Risk Management Program Analysis

Benchmark – Risk Management Program Analysis – Part Two


Risks are inherent within all organizational operations, regardless of the settings. In addition, it is important to manage risks in order to adhere to the legal and ethical requirements as per the health and safety regulations. Healthcare organizations also have the duty of providing patients and community members with healthy and safe environment (Allen-Duck, Robinson & Stewart, 2017). Lastly, healthcare organizations have the responsibility of ensuring that their activities do not put the local community at risk of harm, injury, disease or damage. The purpose of this assignment is therefore to analyze how the quality and improvement processes of the organization contribute to the fall prevention and reduction program.  Risk Management Program Analysis

The Role of the Joint Commission

The role of Joint Commission is to provide performance improvement measures that assist healthcare organizations to ensure continuous improvement of the quality of care and safety. The Joint Commission evaluates healthcare organizations through direct staff interviews, observations, and data analysis in order to determine if the organizations adhere to the required regulations (Allen-Duck et al., 2017). The Joint Commission has the duty to certify healthcare organizations and programs and hence the commission has the role of assessing the implemented risk and fall prevention program. The Joint Commission also issues reports, that integrate measures and strategies whose aim is to track and monitor performance of the quality measures (Allen-Duck et al., 2017). Therefore, the Joint Commission has the role of monitoring the and tracking the performance of the implemented fall and risk prevention program.

In addition, the Joint Commission establishes approaches that continually review best practices that improve patient care. The Commission partners with other experts to identify the quality measures, by establishing performance standards that guide healthcare professionals to administer high-quality care through improved performance. Therefore, the healthcare organization as well as the fall and risk prevention program should comply with the standardized processes on the implemented quality management measures; accordingly, it is important to report the improvements that the fall and risk prevention program achieve.  Risk Management Program Analysis

The healthcare organization should submit its annual periodic performance reviews and reports about the fall and risk prevention program to the Joint Commission. Moreover, it is important to assess the fall and risk prevention program in order to ensure the program’s adherence with the Commission’s standards (Allen-Duck et al., 2017). Lastly, as per the Commissions aim to promote the quality of care, all stakeholders involved in the fall and risk prevention program should collaborate and partner with each other in order to identify the features of the program that indicate the best evidence-based aspects.

Roles played by Various Levels of Administrative Staff

Health care standards and policies are very important in ascertaining the adhering to standards as well as in the provision of safer care to patients and people that require the services. Different administrative staff members have the responsibility of developing and implementing policies that help workers and organizations to adhere to the appropriate practice standards and regulations. Such policies provide the organization and the staff members with the necessary information regarding changes in the industry in order to promote safety and ensure legal compliance (Farokhzadian et al., 2018).


The organizational management in collaboration with the risk management professionals in the healthcare the organization have the role of designing procedures and policies that can mitigate risks by promoting regulatory compliance, workplace safety, as well as the provision of high-quality and safe patient care. The administration also has the responsibility of monitoring whether the organizational staff adheres to the established policies and procedures (Farokhzadian et al., 2015).

Impact of the Quality Improvement Processes and Management Programs on Patient Rights and Responsibilities

Patients have the right to get high-quality and safe care. Therefore, quality improvement processes and risk management programs support the right of patients to quality and safe care. For example, a fall and risk prevention program that was implemented will improve the patient safety by preventing falls among the target patient population (geriatric) in the community. This is supported by Batalden (2018) who explains that by implementing quality improvement processes and risk management programs, healthcare organizations protect patient safety and also ensure provision of high-quality care as per the set care standards. Moreover, the fall and risk prevention program, is based on in-depth ongoing research; this further indicates how the program supports provision of high-quality care to patients.  Risk Management Program Analysis

Before the fall and risk prevention program was implemented, consent was obtained from all patients who participated in the program. In addition, confidentiality and privacy of any information provided by patients who were involved in the program was maintained.

Legal and Ethical Responsibilities Health Care Professionals

Healthcare practitioners are legally and ethically obligated to provide safe are and adhere to the set risk management policies. They have the responsibility to prioritize care of patients and to practice effectively and safely (Kadivar, Manookian, Asghari, Niknafs, Okazi & Zarvani, 2017). Healthcare practitioners must be ethical and trustworthy. Risk management policies are implemented with an aim of improving the quality of care and patient safety. Therefore, healthcare practitioners are ethically and legally obligated to conform with such policies in order to improve the quality of care and at the same time ensure patient safety. For example, a policy that requires all geriatric patients admitted in the hospital to undergo a fall risk assessment aims to ensure patient safety. Therefore, the nursing staff admitting each older adult is ethically and legally obligated to follow such organizational policy in order to ensure patient safety.

Minimizing risks to patients is an essential element of practice. Good practice entails adhering to the right practice standards and the established policies aimed to improve the quality of care (Kadivar et al., 2017). For example, nurses are obligated to take part in systems that support monitoring of adverse events and working within the systems to minimize the probability of the adverse events occurring and improving the safety of patients.

