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Collaborate on Quality: Issue Analysis & Leadership Action Plan
Amber Curtis
BHA-FXP4004: Patient Safety Qual Improv HC
Capella University
Professor Baker
October 2023
1
Collaborate on Quality: Issue Analysis & Leadership Action Plan
Recently, a potential HIPAA violation was reported to administrators at Vila Health. The
violation involved the pediatric unit clerk and a nurse from another unit. A pediatric patient, B.
Moore, was involved in a medication error involving the administration of insulin that she was
not ordered to receive. The mother of this patient was signing in and overheard the unit clerk
discussing her daughter, B. Moore, with a nurse from another unit. The unit clerk was overheard
stating the patient's last name, discussing the medication error; and when asked by the nurse
about the medication dosage error, the unit clerk stated she did not know but that she would look
it up in the patient's chart. This discussion is a severe and direct violation of HIPAA.
Culture
The term "culture" generally includes information, beliefs, the arts, laws, conventions,
and social conduct found in human communities. These factors impact the belief systems and
perceptions of the suppliers of healthcare information or healthcare on health, wellness, sickness,
and the provision of medical services (Cultural Respect, 2021). In order to reduce health
inequalities, cultural sensitivity is essential. It makes it easier to obtain high-quality medical
treatment that is sensitive to and responsive to the requirements of patients from all backgrounds
(Cultural Respect, 2021). By enabling caregivers to provide services that are respectful of and
attentive to the health beliefs, practices, and cultural and linguistic needs of various patients, the
idea of cultural respect positively impacts patient care delivery.
The Hospital Survey on Patient Safety Culture (HSOPSC) was developed by the Agency
for Healthcare Research and Quality (AHRQ) in 2004 to investigate patient safety culture in
hospitals and is currently used all over the world to evaluate and improve patient safety culture
(Hospital survey on patient safety culture, n.d.). Patient safety culture is believed to be a crucial
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organizational factor that affects patient safety and is connected to teamwork, communication
about mistakes, event reporting, and organizational learning (Skoogh et al., 2022). The
importance of the beliefs and conventions held by a group, such as a team, profession, or
organization, is highlighted by patient safety culture.
In the case provided above, the patient's confidentiality was compromised. HIPPA is an
integral part of patient safety and quality. HIPAA guidelines require healthcare institutions to
regulate who has access to health data, limiting who may view health information and who it can
be shared with. HIPAA helps to guarantee that any information supplied to healthcare providers
and health plans, as well as any information produced, transferred, or held by them, is subject to
stringent security standards (Alder, 2023). Patients are also given discretion over who has access
to and shares their information; which in the provided case above, there is no evidence that
permission was granted to the unit clerk to discuss the case or access the client's medical records.
IHI Triple Aim
The Institute for Healthcare Improvement developed the IHI Triple Aim framework,
which outlines a strategy for improving the performance of the healthcare system. The Triple
Aim consists of three dimensions:
improving the patient experience of care (including quality
and satisfaction), improving the health of populations, and reducing the per capita cost of health
care (The IHI Triple Aim, n.d.). The Triple Aim seeks to enhance patient and healthcare
organization safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
The triple aim at risk in this above situation is patient experience. The patient's mother
overheard staff discussing her daughter's care in the open, where anyone could have overheard.
This reflects negatively on the staff and the facility. The mother may not have been made aware
3
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of the medication error before then; it is not stated whether she had been notified or if she had
been called in to discuss the error.
In order to maintain Triple Aim in the facility, all employees will be required to attend a
mandatory refresher on HIPAA and confidentiality. The involved staff members also need to be
disciplined in some form under the HIPAA policy. Furthermore, an audit must be completed to
ensure this is not an ongoing situation of employees reviewing charts they do not have
permission to be in.
Leadership & Collaboration Strategies
An organization needs to have a strong and confident leadership in order to succeed.
