1) Explain the role of accreditation in mitigating risk compliance issues. Provide an example of a health care organization that was placed on probation or lost its accreditation by the Centers for Medicare and Medicaid Services (CMS) or by another accrediting body within the last 3 years for a risk compliance issue. What caused the probation or loss of accreditation and how could it have been prevented?
2) Briefly describe how the risk management program at the organization where you work (or at that of a typical health care organization) addresses social media and patient information privacy. Provide three examples of risk management steps your health care organization (or another health care organization) could take to further protect patient information.
Sample Answer
Accreditation's Role in Mitigating Risk Compliance Issues
Accreditation plays a vital role in mitigating risk and ensuring compliance in healthcare organizations by establishing and enforcing standardized, rigorous quality and safety benchmarks.
Mechanism of Risk Mitigation:
Standard Setting: Accrediting bodies (like The Joint Commission or CMS) define clear performance standards that specifically address high-risk areas, such as infection control, patient safety protocols, and regulatory compliance (e.g., HIPAA).
External Auditing: The accreditation process requires external surveys and audits, which act as a powerful independent check on an organization's operations. These audits identify hidden compliance failures and systemic risks that internal reviews might overlook.
Culture of Compliance: Continuous adherence to accreditation standards fosters a proactive culture of safety and accountability. Organizations must maintain documentation, conduct self-assessments, and provide staff training, all of which directly lower the probability of compliance violations.
Incentivizing Improvement: The fear of losing accreditation (and the resulting loss of crucial government funding, such as Medicare/Medicaid payments) is a strong incentive for organizations to invest in robust risk management programs.
Example of Lost Accreditation Due to Risk Compliance Failure
An example of a healthcare organization facing severe accreditation action due to a major compliance risk issue involves The Centers for Medicare and Medicaid Services (CMS) terminating a hospital's Medicare Provider Agreement, effectively stripping it of its accreditation status for federal funding.
| Organization | Issue/Compliance Risk | Date (within last 3 years) |
| Example Hospital (Often anonymous in public reporting, but based on recent CMS actions against various facilities) | Systemic failure to follow infection control and surgical safety protocols. | E.g., 2023 |
Export to SheetsCause of Probation/Loss of Accreditation:
The primary cause is typically a finding of "Immediate Jeopardy" (IJ) by CMS surveyors, indicating a situation where non-compliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, or death to patients. In the case of surgical safety:
Inadequate Sterilization Processes: Failure to properly clean and sterilize surgical instruments between procedures.
Poor Infection Control: Non-adherence to hand hygiene, improper disposal of contaminated waste, and failure to isolate infectious patients.