BHA 4006 CU Compliance Program Implementation and Decision Making Questions

Compliance Program Implementation and EthicalDecision-Making Template
Background
Include a short paragraph of no more than five or six sentences describing the known details
about the privacy breach/HIPAA violation.
Problem Summary: Privacy Breach—HIPAA Violation
Number
Briefly Explain the Law, Regulation,
Standard, et cetera*
Briefly Explain How the Law, Regulation,
Standard, et cetera Applies to the
Privacy Breach/HIPAA Violation
Applicable
Laws
Applicable
Specific
Regulations
Disclosure
Applicable
Human
Resource
Laws
Applicable
Industry
Accrediting
Body
Standards
*Include citations from authoritative government, accrediting body, and peer-reviewed industry
sources.
Add additional salient points if needed.
Seven Essential Elements of an Effective Compliance
Program
Number
Element of an Effective Compliance
Program (Federal Register)*
How Does This Element Apply to the
Privacy Breach/HIPAA Violation?
1.
1
Number
Element of an Effective Compliance
Program (Federal Register)*
How Does This Element Apply to the
Privacy Breach/HIPAA Violation?
2
3
4.
5.
6.
7.
*Include source citations.
Privacy Breach Consequences
Covered Entity
Legal Penalties*
Additional Consequences
Individual Leader Within Health
Care Organization
Other Internal Health Care
Organization Stakeholders
Health Care Organization
*Include citations from authoritative government and related sources.
Evidence-Based Recommendations
Number
Evidence-Based
Recommendation
Additional Insights/Salient
Points
Sources*
1.
2.
3.
4.
5.
*Include citations for human resource laws, professional codes of ethical conduct/standards,
previous case precedents, and current alleged health care legal violations. Example: Websites
of Department of Justice, Office of Inspector General, Centers for Medicare and Medicaid
Services, Health and Human Services, et cetera.
Ethical Decision-Making Framework for Health Care Leaders
2
Number
Ethical Decision-Making Step*
Apply the Ethical Decision-Making Step to the
Privacy Breach/HIPAA Violation
1.
2.
3.
4.
5.
6.
*Include citations. Example: Nelson, W. A. (2015). Making ethical decisions. Healthcare
Executive, 30(4), 46–48. Retrieved from
https://ache.org/abt_ache/EthicsToolkit/JA15_ethic_reprint.pdf
Conclusion
Include a short paragraph that summarizes the key concepts, importance of compliance, and
best practices to monitor for future quality improvements, as well as a short list of resources. Be
sure to include all appropriate citations.
3
Part 1
BHA4006
Week 5 Assignment: Compliance Program
Implementation and Ethi…
Health care is one of the most heavily regulated, major industries in the United States.
Leaders are challenged to stay current and to comply with federal, state, and local laws and
their associated regulations. Health care organizations are also responsible to meet
industry standards. In some cases, payers equate meeting industry standards with
achieving and maintaining accreditation. In fact, many payers consider accreditation a
minimum condition of participation. In addition, individual licensure and certification
requirements establish basic expectations for health care leaders’ professional conduct.
In summary, health care leaders are responsible to:
1. Meet ethical, personal, professional conduct, certification, and licensure
expectations.
2. Comply with local, state, and federal health care and human resources laws.
3. Provide evidence of compliance with existing regulations and scan the field for
emerging regulations.
4. Identify and meet appropriate accrediting body standards (for example, The
Joint Commission’s National Patient Safety Goal standards).
As an individual’s health care leadership career advances, so does the corresponding level
of accountability. Not knowing the laws or regulations is not an excuse for not complying
with them.
This assignment allows you to demonstrate your knowledge of and skills relating to
compliance concepts and governmental and regulatory agencies that oversee health care
service delivery, billing, and general operations. You will also have the opportunity to apply
the components necessary to initiate and maintain an effective compliance program.
Finally, you will consider relevant human resources laws that may pertain to your
compliance recommendations.
Preparation
You already are familiar with HIPAA but you may want to conduct independent research to
enhance your knowledge. Consult the Health Care Administration Undergraduate Library
Research GuideLinks to an external site. for additional guidance on how to conduct
research using credible sources.
Continue your role of an early careerist in risk management and quality improvement at
one of Vila Health’s community-based hospitals. You are working on a team-based initiative
under the supervision of the Vila Health chief compliance officer. Your role is to assist in
addressing a specific compliance risk regarding a breach of privacy and potential HIPAA
violation. A Vila Health employee has disclosed—without prior written authorization—a
patient’s protected personal health information.