Leaders provide direction, power, control, and management. They can motivate and influence
people. Leaders must create future visions and inspire people to help them realize and achieve
those visions (Barney & Pratt, 2023). The departments needed to be directly involved in the
corrective process are the risk management team, Chief Privacy Officer (CPO), Chief Nursing
Officers (CNO), and Health Information Managers (HIMs).
Hospital risk managers are responsible for preventing medical mistakes, protecting
patient privacy, and ensuring the safety of both patients and employees
(Risk management in
healthcare: What it is and why it matters. (n.d.). They collaborate closely with the hospital
leadership team, including clinical and nursing executives, to identify problem areas and
establish risk-reduction measures
(Risk management in healthcare: What it is and why it matters.
(n.d.). To be HIPAA compliant, covered organizations and business associates must undertake
risk analysis and risk management to demonstrate that they are taking preventative actions to
preserve the privacy and security of protected health information.
4
A chief privacy officer is in charge of developing, implementing, maintaining, and
adhering to privacy policies and procedures for the safe use and handling of protected health
information in accordance with federal and state HIPAA regulations. The CPO works with the
risk management team to determine privacy risk assessments and compliance monitoring. The
CPO ensures that all workers adhere to privacy policies and procedures and imposes
punishments in the event of a violation; therefore, it is essential for the CPO to be involved in the
correction plan.
The Chief Nursing Officer's primary responsibility is to provide leadership to the nursing
staff. This includes maintaining high standards for patient care through the creation of guidelines
and procedures (Christiansen, 2023). The CNO's responsibility is to ensure that the nursing staff
is aware of and understands patient confidentiality. The rights, welfare, and promotion of patients
are the responsibility of nurses. The clause further highlights the duty of nurses to maintain
patient confidentiality and privacy. Additionally, it calls on nurses to take the proper measures in
response to dubious practices and safeguard patients from injury (Christiansen, 2023).
Similar to the CNO, a health information manager (HIM) is responsible for the
appropriate conduct of unit clerks and other clerical staff. Information on symptoms, diagnoses,
medical histories, test findings, and treatments is organized, supervised, and safeguarded by
health information managers (HIM) (Health Information Managers, n.d.).
Leadership Action Plan
According to Shelton (n.d.), a leadership action plan is a crucial tool for making sure your
team is headed in the correct direction. It acts as a kind of "roadmap," directing your team on the
path to achievement. It enables you to specify objectives and tasks that must be performed within
a time limit that is feasible, as well as the strengths and shortcomings within your team. A
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leadership action plan may also assist you in tracking your advancement, thereby making it
smoother to adjust as needed or identify target completion (Shelton, n.d.).
Three evidence-based leadership strategies that would help to solve the incident that
occurred are education training, chart audits, and appropriate disciplinary actions if required. The
most effective way to prevent a HIPAA violation is to ensure that staff understands the HIPAA
policy and its consequences. All employees must understand their responsibilities and duties to
maintain compliance. HIPAA training aids in enhancing productivity, fostering trust, and
preventing costly data breaches and unintentional HIPAA violations.
Although lack of understanding may be the leading cause of a HIPAA violation, another
major one is accessing patients' charts out of curiosity. The auditing of patients' charts is to
determine who has accessed the chart and when. This determines whether the chart has been
accessed without purpose or reason. All employees must be aware that audit logs are used to
protect patient health information at work and can show when staff members have accessed PHI
without authorization (How Employees Can Help Prevent HIPAA Violations, n.d.).
HIPAA violation, knowingly or unknowingly, can be costly, and discipline in some way
may be warranted. The discipline can range from suspension or loss of job, demotion of position,
exemplary, or, in extreme cases, jail time. The violation could cost the organization their
reputation, trust, and/or a fine. Although most cases are due to a lack of training, discipline is
necessary to set a standard. The discipline reiterates that actions have consequences.
