RISK MANEGEMENT PROGRAM ANALYSIS

MIPPA
Cedars Sinai is aware that quality improvement is bound to some risks. In the
implementation of a new risk management plan, the organization put into consideration the
patient safety and quality in healthcare a priority. The organization has a team for evaluation
of risk and improving the cause of the risk to prevent further injury to the patients. Cedars
Sinai medical centre understands that extended hospital stays and complications are inherent
among the older adults, and that can be an avenue to loss of independence or morbidity.
According to Borenstein et al. (2016), the patient outcome can be improved with an
improvement in team-based interprofessional care in a general medical unit. The organization
strives, through the performance improvement department, to improve patient outcomes,
clinical quality, operational processes, and cost-effectiveness and reduce the factors that
would increase adverse events or outcomes to assure patient safety.
Medicare Improvement for Patients and Providers Act (MIPPA) is a multifaceted
legal piece that contains the vital provisions that change the Medicare program and federal
funding allocation directly. Cedars Sinai has the accreditation badge by the Inter-societal
Accreditation Commission (IAC) and the American College of Radiology (ACR). The ACR
and IAC evaluate the quality of imaging and patient safety in the hospital. The accreditation
seals ensure that there are enough personnel and equipment for the performance of study or
procedure at the highest quality level and care. These accreditation standards address the
quality of service, especially in the imaging of patients and the highest consideration of safety
for the patients during their stay. 
Administrative Roles 

RISK MANEGEMENT PROGRAM ANALYSIS
Healthcare standards and policies are essential in achieving compliance with
standards and providing better-quality care and safety to the patients. The achievement of
such milestones requires the cooperation and understanding between different administrative
levels and the employees. Different administrative personnel are responsible for the policy
development aimed at professional and facilities monitoring. Therefore, providing them with
information on the necessary steps in promoting safety and ensuring ethical standards is
important. Management of any organization works on objectives to reduce and monitor risks.
The process of achieving risk control requires effective management through adequate risk
management system implementation. 
The different administrative roles include modification in leadership style, effective
and efficient objective achievement, and a healthy internal control system (Vasile & Croitoru,
2012). The management of the organization would effectively have risk management by
devising and implementing the adequate internal control devices besides the consequences of
treatment measures to limit or eliminate the risk manifestation possibility. The
implementation of such ideas will be beneficial to the organization in mastering risks in
objectives achievement. Furthermore, learning the organization risks allows for the
prioritization of the risks. It will enable the organization to control the magnitude impact and
reducing of the mitigating costs of the unwanted effects. The organization will also achieve
the ethic and sustainability with the employees through a healthy internal control. The
internal control strengthening and enhancement help in the implementation and designing for
risk management.  
Risk Management and Compliance Program
Healthcare providers need to avoid flaws or ineffective care processes. Some of the
cases of healthcare-associated complications are a result of errors in care. Hospitals are more
focused currently in uncovering the failure resulting from system dysfunction and the

RISK MANEGEMENT PROGRAM ANALYSIS
associated human factors patient harm incidences and optimizing the patient outcomes. Most
of the acute care hospitals are striving to adopt a culture of safety. In the achievement of such
a culture, senior leadership plays an essential role in establishing a climate where a safety
system can be effective. Cedar Sinai has changed several the Magnet components using the
five magnet components of transformational leadership from magnet 14 forces with the
current magnet five involving structural empowerment, innovations, improved empirical
outcomes, new knowledge, and exemplary professional practice (Swanson & Tidwell, 2011).
The most characteristic feature of this structure is the achievement of enhanced patient
outcomes, evidenced by exceeding the national quality benchmark and the meeting. Magnet
organization’s maturity arises from an increased patient outcome emphasis in the re-
designation process as the staffs accept the required structure and processes of the magnet. 
The achievement of the compliance and reduction of risk management in Cedar Sinai
medical center comes from the mission of the organization. According to Swanson and
Tidwell (2011), the nursing mission will take into consideration the engagement of the staff,
patients, and diverse community members as they develop and provide excellent evidence
based clinical care that fits the organization for their culture and belief of those who receive
the care. Cedar Sinai also achieves compliance and risk management through shared
governance. The organization adopted recognition for the medical surgical staff nurses
having a critical role in facilitating patient safety and quality outcome. In adopting such
recognition, the organization takes into consideration the nurses with the best knowledge of
patient needs becomes the main part of the evaluation, monitoring, and creation of
improvement programs for performance.
Ethical and Legal Responsibilities
The nurses and healthcare professional providers hold the non-maleficence medical
ethics principle in ensuring patient safety and preventing damage or injury. Moreover, the