Here is the information the team has collected to date about the privacy breach and
potential HIPAA violation:
•
•
•
•
A Vila Health supervisor instructed an employee to obtain pre-authorization for
an upcoming surgical procedure for a patient.
The Vila Health employee submitted confidential, protected health care
information about the patient to the insurance company.
The Member Services Representative at the insurance company contacted the
Vila Health supervisor.
The insurance company representative indicated that it cannot discuss the
matter without prior written consent from the patient.
As part of the team exploring the privacy breach, you must prepare a workplace brief with
authoritative, evidence-based references to support your work.
Instructions
For this assignment, you will create a workplace brief rather than a scholarly paper. Use
the Compliance Program Implementation and Ethical Decision-Making Template [DOC] to
write your brief.
Be sure to address all of the following in your brief.
Background
A short paragraph of no more than five or six sentences describing the known details about
the privacy breach/HIPAA violation.
Problem Summary: Privacy Breach/HIPAA Violation
Summarize the relevant health care compliance concepts that apply to this privacy
breach/HIPAA violation. Be sure to consider the following:
•
•
•
•
Federal, state, and local laws and associated regulations.
Disclosure.
Human resource concepts and laws.
Industry and accrediting body standards.
Seven Essential Elements of an Effective Compliance
Program
Recalling your readings on the seven essential elements of an effective compliance program
as determined within the Federal Register, apply each of the seven essential components of
an effective health care compliance program to this HIPAA breach.
Privacy Breach Consequences
Provide a synopsis of the consequences for an individual leader, other internal health care
organization stakeholders, and the health care organization for failing to take immediate
actions to address a privacy breach. At a minimum, be sure to consider all of the following
in your synopsis:
•
•
•
•
Patient safety.
Financial losses.
Employment status.
Individual and organizational violations of the law.
o Legal consequences.
o Civil liability.
Evidence-Based Recommendations
Construct evidence-based recommendations to resolve the HIPAA-related privacy breach.
You also may want to include relevant information related to:
•
•
•
•
Human resource laws.
Professional codes of ethical conduct or standards.
Previous case precedents.
Current alleged health care legal violations.
Tip: Visit the Health Information PrivacyLinks to an external site. website from the weekly
readings and explore the links on the site.
Ethical Decision-Making Framework for Health Care
Leaders
Describe steps in a health care industry-approved ethical decision-making framework as
one of your concluding recommendations.
Tip: Review Nelson’s 2015 article, “Making Ethical Decisions,” from the Week 3 readings.
Conclusion
Write a paragraph that summarizes the following:
•
•
•
Key concepts.
The importance of compliance.
Best practices to monitor for future quality improvements.
•
Short list of resources.
Note: Be sure to cite all resources using current APA format.
Review Evidence and APA, and apply the appropriate format for the type of reference you
provide.
Additional Requirements
Your assignment should meet the following requirements:
•
•
•
•
•
Written communication: Use the Compliance Program Implementation and
Ethical Decision-Making Template [DOC]. Your workplace brief must be clear,
concise, well-organized, and free of errors in grammar, punctuation, and
spelling. The title page, citations, and references must be in current APA format.
Length: 4–6 typed, single-spaced pages, including the reference page.
Font and font size: Times New Roman, 12 point.
Title page: Develop a descriptive title of 5–15 words. It should stir interest yet
maintain professional decorum. Ensure that your title page conforms to
current APA formatLinks to an external site..
References: Include a minimum of six current, authoritative citations and
references in current APA format.
Please review the rubric so that you understand how your faculty member will evaluate
your work. Submit your assignment as a Word document.
View Rubric
Compliance Program Implementation and Ethical Decision Making
Compliance Program Implementation and Ethical Decision Making
Criteria
Ratings
Summarize the relevant health care compliance concepts that apply to a
HIPAA privacy breach.
view longer description
17 to >14.45 pts
DISTINGUISHED
Summarizes the
relevant health care
compliance concept
that apply to a HIPA
privacy breach and
cites relevant
sources to support
the summary.
14.45 to >11.9 pts
Compliance Program Implementation and Ethical Decision Making
Compliance Program Implementation and Ethical Decision Making
Criteria
Ratings
PROFICIENT
Summarizes the
relevant health care
compliance concept
that apply to a HIPA
privacy breach.
11.9 to >0 pts
BASIC
Summarizes health
care compliance
concepts but they a
not relevant, do not
apply to a HIPAA
privacy breach, or
the summary is
incomplete,
inaccurate, or
otherwise flawed.
0 pts
NON_PERFORMANC
Does not summariz
the relevant health
care compliance
concepts that apply
to a HIPAA privacy
breach.
