Our orders are delivered strictly on time without delay
Paper Formatting
Double or single-spaced
1-inch margin
12 Font Arial or Times New Roman
300 words per page
No Lateness!
Our orders are delivered strictly on time without delay
Our Guarantees
Free Unlimited revisions
Guaranteed Privacy
Money Return guarantee
Plagiarism Free Writing
The role of accreditation in mitigating risk compliance issues
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
1) Accreditation and Risk Compliance
The primary role of accreditation in mitigating risk compliance issues in healthcare is to provide a systematic framework for continuous quality improvement and risk reduction.
Accrediting bodies (like The Joint Commission or DNV) establish rigorous standards that healthcare organizations must meet to achieve and maintain accreditation. These standards are often more stringent than minimum regulatory requirements and focus heavily on patient safety, quality of care, and organizational processes, which directly align with risk management.
Key functions in mitigating risk compliance include:
Establishing a Framework: Accreditation provides a comprehensive structure for managing risks across the organization (e.g., patient care, environment of care, medication safety, data security).
Deeming Status: For organizations that care for Medicare and Medicaid patients, accreditation often grants "deeming authority" from the Centers for Medicare and Medicaid Services (CMS). This means that by maintaining accreditation, the organization is deemed to meet the essential CMS Conditions of Participation (CoPs), thus avoiding separate, duplicative government inspections. Loss of accreditation often means loss of deeming status and, subsequently, loss of eligibility for Medicare/Medicaid reimbursement, which is a significant financial risk.
Proactive Assessment: The preparation for and execution of accreditation surveys force the organization to proactively assess its compliance with standards, identify vulnerabilities, and correct them before a problem results in patient harm or a regulatory penalty.
Culture of Safety: The process encourages a culture of safety and compliance by promoting staff education, standardized procedures, and open communication about safety concerns.
Example of Loss of Accreditation for a Risk Compliance Issue
While publicly searchable, concise examples of major hospitals losing full accreditation (Denial of Accreditation) or having it made public within a tight 3-year window (2022-2025) are rare, as organizations work intensely to correct issues during the Preliminary Denial or Accreditation with Follow-up Survey phase to maintain their deeming status. However, numerous Immediate Threat to Health or Safety findings by an accrediting body, which lead to a Preliminary Denial or CMS intervention, serve as a clear example of failure to mitigate compliance risk.
A representative risk compliance issue that often leads to major non-compliance findings and subsequent jeopardy to accreditation (or loss of deeming status) is widespread Infection Control failure.
Hypothetical Example (Based on common, severe compliance failures):
Organization: A regional Ambulatory Surgery Center (ASC).
Accrediting Body/Regulator: The Joint Commission (TJC) and CMS (via loss of deeming status).
Compliance Issue: Infection Control and Sterilization Failures related to instrument reprocessing.