Organization Compliance

Create a presentation (15-20 slides) to prepare department heads for training their staff on the organization’s new compliance approach. Address the compliance content that department heads will need to convey and best practices for delivery of the compliance training.
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Introduction
At this point in your academic career, you know that health care is a heavily regulated industry. While applicable regulations may vary from one organization type to the next, the typical health care organization must navigate through a wide array of laws, quality standards, regulations, and ethical considerations as part of day-to-day operations. What this means is that the staff working in these organizations must also fully understand their organization’s regulatory environment and their role in regulatory compliance.
Successful compliance depends on how well the staff is trained. Managers need to be able to teach their staff compliance best practices. The compliance content in the training is one aspect of the health care manager’s job. The other critical aspect of the job is to be able to convey the compliance content effectively and efficiently. In today’s environment, it is not enough to simply place a checkmark next to the staff trained item on the manager’s to-do list. Staff members need to be able to retain the compliance best practices they’ve learned and apply them on the job. In successful health care organizations, compliance training doesn’t just need to be done, but it needs to be done effectively and efficiently. This is no easy task given health care regulations’ complexity.
For the purpose of this assessment, you will assume the role of quality assurance officer in your health care organization. You have been tasked with the responsibility of developing a presentation that prepares the organization’s department heads to deliver compliance training to their staff members.
Preparation
Conduct independent research on these following topics:
• Regulations, accreditation requirements, and ethical standards that govern the health care industry.
• Current best practices in compliance training and health care industry-accepted training programs.
Consult your suggested resources as a starting point for your research. You may also want to consult the Health Care Administration Undergraduate Library Research Guide for additional guidance on how to conduct scholarly, professional research.
Instructions
For the purpose of this assessment, you will assume the role of quality assurance officer at one of Vila Health’s community-based hospitals. Vila Health is a medium-sized system of health care operating facilities in Minnesota and Wisconsin. You recently received approval from your organization’s senior leaders to provide compliance training to all staff members based on the new approach to compliance your organization has adopted.
Because of the number of staff requiring training, you will not be able to deliver the compliance training yourself. Instead, your organization’s department heads will conduct the training for their departments. Your job is to develop a presentation to help the department heads train their staff on the organization’s new approach to compliance.
You have scheduled a meeting with the department heads to introduce the compliance training. As you are doing your planning for your presentation to department heads, you have decided that your presentation needs to consist of two parts:
• Part One: Background on Health Care Regulation, Accreditation, and Ethics
o This addresses the compliance content department heads need to cover in their staff training sessions.
• Part Two: Compliance Training Effectiveness
o This addresses how to design and deliver compliance training that staff members retain and apply on the job.
You have determined you will need 15–20 slides to cover the content you plan to deliver to the department heads. You have also created an outline of what specifically you need to include in your presentation. Here is the outline you created:
Part One: Background on Regulation, Accreditation, and Ethics in Health Care (10–12 slides)
• Introduce regulatory, ethical, and accreditation compliance in health care (2–3 slides).
o Distinguish accreditation from regulations and ethical considerations in health care.
• Highlight the risks and consequences of non-compliance (1–2 slides).
• Analyze important health care regulations, such as privacy laws, quality standards, and patient rights (3–4 slides).
• Present key ethical considerations all staff must understand (1–2 slides).
• Explain how the concept of continuous readiness applies to compliance (1–2 slides).
Part 2: Compliance Training Effectiveness (6–8 slides)
• Explain best practices for training health care staff on compliance (2–3 slides).
• Conclude with a final meaningful compliance message, such as a motivational statement or a quote about compliance (1 slide).
• Include your reference slide with current APA formatted references (1 slide).
Now that you have your outline in hand, develop your presentation to department heads on the organization’s new compliance training program that they will be delivering to their staff members.
Additional Requirements
• Written communication: Your slides need to include bullet points highlighting the key concepts. Avoid using block paragraphs or pictures only. Make sure your content is clear, persuasive, well-organized, and free of errors in grammar, punctuation, and spelling.
• Title slide: Develop a descriptive title for your presentation of approximately 5–15 words. It should stir interest, yet maintain professional decorum.