According to Salmond & Echevarria (2017) healthcare providers are required to have the appropriate skills and knowledge to provide effective and safe care. it is the responsibility of healthcare practitioners to promote health in the community through education, disease prevention, and where pertinent screening. This clearly indicates that healthcare practitioners are legally obligated to be competent enough to ensure provision of high-quality care.

The Impact of Organization’s Quality Improvement Processes

The quality improvement processes in the organization have significantly contributed to the success of the organization. The processes lead to better care outcomes and hence increases patient satisfaction. Satisfied patients are likely to be return clients to the organizations and also make referral clients. As a result, through the quality improvement processes, the organization has been able to maintain patient volume and at the same time gain competitive advantage in the industry. In addition, the organization has been able to avoid unnecessary lawsuits associated with provision of low-quality care. Quality improvement processes ensure provision of safe care and thus adverse events such as medical errors are avoided (Macrae & Stewart, 2019). Medical errors are among the leading causes of lawsuits against healthcare organizations.  Risk Management Program Analysis

Moreover, quality improvement processes have allowed the organization to avoid regulatory problems and fines for failure to adhere to the appropriate standards as per the regulatory bodies. For example, the organization has complied with the set standards by the organization with the duty of regulating delivery of safe care such as Joint Commission and Agency for Healthcare Research and Quality (AHRQ). This has ensured that the organization gains positive metrics from such organizations, further improving the reputation of the organization, in addition to evading any regulatory problems.


Healthcare organizations also have the duty of providing patients and community members with healthy and safe environment. Organizations such as Joint Commission provide performance improvement measures that assist healthcare organizations to ensure continuous improvement of the quality of care and safety. Different administrative staff have the responsibility of developing and implementing policies that monitor workers and organizations. The quality improvement processes and risk management programs support the right of patients to quality and safe care. Healthcare providers are legally and ethically obligated to provide safe and high-quality care to the patients.


Allen-Duck, A., Robinson, J. C., & Stewart, M. W. (2017). Healthcare Quality: A Concept Analysis. Nursing Forum, 52(4), 377–386. doi:10.1111/nuf.12207.  Risk Management Program Analysis

Batalden P. (2018). Getting more health from healthcare: quality improvement must acknowledge patient coproduction—an essay by Paul Batalden. The BMJ, 362, k3617. https://doi.org/10.1136/bmj.k3617.

Farokhzadian, J., Dehghan Nayeri, N., & Borhani, F. (2018). The long way ahead to achieve an effective patient safety culture: challenges perceived by nurses. BMC health services research, 18(1), 654. https://doi.org/10.1186/s12913-018-3467-1.

Farokhzadian, J., Dehghan Nayeri, N., & Borhani, F. (2015). Assessment of Clinical Risk Management System in Hospitals: An Approach for Quality Improvement. Global journal of health science, 7(5), 294–303. https://doi.org/10.5539/gjhs.v7n5p294.

Kadivar, M., Manookian, A., Asghari, F., Niknafs, N., Okazi, A., & Zarvani, A. (2017). Ethical and legal aspects of patient’s safety: a clinical case report. Journal of medical ethics and history of medicine, 10, 15.

Macrae, C., & Stewart, K. (2019). Can we import improvements from industry to healthcare? BMJ (Clinical research ed.), 364, l1039. https://doi.org/10.1136/bmj.l1039.

Salmond, S. W., & Echevarria, M. (2017). Healthcare Transformation and Changing Roles for Nursing. Orthopedic nursing, 36(1), 12–25. https://doi.org/10.1097/NOR.00000000000003

The purpose of this assignment is to analyze how an organization’s quality and improvement processes contribute to its risk management program.

This assignment builds on the Risk Management Program Analysis – Part One assignment you completed in Topic 1 of this course.

Assume that the sample risk management program you analyzed in Topic 1 was implemented and is now currently in use by your health care employer/organization. Further assume that your supervisor has asked you to create a high‐level summary brief of this new risk management program to share with a group of administrative personnel from a newly created community health organization in your state who has enlisted your organization’s assistance in developing their own risk management policies and procedures.

Compose a 1,250‐1,500 word summary brief that expands upon the elements you first addressed in the Topic 1 assignment. In this summary brief, address the following points regarding your health care organization and its risk management program:

  1. Explain the role of your organization’s MIPPA-approved accreditation body (e.g., JC, ACR, IAC) in the evaluation of your institution’s quality improvement and risk management processes.
  2. Describe the roles that different levels of administrative personnel play in healthcare ethics and establishing or sustaining employer/employee-focused organizational risk management strategies and operational policies.
  3. Illustrate how your organization’s risk management and compliance programs support ethical standards, patient consent, and patient rights and responsibilities.
  4. Explain the legal and ethical responsibilities health care professionals face in upholding risk management policies and administering safe health care at your organization.
  5. Relate how your organization’s quality improvement processes support and contribute to its overall journey to excellence.

In addition to your textbook, you are required to support your analysis with a minimum of three peer‐reviewed references.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. Risk Management Program Analysis



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