HCS456 V4 Organizational Performance Management Table

Hcs456 V4organizational Performance Management Tablehcs456 V4page 2

Research your chosen health care organization to complete this table, and then share it with your learning team as you collaborate to write your paper. Include your tables as appendixes to your paper.

1. Provide a name of or link to a specific organization. Summarize key products or services provided by the organization and identify the primary customers it serves.

2. Outline the overall content of the major regulations, accreditation requirements, and other standards that affect the organization. Provide the title, section, parts, or subparts, or the numbering system, etc. of the specific regulations or accreditation requirements. Responses should be at least 100 words. For example: Use of electronic signatures in electronic medical records is equivalent to handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200 Electronic Signature: Organization Regulations, Accreditation, and Standards

3. Highlight the effect of each organization’s regulations, accreditation requirements, and other standards on the risk management functions and activities. Responses should be at least 100 words. Effects on Risk Management

4. Specify components of performance-management systems—policies and procedures, self-audits, benchmarking, complaint management, corrective or preventive action, education and training, communication, and other mechanisms—to be used by the organization. Responses should be at least 100 words. Organizational Performance Management Systems

5. Provide links to any relevant sources that will be useful as your learning team completes the paper. Additional Links

Paper For Above instruction

The healthcare organization selected for analysis is the Mayo Clinic, a nonprofit American academic medical center renowned for its comprehensive healthcare services, research, and education (Mayo Clinic, 2024). The Mayo Clinic offers a wide range of services, including specialized medical and surgical treatments across various specialties such as cardiology, neurology, oncology, and orthopedics. Its primary customers are patients seeking high-quality, integrated healthcare services, including both inpatient and outpatient care, from diverse demographics across the globe. The organization also collaborates with insurers and research institutions, positioning itself as a leader in both clinical excellence and innovation (Mayo Clinic, 2024).

Regulatory compliance is fundamental to the operations of the Mayo Clinic. The organization adheres to numerous standards including the Health Insurance Portability and Accountability Act (HIPAA), which mandates data privacy and security protocols for patient information (HIPAA, 1996). Additionally, the Joint Commission accreditation is a key standard, focusing on patient safety, quality improvement, and organizational management (The Joint Commission, 2024). Specifically, the standards under Joint Commission’s Comprehensive Accreditation Manual for Hospitals include requirements for medication management, infection control, and leadership oversight. Other relevant standards include the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, requiring compliance for reimbursement and funding (CMS, 2024).

Effects on Risk Management

The regulations and standards significantly influence the Mayo Clinic’s risk management activities. HIPAA compliance necessitates robust data security measures, staff training, and privacy protocols, reducing the risk of data breaches and associated penalties (Raghupathi & Raghupathi, 2014). Joint Commission standards enforce patient safety protocols, mandating root-cause analyses and corrective actions following adverse events, thus mitigating clinical risks (Sammer et al., 2010). The CMS requirements compel continuous quality improvement initiatives and incident reporting systems, fostering a culture of safety and accountability. Overall, these standards shape comprehensive risk management strategies aimed at minimizing clinical, operational, and financial risks (Manuel & Lloyd, 2018).

Components of Performance-Management Systems

The Mayo Clinic’s performance-management system encompasses several components designed to ensure quality, safety, and continuous improvement. Policies and procedures are systematically documented and regularly reviewed, covering patient care protocols, safety procedures, and staff conduct (Mayo Clinic, 2024). Self-audits are conducted routinely across departments to identify compliance gaps and opportunities for improvement. Benchmarking occurs by comparing organizational performance metrics with national and international standards, facilitating targeted enhancements. Complaint management systems enable patients and staff to report issues, which are then analyzed for corrective action. Additionally, ongoing education and training programs are implemented to keep staff updated on evolving standards, technologies, and safety practices (Mayo Clinic, 2024). Communication channels facilitate transparent dissemination of policies and performance data, fostering a culture of accountability and learning.

Useful Sources and Links

• Mayo Clinic Official Website: https://www.mayoclinic.org
• Health Insurance Portability and Accountability Act (HIPAA): https://www.hhs.gov/hipaa/index.html
• Joint Commission Standards: https://www.jointcommission.org/standards-information/hospitals/
• Centers for Medicare & Medicaid Services (CMS): https://www.cms.gov
• Raghupathi, W., & Raghupathi, V. (2014). Big data analytics in healthcare: Promise and potential. Health Information Science and Systems, 2(3).
• Sammer, C. E., et al. (2010). Patient safety culture and safety outcomes: A systematic review. BMJ Quality & Safety, 19(2), 121-125.
• Manuel, J. I., & Lloyd, S. (2018). Healthcare risk management: Challenging issues. Springer Publishing.
• American Health Care Association. (2023). Quality Assurance in Healthcare. Retrieved from https://www.ahcancal.org
• Institute of Medicine. (2000). To Err is Human: Building a Safer Health System. National Academies Press.
• World Health Organization. (2020). WHO Global Patient Safety Action Plan. WHO Press.

References

• Mayo Clinic. (2024). About Mayo Clinic. Retrieved from https://www.mayoclinic.org/about-mayo-clinic
• Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. No. 104-191, 110 Stat. 1936.
• The Joint Commission. (2024). Accreditation Standards & Certification. Retrieved from https://www.jointcommission.org/standards-information/hospitals/
• Centers for Medicare & Medicaid Services. (2024). Conditions of Participation. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Conditions-Of-Participation
• Raghupathi, W., & Raghupathi, V. (2014). Big Data Analytics in Healthcare: Promise and Potential. Health Information Science and Systems, 2(3), 3.
• Sammer, C. E., et al. (2010). Patient Safety Culture and Safety Outcomes: A Systematic Review. BMJ Quality & Safety, 19(2), 121-125.
• Manuel, J. I., & Lloyd, S. (2018). Healthcare risk management: Challenging issues. Springer Publishing.
• American Health Care Association. (2023). Quality Assurance in Healthcare. Retrieved from https://www.ahcancal.org
• Institute of Medicine. (2000). To Err is Human: Building a Safer Health System. National Academies Press.
• World Health Organization. (2020). WHO Global Patient Safety Action Plan. WHO Press.