Assessment 1 Instructions: Compliance Program Implementation and Ethical Decision-Making
Prepare a workplace brief (8-10 double-spaced pages) to address a privacy breach that occurred in a health care organization. Include the consequences of failure to act and evidence-based recommendations for addressing the breach.
Introduction
Health care is one of the most heavily regulated major industries in the United States. Leaders are challenged to stay current and to comply with federal, state, and local laws and their associated regulations. Health care organizations are also responsible to meet industry standards. In some cases, payers equate meeting industry standards with achieving and maintaining accreditation. In fact, many payers consider accreditation a minimum condition of participation. In addition, individual licensure and certification requirements establish basic expectations for health care leaders’ professional conduct.
In summary, health care leaders are responsible to:
- Meet ethical personal, professional conduct, certification and licensure expectations.
- Comply with local, state and federal health care and human resources laws.
- Provide evidence of compliance with existing regulations and scan the field for emerging regulations.
- Identify and meet appropriate accrediting body standards (Example: Joint Commission’s National Patient Safety Goal standards.)
As an individual’s health care leadership career advances, so does the corresponding level of accountability. Not knowing the laws or regulations is not an excuse for not complying with them.
This assessment allows you to demonstrate your knowledge of and skills relating to compliance concepts, governmental and regulatory agencies which oversee health care service delivery, billing, and general operations. You will also have the opportunity to apply the components necessary to initiate and maintain an effective compliance program. Finally, you will consider relevant human resources laws which may pertain to your compliance recommendations.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
- Competency 1: Analyze health care laws and regulations from a local, state, and federal level.
- Summarize the relevant health care compliance concepts that apply to a HIPAA privacy breach.
- Competency 3: Assess the importance of continuous readiness in the health care organization.
- Apply the seven essential elements of an effective compliance program to a HIPAA privacy breach.
- Recommend evidence-based actions to address a HIPAA privacy breach.
- Describe a health care, industry-approved, ethical decision-making framework.
- Competency 4: Explain how governing body and regulatory agency standards exercise oversight authority within a health care organizational setting.
- Provide a synopsis of the consequences to individual leaders and other internal stakeholders of not addressing a HIPAA privacy breach.
- Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.
- Write a clear, concise, well-organized, and generally error-free workplace brief addressing a HIPAA privacy breach that is reflective of professional communication in the health care field.
Instructions
In this assessment, you are assuming the role of an early careerist in risk management and quality improvement at one of Vila Health’s community-based hospitals. Vila Health is a medium-sized system of health operating facilities in Minnesota and Wisconsin. You are working on a team-based initiative under the supervision of the Vila Health Chief Compliance Officer. Your role is to assist in addressing a specific compliance risk regarding a breach of privacy and potential HIPAA violation. A Vila Health employee has disclosed—without prior written authorization—a patient’s protected personal health information.
Here is the information the team has collected about the privacy breach and potential HIPAA violation to date. A Vila Health supervisor instructed an employee to obtain pre-authorization for an upcoming surgical procedure for a patient. The Vila Health employee submitted confidential, protected health care information about the patient to the insurance company. The Member Services Representative at the insurance company contacted the Vila Health supervisor. The insurance company representative indicated that further discussion of the matter without prior written consent from the patient is prohibited.
As part of the team exploring the privacy breach, you will prepare a workplace brief with authoritative, evidence-based references to support your work.
Preparation
You are already familiar with HIPAA but may want to conduct independent research to enhance your knowledge. Consult this resource for additional guidance on how to conduct research using credible sources: Health Care Administration Undergraduate Library Research Guide.
Instructions
This is a workplace brief rather than an academic paper. Download the Compliance Program Implementation and Ethical Decision-Making Template [DOCX]. Be sure to address all of the following in your brief:
Background
Include a short paragraph of no more than five or six sentences describing the known details about the privacy breach and HIPAA violation.
Privacy Breach—HIPAA Violation
Summarize the relevant health care compliance concepts that apply to this privacy breach and HIPAA violation. Be sure to consider the following:
- Federal, state, and local laws and associated regulations.
- Disclosure.
- Human resource concepts and law(s).
- Industry and accrediting body standards.
Seven Essential Elements of an Effective Compliance Program
Apply to this HIPAA breach the seven essential components of an effective health care compliance program, as determined within the Federal Register.
Privacy Breach Consequences
Provide a synopsis of the consequences for an individual leader and for other internal health care organization stakeholders for not taking immediate actions to address a privacy breach. At a minimum, be sure to consider all of the following in your synopsis:
- Patient safety.
