheres to the
federal regulatory- Agency for Healthcare Research and Quality Patient Safety Indicators(PSI) which
consist of 26 indicators to assess the facility’s compliance in patient safety. The Mayo clinic follows the
HIPAA Privacy Rule, the EMTALA Act regarding the anti-dumping in patient emergency situations and
the HITECH Act regarding the meaningful use of health information technology. The Mayo Clinic is
accredited by the Joint Commission.
Rules and Regulations:
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Agency for Healthcare Research and Quality 26 Patient Safety Indictors (PSI)
Health Insurance Portability and Accountability Act (HIPAA), Privacy Rule (2000), Pub. L. No. 104-191
(42 U.S.C. § 1320d-2 note) 45 C.F.R. Part 160 and Subparts A and E of Part 164
Meaningful use of Health Information Technology, Health Information Technology for Economic and
Clinical Health Act(2009), Pub. L. No. 111-5, 123 Stat 115.
Emergency Medical Treatment and Labor Act (1986), 42 CFR Parts 413, 482, and 489 [CMS-1063-F]
RIN 0938-AM34
Health care Reform Patient Protection and Affordable Care Act 2010, Public Law 111-148, HR 3590
3. Highlight the effect the organization’s regulations, accreditation requirements, and other
standards have on risk management functions and activities. Responses should be at least 100
words.
Effects on Risk Management
The Mayo Clinic’s success is dependent on the capability to adhere to the federal regulations and
accreditation standards set forth by agencies. Patients have a high level of expectations regarding
their care and expect facilities such as the Mayo Clinic to be in compliance. Stakeholders Risk
management teams must understand and monitor the regulatory and accreditation requirements in
addition to, performing risk analysis assessments and demonstrate willingness throughout all aspects
of the facility to make improvements. As these regulations and requirements drive the policies and
procedures of risk management. Utilization of the Enterprise Risk Management core domains and
drivers will greatly assist in formulating structured processes throughout all levels of the organization to
further enhance patient safety and outcomes.
4. Identify specific components of performance-management systems—policies and procedures,
self-audits, benchmarking, complaint management, corrective or preventive action, education and
training, communication, and other mechanisms—to be used by the organization. Responses
should be at least 100 words.
Organizational Performance Management Systems
There are important components of performance management systems that can be utilized by
organizations such as the Mayo Clinic in order to identify potential risks, make necessary
improvements, and achieve compliancy. For instance, conducting patient satisfaction and employee
surveys to measure results for areas of focus and improvements. Another component is the use of
information technology applications that can electronically report any “near miss” or incidents within the
facility. If a patient safety event occurs, conducting an interview to determine the risk and the correct
course of preventive action. Another aspect is continual education and training for employees
regarding compliance and risks. The Mayo Clinic organization has an Audit and Compliance
Committee that conducts self-audits in consultation with the Chair of Risk management to investigate
any improprieties of the organization.
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5. Provide several links to relevant sources that will be useful as your learning team completes the
paper.
Additional Links
https://www.nursingworld.org/organizational-programs/magnet/ – Magnet recognition program
https://www.ahrq.gov/cpi/corecompetencies/index.html- Agency for Healthcare Research and Quality
https://www.qualityindicators.ahrq.gov/modules/psi_resources.aspx AHRQ quality indicators https://www.hhs.gov/regulations/index.html – Regulations for health care organizations
https://www.hhs.gov/regulations/additional-regulations/index.html
https://www.qualitycheck.org/quality-report/?keyword=mayo%20clinic&bsnid=369946 -Joint
Commission Accreditation.
https://www.healthit.gov/sites/default/files/privacy-security/federal-privacy-laws-table2-26-10-final.pdf
https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/Downloads/CMS-1063-F.pdf
https://www.mayoclinic.org/documents/audit-and-compliance-committee-charter/doc-20462821 -Audit
and Compliance Officer committee of Mayo Clinic
Copyright 2020 by University of Phoenix. All rights reserved.
HCS/456 v5
Organizational Performance Management
Table
Choose a health care organization and research it to complete this table, and then share it with your
learning team as you collaborate to complete your presentation. Include your tables as appendices in
your presentation.
1. Provide a name of or link to a specific health care organization. Summarize the key products or
services provided by the organization and identify the primary customers it serves.
Organization Overview
Houston Methodist Orthopedics & Sports Medicine in Nassau Bay. The key services is rehabilitation
as far as physical therapy, rehabilitation therapy and speech therapy. Primary customers are those
that have musculoskeletal system issues and those that have impairments preventing them from
moving efficiently.
2. Outline the overall content of the major regulations, accreditation requirements, and other
standards that affect the organization. Provide the title, section, parts, or subparts, or the
numbering system, etc. of the specific regulations or accreditation requirements. Responses
should be at least 100 words.
For example: Use of electronic signatures in electronic medical records is equivalent to
handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200
Electronic Signature
Organization Regulations, Accreditation, and Standards
Some of the regulations that must be adhered to are the Antitrust laws (the Sherman Act, the Federal
trade Commission Act (FTC) and the Clayton Act, the Health Insurance Portability and Accountability
Act (HIPAA) Privacy rule located at 45 CFR Part 160 and Subparts A and E Part 164, the patient
safety and Quality Improvement Act of 2005 Statute and Rule subpart C pursuant to section 922,
HIPAA’s security rule found at 45 CFR 160, 162, and 164, HIPAA’s privacy and Security Framework,
HIPAA’s personal health records and the submission notice of a breach in 45 CFR Part 164.408.
There are also standard within their own facility in relation to accuracy of records, charts and other
documents, retention and disposal of records, charts and other documents, information security and
confidentiality, computer passwords, medical and billing records and personnel records.
3. Highlight the effect the organization’s regulations, accreditation requirements, and other
standards have on risk management functions and activities. Responses should be at least 100
words.
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Organizational Performance Management Table
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Effects on Risk Management
The regulations and standards mentioned in section 2 play a major role on the effects of risk
management. These regulations and standards allow the organization to have things in place that
must be adhered to in order to ensure the safety and security of patients while performing tasks with
the patients, but also the information that they input electronically related to the diagnosis and progress
of the patient. It helps to safeguard their personal information. Another thing that the regulations and
standards does is that it sets the tone for the culture of the organization which embeds risk
management in every step of the process that they do from discussing the diagnosis of the patient to
their billing information , etcetera.
4. Identify specific components of performance-management systems—policies and procedures,
self-audits, benchmarking, complaint management, corrective or preventive action, education and
training, communication, and other mechanisms—to be used by the organization. Responses
should be at least 100 words.
Organizational Performance Management Systems
Lets look at promotions and transfers. In order for an employee to be promoted they must meet the
minimum experience, background and education requirements, have a minimum of six months of
active employment in current role, have n formal counseling record for misconduct in the last six
month, complete a formal online application notify current manager prior to attending a scheduled
interview with hiring manager and immediately notify their current manager upon acceptance of the
internal transfer offer. They are given the opportunity of reporting questionable practices which can be
kept anonymous. There is a hotline number and email provided which helps to keep performance
management systems intact. There are values that assist with performance which are integrity,
compassion, accountability, respect and excellence (ICARE).
5. Provide several links to relevant sources that will be useful as your learning team completes the
paper.
Additional Links
https://www.houstonmethodist.org/-/media/pdf/hr/Employee_Handbook
https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/HIPAAACA/StatutesandRegulations?gclid=EAIaIQobChMIvLqr96L6gIVycDACh0IZwYdEBYYASAAEgLQOvD_BwE
https://www.hhs.gov/hipaa/for-professionals/breach-notification/breach-reporting/index.html
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