RISK MANEGEMENT PROGRAM ANALYSIS
safety of patients involves ethical and legal imperatives. Therefore, the solution and
management of legal and ethical challenges define patient safety. Medical errors within the
healthcare system are significant challenges in patient safety. Researches indicate that several
patients are exposed to healthcare-related injuries due to medical errors. Patient safety has
several guidelines and standards with less attention to the ethical and legal aspects (Kadivar
et al., 2017). The main goal for patient safety is improved patient outcomes, which is moral.
Moreover, the nurses and the professional health providers have the responsibility for an
improved patient outcome, which makes it legal. 
Cedar Sinai has an ethical standard of uncovering the root cause of risk and devising a
risk management system to prevent further cases. The professional healthcare providers must
uphold the medical ethics of non-maleficence in providing for a solution to the risk (Kadivar
et al., 2017). Disclosure of medical errors is also used in upholding risk management and the
administration of safe health. The organization has a policy for accuracy in the lab specimen
labeling. Where there is a mislabeled lab or blood bank specimen, a root cause analysis is
done immediately to identify the issue, and the solution is found. 
Quality Improvement
Cedar Sinai’s quality improvement has been an evolution accumulated from learning,
change, and customization of quality approaches, methods, and tools. The organization has
developed a continuous quality improvement process that is used as a quality indicator.
Organizations use learning a method of quality improvement. For Cedar Sinai, it is
developing the ability of the organization itself to learn. Organizations learn in different
depths, including changing a result into the new procedure and changing the mindset and
decision-making patterns. For Cedar Sinai, it is a double loop learning. According to Bate,
Mendel, and Robert (2007), learning involves exploration and exploitation. Exploration is
where there is a search for new technologies and knowledge and learning about new thinking

RISK MANEGEMENT PROGRAM ANALYSIS
and working. Exploitation consists in taking advantage of the resource of what is known in
the organization and its members in profiting from investment in intellectual and social
capital accrued through prior exploration. The organization learning, including the changes of
leadership and structure, shows the advancement in the right direction. Currently, the
organization has successfully used the AHRQ Quality Indicators (Qis) toolkit in
accomplishing the objectives of getting support across the institution, improving coding and
documentation and gathering real-time data, and addressing clinical care issues.

RISK MANEGEMENT PROGRAM ANALYSIS

Reference

Bate, P., Mendel, P., & Robert, G. (2007). Organizing for quality: the improvement journeys
of leading hospitals in Europe and the United States. CRC Press.
Borenstein, J. E., Aronow, H. U., Bolton, L. B., Dimalanta, M. I., Chan, E., Palmer, K., … &
Braunstein, G. D. (2016). Identification and team-based interprofessional
management of hospitalized vulnerable older adults. Nursing outlook, 64(2), 137-145.
 doi: 10.1016/j.outlook.2015.11.014.
Kadivar, M., Manookian, A., Asghari, F., Niknafs, N., Okazi, A., & Zarvani, A. (2017).
Ethical and legal aspects of patient’s safety: a clinical case report. Journal of medical
ethics and history of medicine, 10.
Swanson, J. W., & Tidwell, C. (2011). Improving the culture of patient safety through the
Magnet® journey. OJIN: The Online Journal of Issues in Nursing, 16(3).
Vasile, E., & Croitoru, I. (2012). Integrated risk management system–key factor of the
management system