Healthcare Regulations Project

You are a HIPAA privacy officer working for a local healthcare organization with multiple clinics. During a recent clinic visit, you observe the following scene in a waiting room:
Daniel Draper accompanies his mother, Donna, into the outpatient clinic. When they enter the clinic’s waiting room, the receptionist, seated at a desk in the center of the waiting area, calls out, “Welcome, Mrs. Draper. You are right on time!” Other people in the waiting room look up and smile at them. The receptionist instructs Donna and Daniel to sit next to her. As Daniel sits down, the receptionist’s computer screen is visible. He notices an open health record on the receptionist’s computer and comments to his mother about the name in the record. The receptionist asks Donna to provide her full name, address, social security number, birth date, and the name of her health insurance company. When the check-in process is over, Donna and Daniel take their seats with the other patients waiting to see a doctor.
You notice an electronic display on one wall. The display shows each patient’s name, their doctor’s name, and the status of their surgery. A nurse opens the door into the waiting room and says, “Donna, we are ready for you now.” Two women, both named Donna, stand up. The nurse checks her chart and says, “Which one of you is here for the biopsy?” Daniel’s mother goes with the nurse, and her name lights up on the electronic board. While Daniel waits for his mother, he talks with other people in the waiting area. A different nurse enters the waiting area and chats with the receptionist about a patient they saw yesterday. The nurse says, “Harriet Hall has always been a difficult person, but yesterday was the worst!” The nurse leaves, and Donna’s physician enters the waiting room, looking for Daniel. The physician sits down next to Daniel, and you hear him tell Daniel that his mother’s biopsy went well and no further problems are expected. He then takes out his smartphone and shows Daniel a before-after image of Daniel’s mother’s biopsy site that he has uploaded to his personal Facebook page. The physician tells Daniel that he uploads these images for educational purposes but that he is sure to avoid sharing any identifying details.
On returning to your office, you decide it is time to retrain clinic staff and reemphasize the importance of following key regulations. After speaking with your manager, you have been asked to create a healthcare regulations presentation that emphasizes the importance of adhering to healthcare regulations and addresses some of the specific violations witnessed in your visit to the clinic’s waiting room.

Directions

For this project, you will create a presentation designed to inform staff at your clinic about various healthcare regulations and address specific violations witnessed during a recent visit to the clinic’s waiting room. In this presentation, specifically address the following:
• Healthcare Regulations: In developing your presentation, you are tasked with defining fundamental aspects of healthcare regulation. As you develop this presentation, keep in mind that your audience is clinical staff operating in direct contact with patients. As you address these fundamentals in your presentation, be sure to address the following:
o Describe the Health Insurance Portability and Accountability Act (HIPAA) and its relevance to healthcare organizations. In describing HIPAA, answer the following questions:
 What is HIPAA and who is it designed to protect?
 How is HIPAA relevant to front-office staff? To nurses? To clinicians?
 What are key practices to keep in mind while communicating with patients to ensure you are compliant with HIPAA?
o Describe and give at least two examples of protected health information (PHI). You may use examples from the observed scenario or examples from your own practice. In describing PHI, consider the following:
 What constitutes PHI?
 How should clinic staff communicate PHI?
 What constitutes a HIPAA breach?
 What are the breach notification requirements?
o Describe patient protection regulations relevant to clinic staff. In describing patient protection regulations, consider the following:
 What are some key pieces of patient protection regulations relevant to healthcare organizations?
 What is informed consent?
 What is the provider’s role in ensuring informed consent is understood?
 What is the patient’s role in ensuring informed consent is understood?
o Illustrate the importance of adhering to healthcare regulations for the benefit of organizations, clients, and the community.
• Violations: As you have recently completed the site visit that led to this training being developed, your manager has asked you to specifically address at least four violations that you witnessed. In addressing these violations, be sure to address the following:
o Identify at least four actions in violation of HIPAA or other healthcare regulations.
o Explain why the identified actions are violations of HIPAA or other healthcare regulations.
o Make concrete recommendations to clinic staff to remediate these violations.

What to submit
Healthcare Regulations Presentation
Create a presentation (consisting of 8 to 10 slides with speaker notes) to give clinic staff an overview of various healthcare regulations specific to their clinic setting.