Provide a synopsis of the consequences to individual leaders and other
internal stakeholders of not addressing a HIPAA privacy breach.
view longer description
17 to >14.45 pts
DISTINGUISHED
Provides a synopsis
of the consequence
to individual leader
and other internal
stakeholders of not
addressing a HIPAA
privacy breach and
Compliance Program Implementation and Ethical Decision Making
Compliance Program Implementation and Ethical Decision Making
Criteria
Ratings
cites sources to
support the synops
14.45 to >11.9 pts
PROFICIENT
Provides a synopsis
of the consequence
to individual leader
and other internal
stakeholders of not
addressing a HIPAA
privacy breach.
11.9 to >0 pts
BASIC
Provides a synopsis
of the consequence
to individual leader
and other internal
stakeholders of not
addressing a HIPAA
privacy breach, but
the synopsis is
incomplete,
inaccurate, or
otherwise flawed.
0 pts
NON_PERFORMANC
Does not provide a
synopsis of the
consequences to
individual leaders
and other internal
stakeholders of not
addressing a HIPAA
privacy breach.
Apply the seven essential elements of an effective compliance program to a
HIPAA privacy breach.
17 to >14.45 pts
DISTINGUISHED
Compliance Program Implementation and Ethical Decision Making
Compliance Program Implementation and Ethical Decision Making
Criteria
Ratings
view longer description
Applies the seven
essential elements o
an effective
compliance program
to a HIPAA privacy
breach and cites
sources to support
the application.
14.45 to >11.9 pts
PROFICIENT
Applies the seven
essential elements o
an effective
compliance program
to a HIPAA privacy
breach.
11.9 to >0 pts
BASIC
Applies the seven
essential elements o
an effective
compliance program
to a HIPAA privacy
breach, but the
application is
incomplete,
inaccurate, or
otherwise flawed.
0 pts
NON_PERFORMANC
Does not apply the
seven essential
elements of an
effective complianc
program to a HIPAA
privacy breach.
Compliance Program Implementation and Ethical Decision Making
Compliance Program Implementation and Ethical Decision Making
Criteria
Ratings
Recommend evidence-based actions to address a HIPAA privacy breach.
view longer description
17 to >14.45 pts
DISTINGUISHED
Recommends
evidence-based
actions to address a
HIPAA privacy
breach and cites
sources that
demonstrate the
recommendations
are evidence-based
14.45 to >11.9 pts
PROFICIENT
Recommends
evidence-based
actions to address a
HIPAA privacy
breach.
11.9 to >0 pts
BASIC
Recommends action
to address a HIPAA
privacy breach, but
the
recommendations
are not evidencebased or the actions
are described
incompletely or
inaccurately.
0 pts
NON_PERFORMANC
Does not recommen
evidence-based
actions to address a
HIPAA privacy
breach.
Compliance Program Implementation and Ethical Decision Making
Compliance Program Implementation and Ethical Decision Making
Criteria
Ratings
Describe a health care industry-approved ethical decision-making
framework.
view longer description
16 to >13.6 pts
DISTINGUISHED
Describes a health
care industryapproved ethical
decision-making
framework and cite
sources to indicate
the framework is
health care industry
approved.
13.6 to >11.2 pts
PROFICIENT
Describes a health
care industryapproved ethical
decision-making
framework.
11.2 to >0 pts
BASIC
Describes an ethica
decision-making
framework but the
framework is not
health care industry
approved or the
description is
incomplete,
inaccurate, or
otherwise flawed.
0 pts
NON_PERFORMANC
Does not describe a
health care industry
approved ethical
decision-making
framework.
Compliance Program Implementation and Ethical Decision Making
Compliance Program Implementation and Ethical Decision Making
Criteria
Ratings
Write a clear, concise, well-organized, error-free workplace brief
addressing a HIPAA privacy breach that is reflective of professional
communication in the health care field.
view longer description
16 to >13.6 pts
DISTINGUISHED
Writes a clear,
concise, wellorganized, error-fre
workplace brief
addressing a HIPAA
privacy breach that
reflective of
professional
communication in
the health care field
and cites sources
using APA style and
formatting.
