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BHA FPX 4006 Assessment 3 Compliance Training

BHA FPX 4006 Assessment 3

BHA FPX 4006 Assessment 3

Compliance Training

  • Slide 1

Hi, everyone. This is the compliance training presentation. Let me introduce myself. My name is XYZ. The objectives of the presentation are to remind the subject employees of the necessity of compliance with the requirements of the current legislation, professional, moral, and ethical standards, as well as the rules of the organization.

Finally, several practices will be mentioned to assist you in training employees. At the end of this session, you will have specific knowledge and instruments to ensure the organization’s commitment to various aspects of healthcare delivery.

Ethical and Regulatory Compliance Analysis

  • Slide 2

The healthcare sector aims to enhance the health standards and quality of life of the community, hence requiring quality healthcare services. As such, health providers have to take responsibility for adhering to clinical ethical demands and regulatory frameworks that pertain to the healthcare systems’ and patients’ health.

When used in their professional practice, caregivers guarantee procedural compliance with ethical standards like beneficence, non-maliciousness, patient self-rule, and fairness.

BHA FPX 4006 Assessment 3 Compliance Training

Some of the other general ethical considerations that are derived from these broad principles are issues related to truthfulness and equity. These considerations act as a practical tool for healthcare providers to make morally and ethically reasonable decisions. Providers can also experience ethical dilemmas in healthcare; they arise, for example, in issues to do with end-of-life care and the use of resources (Varkey, 2021).

For instance, if a provider performs surgery or treatment that results in an injury to a patient or if a provider has to operate on a person again due to an earlier operation, then, indeed, the provider has an ethical obligation to advise the patient of the mistake and explain consequences and issues that occurred and to apologize to the patient, which is consistent with the principles of truth-telling and patients’ rights (Varkey, 2021).

Therefore, several ethical issues that exist in health care require some ethical standards for the caregivers.  Another critical area of concern in regard to health care is the aspect of regulatory compliance, which is the process of following the legal requirements that have been put in place by the government and other professional associations to enhance the quality of various aspects of health care, including the delivery of services, management, staff training, and many others. Non-compliance with these regulations may attract sanctions or penalties on the providers (Dunbar et al., 2021).

Ethical and Regulatory Compliance Analysis

  • Slide 3

Healthcare providers can ensure high-quality care through another systematic approach: First of all, the focus is made on compliance with the requirements of accreditation. In this regard, to validate the healthcare organization’s commitment to the quality of care and performance, it is recommended to follow specified and proven protocols.

There are bodies or agencies outside the EU that provide accreditations, such as the Joint Commission for the purpose in the United States. Also, it involves a comprehensive assessment of a healthcare facility’s policies and practices to confirm whether it supports following specific standards of patient safety, quality improvement, or organizational performance ( Mashhor et al., 2021).

For example, The Joint Commission assesses the benchmarks in infection control, medication usage, and patients’ rights for hospitals. The findings enlighten them on the level of compliance, dedication to quality outcomes from the care delivery structure, and efforts towards boosting the patient’s confidence and satisfaction (The Joint Commission, 2023).

Hence, the bodies set to ensure the strict implementation of accreditation play a crucial role in enhancing the standards of the concerned organizations.

Distinction Between Accreditation and Other Compliances

  • Slide 4

Different from accreditation compliance, ethical and regulatory compliance is more concerned with its ability to represent the willingness of the organizations to conform to benchmark standards voluntarily set by the status industry and the evaluation of the quality of overall healthcare (Hussein et al., 2021).

For instance, while the ethical notion of autonomy mandates healthcare practitioners to uphold patient self-determination, accreditation may extend the extent to which the organization benchmarks its operations’ efficacy and efficiency. Besides, compliance, like HIPAA, is more specific, as it deals with certain criteria or aspects of quality.

At the same time, accreditation examines the extent of overall quality, or performance quality, as seen in Hussein et al. (2021). Nevertheless, these standards and regulations are followed to increase organizational efficiency and serve patients better.

Non-Compliance Risks and Consequences

  • Slide 5

Penalties and risks that healthcare organizations and suppliers encounter because of ethical or lawful violations include the following. Erichson et al. (2012) posit that the social consequences that arise out of failure to adhere to ethical standards include The patient’s demography and lack of any element of trust when in the setting.