• Length: Approximately 15–20 slides. Slides should be professional and appropriately balance text and visuals. Avoid making your slides too text-heavy. Instead, make use of speaker notes to include additional content.
• References and reference slide: Include a minimum of 3 citations of peer-reviewed sources in current APA format on a final reference slide.
• Scoring guide: Please review the scoring guide for this assessment so that you understand how your faculty member will evaluate your work.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
• Competency 1: Analyze health care laws and regulations from a local, state, and federal level.
o Analyze regulatory compliance and ethical considerations in the health care setting.
o Describe common health care regulations, compliance requirements, and laws.
• Competency 2: Explain the concept of accreditation in health care.
o Distinguish accreditation from regulations and ethical considerations in health care.
• Competency 3: Assess the importance of continuous readiness in the health care organization.
o Explain best practices for training health care staff on compliance.
• Competency 4: Explain how governing body and regulatory agency standards exercise oversight authority within a health care organizational setting.
o Explain the consequences for noncompliance or ethical breaches.
• Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with the expectations of health care professionals.
o Develop a clear, persuasive, well-organized, and generally error-free presentation for department heads that prepares them to conduct compliance training for their departments.

Resources
Use the resources linked below to help complete this assessment.
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Continuous Readiness and Compliance
VitalSource Resources
• Moseley, G. B., III. (2015). Managing legal compliance in the health care industry. Jones & Bartlett. Available in the course room via the VitalSource Bookshelf link.
o Chapter 7, “Corporate Integrity Agreements,” pages 117–133.
o Chapter 14, “Auditing & Monitoring,” pages 249–257.
Capella Library Resources
• Braithwaite, J., Glasziou, P., & Westbrook, J. (2020). The three numbers you need to know about healthcare: The 60-30-10 challenge. BMC Medicine, 18(102), 1–18.
• Chernyshev, M., Zeadally, S., & Baig, Z. (2019). Healthcare data breaches: Implications for digital forensic readiness. Journal of Medical Systems, 43(1), 1–12.
• Lee, S. J., Ventkataraman, S., Heim, G. R., Roth, A. V., & Chilingerian, J. (2020). Impact of the value-based purchasing program on hospital operations outcomes: An economic analysis. Journal of Operations Management, 66, 151–175.
• Polonsky, M. S. (2019). High-reliability organization: The next frontier in healthcare quality and safety. Journal of Healthcare Management, 64(4), 213–221.
• Rezaei, F., Yarmohammadian, M. H., Haghshenas, A., Fallah, A., & Ferdosi, M. (2018). Revised risk priority in failure mode and effects analysis model from the perspective of healthcare system. International Journal of Preventive Medicine, 9(1), 7.
• Schmidt, R. N., House, M., & Rodriguez, O. O. (2019). Journey into DNV hospital accreditation and the implementation of an electronic contract management system (ECMS). Journal of Business and Educational Leadership, 9(1), 67–75.
• Vaishnavi, V., Suresh, M., & Dutta, Pankaj. (2019). Modelling the readiness factors for agility in healthcare organization: A TISM approach. Benchmarking: An International Journal, 26(7), 2372–2400.
Internet Resources
• The Joint Commission. (n.d.). Joint Commission FAQ. https://www.jointcommission.org/about/jointcommissionfaqs.aspx
• The Joint Commission. (2018). Patient safety systems (PS) [PDF]. https://www.jointcommission.org/assets/1/6/PS_chapter_HAP_2018.pdf
Health Care Industry Accreditation and The Joint Commission
VitalSource Resources
• Moseley, G. B., III. (2015). Managing legal compliance in the health care industry. Jones & Bartlett. Available in the course room via the VitalSource Bookshelf link.
o Chapter 13, “Training and Education,” pages 231–244.
o Chapter 15, “Hospitals,” pages 263–281.
Capella Library Resources
• Bogh, S. B., Blom, A., Raben, D. C., Braithwaite, J., Thude, B., Hollnagel, E., & Von Plessen, C. (2018). Hospital accreditation: Staff experiences and perceptions. International Journal of Healthcare Quality Assurance, 31(5), 420–427.
• Swathi, K. S., Gopalkrishna, B., & Somu, G. (2020). Impact of accreditation on performance of healthcare organizations. International Journal of Quality and Service Sciences, 12(1), 85–108.