Opportunities to Enlist Governing Board
Healthcare organizations require governance along with leadership. Governance is the
process through which the representatives of the organization's owners supervise the mission,
strategy, executive leadership, high standards of performance, and financial management of the
6
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institution (Nash, 2019). A board of directors or board of trustees, which acts as the primary body
accountable for the standard of care delivered, is in charge of supervising all not-for-profit
hospitals and health systems in the United States. According to Nash (2019), the board is bound
by fiduciary obligations that must be followed in order for the organization to carry out its goal
of giving patients safe, effective care.
Additionally, they are required by law to establish the organization's vision and strategic
direction as well as to assure solid financial stability. The medical staff and executive leadership
cannot assume the board's role in ensuring and enhancing treatment; instead, the board has a
legal obligation to ensure that patients receive safe and harm-free care. When effectively carried
out, the leadership activity of an active board in collaboration with executive leadership can
significantly and continuously raise system-level expectations and accountability for high
performance and the elimination of harm (Nash, 2019).
Conclusion
A strong leadership team is vital for the success of an organization. Leaders set the
standards for others regarding culture, attitudes, and collaboration. As shown in the HIPAA
violation case, several team leaders and members collaborated to determine the violation and
provide a productive action plan. An action plan and communication promote patient safety and
quality, which are what hospital staff strive for.
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References
Alder, S. (2023). Why is HIPAA important? The HIPAA Journal.
https://www.hipaajournal.com/why-is-hipaa-important/#:~:text=HIPAA%20helps%20to
%20ensure%20that,who%20it%20is%20shared%20with
.
Barney, N., & Pratt, M. K. (2023). leadership. CIO.
https://www.techtarget.com/searchcio/definition/leadership#:~:text=Leadership%20is
%20the%20ability%20of,or%20ranking%20in%20a%20hierarchy
.
Christiansen. S. (2023). What is a chief nursing officer (CNO)? Nurse Journal.
https://nursejournal.org/careers/chief-nursing-officer/
.
Cultural Respect. (July 7, 2021). National Institute of Health.
https://www.nih.gov/institutes-
nih/nih-office-director/office-communications-public-liaison/clear-
communication/cultural-respect
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Health information managers. (n.d.). Mayo Clinic College of Medicine and Science.
https://college.mayo.edu/academics/explore-health-care-careers/careers-a-z/health-
information-manager/#:~:text=Health%20information%20managers%20(HIM)
%20organize,%2C%20test%20results%2C%20and%20procedures
.
Hospital survey on patient safety culture. (n.d.). Agency for Healthcare Research and Quality.
https://www.ahrq.gov/sops/surveys/hospital/index.html
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How Employees Can Help Prevent HIPAA Violations. (n.d.). The HIPPA journal.
https://www.hipaajournal.com/employees-prevent-hipaa-violations/
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Nash, David. (2019).
The Healthcare Quality Book: Vision, Strategy, and Tools, Fourth Edition
,
Health Administration Press, 2019.
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http://ebookcentral.proquest.com/lib/capella/detail.action?docID=5909626
.
8
Risk management in healthcare: What it is and why it matters. (n.d.).
https://dhge.org/about-
us/blog/risk-management-in-healthcare#:~:text=Hospital%20risk
%20management,develop%20processes%20to%20reduce%20risk
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Shelton, S. (n.d.). Creating an action plan for leadership development. Executive Leadership
Consulting.
https://executiveleader.com/creating-an-action-plan-for-leadership-
development/#:~:text=A%20leadership%20action%20plan%20is%20a%20document
%20that%20outlines%20the,in%20building%20a%20successful%20team
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Skoogh, A., Bååth, C., & Hall-Lord, M. L. (2022). Healthcare professionals' perceptions of
patient safety culture and teamwork in intrapartum care: a cross-sectional study. BMC
health services research, 22(1), 820.
https://doi.org/10.1186/s12913-022-08145-5
.
The IHI Triple Aim. (n.d.). Institute for Healthcare Improvement.
https://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
.
9
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