In the given setting, there is little accountability; The institution is not credible. For example, in the Tuskegee Syphilis Study, black patients intentionally were denied treatment for the symptoms of syphilis, and this led to a lot of ethical violations and, consequently, to the blacks’ distrust in the medical industry (Centers for Disease Control and Prevention, 2022).

These principles and practices suggest that ethical breaches and their ramifications mean that the professionals working in the field have to think about these problems and their relationship with patients.

Non-compliance with Legal and Regulatory Considerations

  • Slide 6

There are serious legal consequences of not obeying inevitable legal repercussions in the healthcare setting, where healthcare providers are punishable by both severe monetary fines and criminal offenses. Two of the compliant behaviors can be explained with the help of non-compliance cases such as Dr. Michael Swango.

However, two of the ethical violations involved him killing multiple patients simply for the satisfaction he received from their deaths, demonstrating the dangers of ethical transgressions and failing to adhere to legal regulations in the field of healthcare, which ultimately results in imprisonment and revocation of the doctor’s license (Kaufman, 2022).

They can provoke fines and legal actions against the institutions and professionals who were involved in the particular case. Another type of noncompliance with the set regulatory standards is a violation of the Health Insurance Portability and Accountability Act (HIPAA), which leads to financial penalties.

HIPAA and its mandates were presented and imposed by the U. S. Department of Health & Human Services (HHS), which also set fines on healthcare facilities for data violations (CDC, 2022).  These examples pinpoint the various aspects of threat and grave outcomes of unethical and unlawful behavior or repression of their repercussions.

Health Care Regulations

  • Slide 7

Healthcare regulations consist of numerous laws, rules, and policies that serve as guidelines to healthcare service providers regarding the delivery of safe and high-quality care.

They consider laws on patient privacy and principles guiding the protection of patients’ rights. HIPAA privacy laws are some of the rules that have been put in place to enhance the protection of patients’ information.

The rules issued by the Bush administration under the Department of Health and Human Services in the United States mandate protecting patients’ personal health information through specifications of safe care services and penalty rules—the Accountability Act (HIPAA).

Quality standards established by particular benchmarking sources, such as the Centers for Medicare & Medicaid Services (CMS) via the Hospital Value-Based Purchasing Program, outline the set of measures to enhance the quality of care delivery and patient outcomes.

BHA FPX 4006 Assessment 3

Compliance Requirements

  • Slide 8 

Under this program, providers are paid to deliver quality healthcare services because quality services provide a way through which they can get more reimbursement, hence encouraging them to uphold the high standards (Centers for Medicare & Medicaid Services, 2023).

Specific rules in healthcare are also mainly regulated to safeguard patients’ interests by enacting the Patient’s Bill of Rights, which covers issues such as Informed consent, patient privacy, and the right to timely and accessible care (Olejarczyk & Young, 202Thereforereby, the laws and the regulations phenomenized in the sphere of healthcare stress the quality preservation ofving patients’ interests as well as the density of their practitioners.

Policies may be categorized as the rules that must be complied with by healthcare in order to demonstrate readiness to comply with regulations and quality indicators.

For example, organizations and providers should implement some protocols or safety measures for electronic Protected Health Information (ePHI) to define whether they followed HIPAA’s guidelines. Some of the guidelines may involve proper storage of the data and allowing only access by the appropriate personnel (CDC, 2022).

Quality standards compliance requires that hospitals adhere to patient safety and performance improvement standards. For example, they can set metrics to decrease the incidence of healthcare-associated infections or enhance patients’ loudness ratings (Murphy et al., 2020). Other related applications can benefit healthcare facilities by helping them manage their activities efficiently.

Healthcare Laws

  • Slide 9

Other than patient safety and enhancing the performance of an organization, healthcare laws also cover questions of cost and distribution of healthcare to humans. For instance, the Affordable Care Act (ACA) includes measures aimed at enhancing the population’s healthcare availability, costs, and outcomes.

This act enables affordable care and improved healthcare plans through the concept of economic health insurance, new Medicare, and dependent coverage for youthful adulthood (Isola & Reddivari, 2019).