- Financial losses.
- Individual and organizational violations of the law.
Evidence-Based Recommendations
Construct evidence-based recommendations to resolve the HIPAA-related privacy breach. You may also want to include relevant information related to:
- Human resource laws.
- Professional codes of ethical conduct and standards.
- Previous case precedents.
- Current alleged health care legal violations.
For help in identifying appropriate evidence-based recommendations, you may want to visit some of the authoritative sources, such as the DOJ/OIG, CMS/HHS, et cetera, listed under the suggested resources for this assessment.
Ethical Decision-Making Framework for Health Care Leaders
Describe an ethical decision making framework as one of your concluding recommendations. Tip: You may want to use the ACHE’s ethical decision-making framework:
- Nelson, W. (2015). Making ethical decisions. Healthcare Executive, 46–48. Retrieved from
Conclusion
Write a paragraph that summarizes the following:
- Key concepts.
- Importance of compliance.
- Best practices to monitor for future quality improvements.
- Short list of resources.
Expert Solution Preview
Introduction: This workplace brief focuses on addressing a privacy breach that occurred in a health care organization, specifically related to a potential HIPAA violation. As an early careerist in risk management and quality improvement, the goal is to demonstrate knowledge of compliance concepts, government regulations, and ethical decision-making frameworks through evidence-based recommendations. This brief will cover the relevant healthcare compliance concepts and seven essential elements of an effective compliance program and their application to the privacy breach. It will also discuss the consequences of not addressing a privacy breach and make evidence-based recommendations to resolve the issue.
Privacy Breach – HIPAA Violation: The privacy breach occurred when a Vila Health employee submitted confidential, protected health care information about a patient to the insurance company without proper pre-authorization. The relevant health care compliance concepts that apply to this privacy breach include federal, state, and local laws and associated regulations, disclosure, human resource concepts and laws, as well as industry and accrediting body standards. For instance, the HIPAA Privacy Rule mandates that healthcare organizations protect individuals’ medical records and other personal health information. The breach has, therefore, violated HIPAA’s privacy rule.
Seven Essential Elements of an Effective Compliance Program: To apply the seven essential elements of an effective healthcare compliance program to this privacy breach, the health care organization must assess and identify areas of potential HIPAA violations that require compliance. They should develop effective policies and procedures related to privacy management, provide training and education programs to the workforce, employ effective compliance committees, conduct regular monitoring and auditing, and establish a system for reporting detected compliance issues. The organization must also discipline individuals guilty of violating HIPAA requirements and effectively educate healthcare professionals on ensuring that the violation does not occur.
Privacy Breach Consequences: Failure to take immediate actions to address a privacy breach may have dire consequences for an individual leader and other internal stakeholders. This includes potential patient safety threats, financial losses to affected patients, individuals and Healthcare organizations violating the law. In severe cases, there may be a loss of reputation and loss of trust among patients. The health care organization leadership is required to address a privacy breach promptly and avoid any potential aftermath and consequences that may affect the organization negatively.
Evidence-Based Recommendations: To resolve this HIPAA-related privacy breach, the health care organization should adopt a multi-step approach to ensure its workforce remains HIPAA compliant. It should re-educate its workforce on HIPAA Compliance policies, conduct immediate investigations into this breach, and possibly consider disciplinary action on individuals guilty of breaching patient privacy. Additionally, the healthcare organization should enhance its monitoring and auditing programs to identify potential HIPAA vulnerabilities and avoid privacy breaches.
Ethical Decision-Making Framework for Healthcare Leaders: The ethical decision-making framework for healthcare leaders should explicitly prioritize the patients’ best interests and ensure that privacy breaches are dealt with immediately. Ethical decision-making frameworks should incorporate factors that consider the fair and equitable treatment of patients. The American College of Healthcare Executives (ACHE) has published the ethical decision-making framework, which was designed to guide healthcare leaders to make optimal choices in clinical decision-making that respects the autonomy of the patient.
Conclusion: Understanding healthcare compliance concepts is crucial in managing the implementation of compliance programs. This workplace brief focused on a privacy breach that occurred in a health care organization. By applying the seven essential elements of an effective compliance program and ethical decision-making frameworks, healthcare leaders can ensure the protection of patient information and avoid HIPAA violations. Healthcare leaders must ensure that their workforce is HIPAA compliant and implement effective organizational frameworks for continuous risk assessment and rectification.
