Benchmark – Risk Management Program Analysis – Part Two

Benchmark – Risk Management Program Analysis – Part Two

            Risk management plays a crucial role in preventing risks to healthcare organizations, patients, healthcare providers, and the community. Risk management helps in fostering evaluation, creation, implementation, and monitoring of the probable risks to prevent or reduce risk exposure. As such, the implementation of risk management programs is crucial in promoting the safety of stakeholders within the healthcare organization (Bargmann & Brundrett, 2020). Therefore, it is imperative to carefully implement such programs based on the given guidelines to ensure the realization of the full benefits in the long term. The successful implementation of the risk management program sufficient insights from various aspects of such initiatives including the responsibilities ofMIPPA-approved accreditation bodies and the responsibilities tasked on various levels of the administrative workforce in healthcare ethics. Consequently, the purpose of this paper is to explore different aspects of the risk management initiative involving the prevention of patient falls, which was explored in the first part of this project.

The Role of Organization’s MIPPA-Approved Accreditation Body

            The MIPPA-approved accreditation body used in my healthcare organization is the Joint Commission (JC). The role of JC is to consistently enhance the safety and quality of healthcare delivered to the public by ensuring the delivery of healthcare accreditation and associated services that promote performance improvement in healthcare facilities. The JC has also created standards to fulfill its mission of enabling healthcare organizations to carry out sound assessment processes to review, examine, and improve performance. These standards emphasize the essential patient, personal, or resident care and the roles of the organization that are crucial in the delivery of high-quality and safe care (Despotou et al., 2020). The JC’s state-of-the-art standards place expectations for sound, attainable, and survivable organizations’ performance. JC also plays a critical role as a convener, associate, and listener. As such, the JC plays a shared role because it works alongside the healthcare organization to achieve accreditation and certification, diffuse information, gauge performance, participate in public policy programs, and ensure patient safety. Moreover, the JC also performs organizational assessments against the existing standards and participates in the decision-making process for accreditation.

            The JC proposes measures that facilitate loss mitigation actions in the organization. These measures include Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), and a systematic approach to addressing the causes of accidents and overcoming them (Despotou et al., 2020). The RCA is critical in fall prevention by facilitating the identification and scrutiny of reasons for falls and their solutions. The FMEA is vital in recognizing the weaknesses in the highly risky procedures and clinical services. The FMEA measures and proposals enable the organization to recognize risks depending on different procedures and how limitations of different services can trigger risks of falls.

The Role that Different Levels of Administrative Personnel Play in Healthcare Ethics and Risk Management Strategies and Operational Policies

            Managers play a crucial role in overseeing the risk investigation and prevention initiatives to ensure they are rationalized and properly attain their intended objectives. The managers in charge of risk management and procurement are tasked with the responsibility of ensuring that healthcare organization has sufficient resources to address the risk. They should ensure that the setting has special equipment such as devices to assist in the movement of patients, which are crucial in the realization of quality standards and safety as required by theJoint Commission.  The manager in charge of risk management is tasked with the role of risk identification and analysis. They scrutinize all the services in the organization to recognize possible sources of risk. They also partner with departments to identify contributory risk factors in the organization. Collectively, managers in the risk department work in collaboration with other teams to create awareness among all stakeholders on how to implement different aspects of risk management initiatives in their departments (Wang, 2018). 

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            The department of human resources has a responsibility of ensuring that the healthcare organization has the appropriate workforce to implement risk management procedures. The department is required to qualified and sufficient workforce to enhance healthcare services given to people. The objective of hiring enough personnel is to provide a proper patient-nurse ratio to help in minimizing the risk of falls due to insufficient nursing care and help. Training healthcare providers is also an important responsibility of the human resources department to ensure the workforce has the needed skills and competency to execute different risk prevention standards formulated by the healthcare organization.

            The information technology (IT) department is also critical in implementing different security measures to trail and assess the movement of patients within the healthcare setting to minimize risks of falls. IT department can also adopt various technologies necessary in implementing safety standards and vital procedures in the management of falls in the hospital.

How the organization’s Risk Management and Compliance Programs Support Ethical Standards, Patient Consent, and Patient Rights and Responsibilities

            The objective of fall prevention initiatives was to minimize the risks of fall occurrence. The organization adopted the Total Quality Management measure to ensure that different organization procedures, services, and processes are in line with the JC standards for risk management. This initiative examines all the activities and processes to detect possible weaknesses and address them based on the standards of JC to create risk assessment protocols. The protocols also elevate the safety and vigilance standards to avert risks. The organization has equally adopted structural changes including proper bed heights and alert warnings, which are informed by the FMEA standards that task organizations to recognize processes and structures that may lead to or address considerable risks. The organization’s legal department has also implemented measures to address ethical concerns including breach of patient privacy and confidentiality (Pozgar, 2019). This department ensures that activities such as patient tracking and movement investigation do not breach patient privacy. 

Legal and Ethical Responsibilities of Health Care Professionals            

    Health care professionals are expected to uphold various legal and ethical responsibilities when implementing risk management policies and administering safe health care in the organization (Pozgar, 2019). One of the responsibilities is upholding patient privacy. Some measures such as trailing patients tend to expose the organization to various privacy and ethical issues including data safety and security. Clinicians should be careful because a breach of patient privacy could lead to negative consequences. The other responsibility is to safeguard patients against damages or injuries. However, this responsibility is often challenging to be upheld due to issues such as limited resources leading to compromise in the quality of care. The other responsibility is to ensure the informed consent of patients. However, obtaining informed consent is always challenging in situations where there are controversies in the opinions between patients and healthcare providers. Moreover, sometimes patient information is accidentally exposed, which is a significant ethical and legal challenge.

How quality improvement processes support contribute to the program’s excellence.

            The quality improvement process is essential in ensuring that the healthcare setting adheres to different regulatory and legal measures leading to reduced controversies within different regulatory bodies. As a result, the organization’s reputation is elevated. The quality improvement processes also help the organization to obtain positive reviews from the clients and also facilitate the identification of probable areas that need improvement. Effective quality improvement measures also improve employee loyalty and commitment to the safety and quality protocols in the organization. The integration of the processes also enables the organization to enhance its services and recognize mistakes and issues that may compromise the quality improvement progress.


            Risk management initiatives in the healthcare system are crucial components of the quality improvement processes and they are crucial in enabling the organization to reduce quality and safety challenges that patients and healthcare professionals could potentially experience in the healthcare organization. The MIPPA-approved accreditation body used in the current hospital is JC. Different administrative personnel in the organization work collaboratively at various levels to ensure the successful implementation of the risk management program.  The program was developed to ensure compliance with the ethical code of conduct when providing care to patients. Taken together, the risk management program plays a critical role in the entire organization’s success and excellence.


Bargmann, A. L., & Brundrett, S. M. (2020). Implementation of a multicomponent fall prevention program: Contracting with patients for fall safety. Military medicine, 185(Supplement_2), 28-34.

Despotou, G., Her, J., & Arvanitis, T. N. (2020). Nurses’ perceptions of joint commission international accreditation on patient safety in tertiary care in South Korea: a Pilot Study. Journal of Nursing Regulation, 10(4), 30-36.

Pozgar, G. D. (2019). Legal and ethical issues for health professionals. Jones & Bartlett Learning.

Wang, L. (2018). Research on risk management for healthcare supply chain in hospital. Liverpool John Moores University (United Kingdom).

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