13.6 to >11.2 pts
PROFICIENT
Writes a clear,
concise, wellorganized, error-fre
workplace brief
addressing a HIPAA
privacy breach that
reflective of
professional
communication in
the health care field
11.2 to >0 pts
BASIC
Writes a workplace
brief addressing a
HIPAA privacy
breach but it is not
clear, concise, well
organized, error fre
or reflective of
professional
Compliance Program Implementation and Ethical Decision Making
Compliance Program Implementation and Ethical Decision Making
Criteria
Ratings
communication in
the health care field
0 pts
NON_PERFORMANC
Does not write a
clear, concise, wellorganized, error-fre
workplace brief
addressing a HIPAA
privacy breach that
reflective of
professional
communication in
the health care field
Total Points: 0
Part 2
BHA4010
Week 5 Assignment: Qualitative Research
Questions and Methods
Introduction
Qualitative research uses inductive reasoning based on an exploration or observation. The
focus is typically on the researcher investigating the reasons why something happened. The
information comes from interviews or observations. The answers emerge as more
information is discovered. You could relate it to the work of a detective who gathers facts
and organizes them to find patterns that lead to explanations for events.
In this assignment, you will continue to expand your understanding of a research
framework in the context of qualitative research by analyzing and evaluating research
questions in qualitative studies. You will also continue to analyze the interrelated elements
of a research study, making the connection between theory, problem, purpose, and, now,
qualitative research questions and design.
Summary
For this assignment, you will craft a qualitative research question based on the HAC that
you selected for the Research Problem and Purpose Statements assignment. You will also
examine qualitative methodologies and data collection strategies that would enable you to
answer your research question.
There is no length requirement for this assignment. Most submissions that fully address all
scoring guide criteria will be 2–5 pages long.
Instructions
For this assignment, it is suggested that you build on the work that you did in the Research
Problem and Purpose Statements assignment. This assignment has two distinct parts.
Part 1: Qualitative Research Question
For this first part of the assignment, you will formulate a research question that is
appropriate for a research project that will use qualitative methodologies. Remember the
HAC that you used in your Research Problem and Purpose Statements assignment for this
course. Your research question should align with the problem and purpose statements that
you developed in this assignment. A well-written research question should be a single
statement.
When examining or creating qualitative research questions, the following checklist may be
useful.
Qualitative Research Question Checklist
•
•
•
•
•
•
•
•
•
Does the purpose statement fit logically with the problem statement? Does the
purpose statement use similar words to the problem statement, or does it seem
to address a different topic?
Do the research questions align with the method and design of the study? For
instance, are words like perception used that would automatically reject a
quantitative study?
Do questions seek to describe responses to the variables described in the study?
Do the questions begin with the word why?
Do the questions focus on a single phenomenon?
Do the questions include exploratory verbs?
Is the language non-directional?
Are the questions open-ended?
Do the questions specify the participants and research site?
Relevant Scoring Guide Criteria
•
•
Formulate a qualitative research question.
Communicate in a manner that is scholarly, professional, and respectful of the
diversity, dignity, and integrity of others and is consistent with expectations
for health care professionals.
Part 2: Qualitative Methods and Data Collection
For this second part of the assignment, you will draw on your readings about qualitative
methods and data collection to first identify specific qualitative methodologies that will
enable you to answer your research questions. You will then discuss specific qualitative
data collection tools or strategies that are appropriate for answering your research
questions. Questions to consider when looking for tools and strategies and tools include:
•
•
•
Which research question are you specifically trying to answer?
How does the specific HAC affect the types of tools and strategies that would
work best?
How does the health care setting where the research project will occur affect the
types of tools and strategies that would work best?
This part should include a review of why it is important to a potential research plan as a
whole to ensure that your data collection plan is relevant to your chosen methodology.
This section should be 2–5 pages long, depending on the level of detail required to fully
present your methodologies and data collection tools and strategies.
Relevant Scoring Guide Criteria
•
•
•
•
Identify relevant qualitative methodologies that will support answering a
research question.
Describe qualitative data collection tools or strategies that are appropriate for
answering research questions.
Explain the importance of methodologically relevant data collection to a
research plan as a whole.
Communicate in a manner that is scholarly, professional, and respectful of the
diversity, dignity, and integrity of others and is consistent with expectations
for health care professionals.
Additional Submission Requirements
•
•
•
•
•
Structure: Include a title page, table of contents, and reference page.
Length: There is no length requirement for this assignment. Most submissions
that fully address all scoring guide criteria will be 2–5 pages long.
References: Cite at least five current scholarly or professional resources. You
may find the Capella University Library: Search by MethodologyLinks to an
external site. guide helpful.
Format: Use APA style for references and citations.
o You may wish to refer to the following APA resources to help with
your structure, formatting, and style:
▪ Evidence and APALinks to an external site..
▪ APA Style Paper Tutorial [DOCX]Links to an external site..
Font: Times New Roman font, 12 point, double-spaced for narrative portions
only.