Likewise, the effects of the EMTALA aid the accessibility of care for people experiencing poverty as it requires the providers to give quality and immediate treatment to such patients. This act sustains non-discrimination by requiring primary care, such as screening and stabilization care if the disease is detected during screening for emergency care seekers (Lulla & Svancarek, 2019). Altogether, these laws make up an extensive structure that can regulate healthcare activities and safeguard patients’ rights and interests.

Key Ethical Considerations

  • Slide 10

A number of ethical matters are already included in this presentation, which the staff has to adhere to and apply. For example, patient data must be protected, patients’ self-governance must be considered, and the principle of doing good or maximizing good must be followed.

Also, they should conform to righteousness and equality while interacting with patients to promote justice. It should also focus on patients’ requirements and integrate them within clinical choice for care processes (Hunt et al., 2021). It is essential to comprehend and apply these principles in practice for the organization’s best ethical conduct.

Continuous Readiness and Compliance

  • Slide 11

Stakeholders’ constant preparedness focuses on the detection of the assessment and enhancement of procedures in health care Provision, which can relate to compliance as an unceasing and positive approach to addressing regulations, standards, and ethical practices.

Organizations can use the Assessment and Improvement process, where change is occurring for the better over time, compared to sole compliance, where the organization minimally upgrades its quality through compliance. For this, the providers can continue to quickly check the internal practices’ compliance with the standards of regulation and the changes in the regulation and enhance compliance by enhancing compliance requirements.

Thus, by building a culture of compliance readiness, the organization can achieve timely responses to emerging compliance demands and guarantee the regularity of ethical and regulatory compliance (Thomson et al., 2022). In general, the continuous readiness approach can improve compliance effectiveness as well as performance in the future.

Best Practices for Training

  • Slide 12

Successful strategies for teaching healthcare personnel about compliance rules include using educational details aimed at understanding the necessity of such regulations and providing constant improvement.

Compliance training can be interactive in the following ways, implying that the principles of compliance training can be ensured by including scenario-based training in the following ways: Including examples of ethical issues and regulatory concerns facing the company, realistic organizational case studies can be used to enforce the theoretical concepts among the staff.

To their daily tasks. The case studies can help them gain more knowledge while thinking about the peculiarities of the contexts and situations (O’Mathúna & Iphofen, 2022).

Technology such as virtual simulation may likely improve staff participation and clinical decision-making abilities in compliance training (Sim et al., 2022). They can adopt more strategies, which I will get to on the next slide.

Slide 13

Continuing education programs should focus on the particular compliance issues that are applicable to the specific functions of the healthcare organization. To keep the staff current and competent, current updates on changing regulations and ethical guidelines must occur.

The quizzes must follow them and determine if the staff has reviewed them. This helps to encourage respective staff to ask questions or report specific issues that they might be unclear about or uncomfortable about sharing in their organization without any repercussions (Malik et al., 2021).

Thus, it would be possible to encourage staff participation to attain the ultimate goal of achieving excellent performance by implementing these practices in the context of healthcare providers.

Conclusion

  • Slide 14

The presentation on compliance training has again highlighted the need for regulation and ethical standards besides following established rules in the facility. Aware of how much is at stake when compliance is not ensured, staff can also promote the culture of constant preparedness – a concept of being ready and willing to change for the better as soon as new requirements come into view.

Moving forward, I would like to conclude the presentation with Peter Drucker’s words: ‘Quality is not the pin that you put into it but what the customer feels and receives from it. ’ The commitment of staff to compliance will call for the best for those that we serve.  To this end, let the united principles be the beacon to maintain integrity and excellence in health facilities. Explore our sample BHA FPX 4006 Assessment 1 Compliance Program Implementation and Ethical Decision-Making for complete information about the class.

References

  • Slide 15

CDC. (2022, June 27). Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Centers for Disease Control and Prevention.

https://www.cdc.gov/phlp/publications/topic/hipaa.html

Centers for Disease Control and Prevention. (2022, December 5). The untreated syphilis study at Tuskegee Timeline. Centers for Disease Control and Prevention; CDC.

https://www.cdc.gov/tuskegee/timeline.htm

Centers for Medicare & Medicaid Services. (2023, September 6). CMS’ value-based programs.

