Regulatory Environment – Executive Summary

Assume you have taken on a new role as the chief operating officer. You are charged with leading system-wide risk-management efforts to identify risk and minimize HACs. Your organization’s financial viability depends on receiving proper reimbursement for services delivered. As the chief operating officer, you must create an executive summary that describes your organization’s compliance with the regulatory requirement, to promptly identify conditions that are POAs and proactively assess and manage risk.

Step One: Executive Summary Table
Select a risk-management issue within a specific health care setting or organization. You will use this issue as a starting point for your work on this assessment. Use the Executive Summary Table from the Required Resources to complete this step.

Issue: Write a brief description of the risk-management issue you selected. Explain why this risk-management issue is important to your organization.
Regulatory Requirements: Compile a list of the applicable regulatory requirements and an explanation of what they mean to your chosen risk-management issue.
Risk-Management Implications: Identify the associated risk-management implications. For example, HACs result in no reimbursement, and poor quality ratings. Also, there is a risk of losing repeat admissions, a risk of losing Joint Commission and Magnet accreditation or excellence, or other negative implications.
Environmental Assessment: Assess the internal versus external environment relative to the risks associated with your chosen risk-management issue. You may use strengths, weaknesses, opportunities, and threats (SWOT) analysis or another suitable tool. Be sure to cite the source.
Resources to Address Issue: Describe any resources or strengths your organization possesses that could aid in addressing the risk-management issue.
Philosophy or Culture Statement: Summarize your organization’s philosophy or culture as it relates to patient safety and error reporting.
Measuring and Monitoring:
Identify metrics for measuring or monitoring the risk-management issue.
Propose how you will make use of the outcome data for organizational improvement.
Organizational Improvement: State how you will encourage voluntary reporting.
Ethics Considerations: Describe legal and ethical implications related to the handling of this risk-management issue.
Utilize established sources of information. Some sources that may be useful to you include the federal register, statutes, discipline-specific peer-reviewed journals, and government agency references.