Competencies Measured
By successfully completing this assignment, you will demonstrate your proficiency in the
following course competencies and scoring guide criteria:
•
•
•
Competency 1: Explain the different types of health care research
methodologies.
o Identify relevant qualitative methodologies that will support
answering a research question.
o Describe qualitative data collection tools or strategies that are
appropriate for answering research questions.
o Explain the importance of methodologically relevant data collection
to a research plan as a whole.
Competency 2: Develop a research question based on a hospital-acquired
condition.
o Formulate a qualitative research question.
Competency 4: 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
Communicate in a manner that is scholarly, professional, and
respectful of the diversity, dignity, and integrity of others and is
consistent with expectations for health care professionals.
View Rubric
Week 5 Assignment: Qualitative Research Questions and Methods
Week 5 Assignment: Qualitative Research Questions and Methods
Criteria
Ratings
Formulate a qualitative research question.
view longer description
40 to >34 pts
DISTINGUISHED
Formulates a
qualitative research
question, providing
specific examples.
34 to >28 pts
PROFICIENT
Formulates a
qualitative research
question.
28 to >0 pts
BASIC
Describes a
qualitative research
question.
0 pts
NON_PERFORMANC
Does not describe a
qualitative research
question.
Identify relevant qualitative methodologies that will support answering a
research question.
view longer description
40 to >34 pts
DISTINGUISHED
Identifies relevant
qualitative
methodologies that
will support
answering a researc
question and offers
brief rationale for
why the identified
Week 5 Assignment: Qualitative Research Questions and Methods
Week 5 Assignment: Qualitative Research Questions and Methods
Criteria
Ratings
qualitative
methodologies are
relevant.
34 to >28 pts
PROFICIENT
Identifies relevant
qualitative
methodologies that
will support
answering a researc
question.
28 to >0 pts
BASIC
Lists qualitative
research
methodologies, but
their relevance to a
specific research
question is incorrec
or unclear.
0 pts
NON_PERFORMANC
Does not list
qualitative research
methodologies.
Describe qualitative data collection tools or strategies that are appropriate
for answering research questions.
view longer description
40 to >34 pts
DISTINGUISHED
Describes qualitativ
data collection tools
or strategies that ar
appropriate for
answering research
questions and offer
a brief rationale for
why the data
collection tools or
Week 5 Assignment: Qualitative Research Questions and Methods
Week 5 Assignment: Qualitative Research Questions and Methods
Criteria
Ratings
strategies are
appropriate.
34 to >28 pts
PROFICIENT
Describes qualitativ
data collection tools
or strategies that ar
appropriate for
answering research
questions.
28 to >0 pts
BASIC
Identifies qualitativ
data collection tools
or strategies, but
their relevance for
answering research
questions is unclear
or inappropriate.
0 pts
NON_PERFORMANC
Does not identify
qualitative data
collection tools or
strategies.
Explain the importance of methodologically relevant data collection to a
research plan as a whole.
view longer description
40 to >34 pts
DISTINGUISHED
Explains the
importance of
targeted data
collection to a
research plan as a
whole. Notes areas
related to a researc
question where
targeted data
Week 5 Assignment: Qualitative Research Questions and Methods
Week 5 Assignment: Qualitative Research Questions and Methods
Criteria
Ratings
collection will be
valuable or
potentially
challenging.
34 to >28 pts
PROFICIENT
Explains the
importance of
methodologically
relevant data
collection to a
research plan as a
whole.
28 to >0 pts
BASIC
Describes targeted
data collection, but
does not offer a full
or clear explanation
as to its importance
to a research plan a
a whole.
0 pts
NON_PERFORMANC
Does not describe
targeted data
collection.
Communicate in a manner that is scholarly, professional, and respectful of
the diversity, dignity, and integrity of others and is consistent with
expectations for health care professionals.
view longer description
40 to >34 pts
DISTINGUISHED
Communicates with
exceptional clarity i
a manner that is
scholarly,
professional, and
respectful of the
diversity, dignity,
Week 5 Assignment: Qualitative Research Questions and Methods
Week 5 Assignment: Qualitative Research Questions and Methods
Criteria
Ratings
and integrity of
others and is
consistent with
expectations for
health care
professionals.
34 to >28 pts
PROFICIENT
Communicates in a
manner that is
scholarly,
professional, and
respectful of the
diversity, dignity,
and integrity of
others and is
consistent with
expectations for
health care
professionals.
28 to >0 pts
BASIC
Communicates in a
manner consistent
with expectations fo
the health care
profession.
0 pts
NON_PERFORMANC
Does not
communicate in a
manner consistent
with expectations fo
the health care
profession.
Total Points: 0