Www.cms.gov.

https://www.cms.gov/medicare/quality/value-based-programs

Dunbar, P., Browne, J. P., & O’Connor, L. (2021). Determinants of regulatory compliance in health and social care services: A systematic review protocol. Health Research Board Open Research, 4, 13.

https://doi.org/10.12688/hrbopenres.13214.3

HHS. (2023, November 6). General compliance program guidance. Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services.

https://oig.hhs.gov/compliance/general-compliance-program-guidance/

HIPAA Journal. (n.d.). HIPAA explained. HIPAA Journal.

https://www.hipaajournal.com/hipaa-explained/

Hunt, D. F., Dunn, M., Harrison, G., & Bailey, J. (2021). Ethical considerations in quality improvement: Key questions and a practical guide. BioMed Journal, 10(3).

https://doi.org/10.1136/bmjoq-2021-001497

Hussein, M., Pavlova, M., Ghalwash, M., & Groot, W. (2021). The impact of hospital accreditation on the quality of healthcare: A systematic literature review. BioMed Central Health Services Research, 21(1), 1057.

https://doi.org/10.1186/s12913-021-07097-6

Isola, S., & Reddivari, A. K. R. (2019, November 13). Affordable Care Act (ACA). Nih.gov; StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/books/NBK549767/

Kaufman, E. (2022, May 3). “Double-O Swango”: What happened to Dr. Michael Swango, who left a trail of dead patients in the Midwest and elsewhere. Mitchell Republic.

https://www.mitchellrepublic.com/news/the-vault/double-o-swango-what-happened-to-dr-michael-swango-who-left-trail-of-dead-patients-in-midwest-elsewhere

Koukourikos, K., Tsaloglidou, A., Kourkouta, L., Papathanasiou, I., Iliadis, C., Fratzana, A., & Panagiotou, A. (2021). Simulation in clinical nursing education. Acta Informatica Medica, 29(1), 15–20.

https://doi.org/10.5455/aim.2021.29.15-20

Lulla, A., & Svancarek, B. (2019, March 14). EMS, Emergency Medical Treatment and Active Labor Act, USA. Nih.gov; StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/books/NBK539798/

Malik, R. F., Buljac-Samardžić, M., Amajjar, I., Hilders, C. G. J. M., & Scheele, F. (2021). Open organizational culture: What does it entail? Healthcare stakeholders reach a consensus using the Delphi technique. British Medical Journal Open, 11(9).

https://doi.org/10.1136/bmjopen-2020-045515

Murphy, F., Tchetchik, A., & Furxhi, I. (2020). Reduction of Health Care-Associated Infections (HAIs) with antimicrobial inorganic nanoparticles incorporated in medical textiles: An economic assessment. Nanomaterials, 10(5).

https://doi.org/10.3390/nano10050999

O’Mathúna, D., & Iphofen, R. (2022). Making a case for the case: An introduction (D. O’Mathúna & R. Iphofen, Eds.). PubMed; Springer.

https://www.ncbi.nlm.nih.gov/books/NBK589353/

Olejarczyk, J. P., & Young, M. (2022, November 28). Patient rights and ethics. National Library of Medicine; StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/books/NBK538279/

Sim, J. J. M., Rusli, K. D. B., Seah, B., Levett-Jones, T., Lau, Y., & Liaw, S. Y. (2022). Virtual simulation to enhance clinical reasoning in nursing: A systematic review and meta-analysis. Clinical Simulation in Nursing, 69, 26–39.

https://doi.org/10.1016/j.ecns.2022.05.006

The Joint Commission. (2023). The Joint Commission. Jointcommission.org.

https://www.jointcommission.org/

Thomson, N., Hunter, K., Srivastava, R., Hassan, M., Anderson, L., & Sequeira, L. (2022). Enhancing hospital accreditation practices: Building and implementing a continuous readiness model. Healthcare Quarterly, 25(2), 34–40.

https://doi.org/10.12927/hcq.2022.26891

U.S. Food and Drug Administration. (n.d.). About FDA. U.S. Food and Drug Administration.

https://www.fda.gov/about-fda

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28.

https://doi.org/10.1159/000509119

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