Orginizational Compliance and Regulation


Imagine that you are an executive with a healthcare consultancy that helps hospitals improve patient experiences by creating and implementing sustainable quality improvement programs. Consider your role as you answer the questions in this Assessment.


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    1. An important part of your role at the consulting firm is to lead training sessions at hospitals nationwide. At the training sessions, you educate hospital administrators on the history of the quality-management movement in healthcare. Many of the individuals you train have little or no background in quality management, and you have found that leadership is more receptive to changes if they understand the history of the quality-management movement in healthcare.
      • Briefly summarize the history of the quality movement, in general, to set the context for this presentation.
      • Explain the influence of Deming and Donabedian (referenced in Chapter 1 of the Varkey text) in the healthcare quality-management movement.
      • Describe the impact that the two reports, To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, had on quality management in the healthcare system.
      • Describe the role of the Centers for Medicare & Medicaid Services (CMS) in the healthcare quality-management movement.
      • Summarize the impact of The Joint Commission accreditation in the quality-improvement process of participating hospitals.

Create a PowerPoint presentation to communicate the following information to your audience. (8–10 slides)

    1. As a result of your success as a healthcare-quality consultant, you have been invited to appear as a guest on a nationally syndicated news show. The show explores the topic of quality in healthcare. The interviewer asks you, “Why is a hospital different than a nuclear power plant or a commercial airline? Why can’t hospitals achieve the same quality levels as high-reliability organizations?” Respond to the questions by explaining the challenges related to ensuring quality and safety standards in hospitals. In addition, explain how hospitals can achieve the same quality levels as high-reliability organizations. (1 page)
    2. In your role as a healthcare consultant, administrators and executives often ask you about the differences and similarities between the major accrediting agencies. Many want to know about the DNV surveys and how they compare to The Joint Commission (JC) surveys. Prepare a 1-page document that summarizes the differences and similarities between the JC and DNV surveys. (1 page)
    3. Your hospital has recently received deemed status recognition from the Centers for Medicare & Medicaid Services (CMS). At the same time your healthcare analytics department has presented you with the following data:

Does the deemed status determination alone guarantee the public that you provide quality healthcare? (1–2 pages)

    1. The dean of the Master of Healthcare Administration (MHA) program at your alma mater has asked you to participate in a debate on transparency in the healthcare system. As part of your preparation for the debate, prepare a 2- to 3-page paper in which you:
      • Address your definition of the concept of transparency in the healthcare system.
      • Explain the primary benefits and drawbacks of transparency in the healthcare system.
      • Address your opinion on whether the benefits of transparency in the healthcare system outweigh the drawbacks? Will transparency create more informed healthcare consumers, lead to more questions, or both? Explain your answer.
    2. Review the National Patient Safety Goals (NPSG) at Then, read the scenarios presented on the Compliance Issues Worksheet provided, and evaluate whether a violation had occurred. Based on your evaluation, complete the worksheet as follows:
      • If a compliance issue occurred, identify and classify the issue in the second column of the worksheet.
      • If no compliance issue occurred, explain why not (in the second column of the worksheet).
      • For each scenario, provide a recommended course of action in the third column of the worksheet.

Examples have been provided in the first two rows of the worksheet.


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