Risk Management Program Analysis



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.










Risk Management Program Analysis (Part 2)

Grand Canyon University


















The Role of Joint Commission in evaluating organizational risk.

The joint commission plays a significant role in evaluating the organization’s risk management program. The JC stresses the connection between risk management and performance activities (MIPAA, 2019). The provision calls the hospital to analyze various activities for any potential risks. By allowing the organization to connect preference activities to risk management, it facilitates risk analysis in every job to help in the identification of risk. The measures also enable risk management professionals to identify risks that cannot be identified through ordinary procedures.

The JC recommends measures to allow organizations to target loss prevention actions. The commission suggests measures such as Root Cause Analysis (RCA), a systematic approach for identifying the causes of accidents and the measures to overcome the causes (MIPAA, 2019). The RCA is significant for fall prevention because it enables the organization to identify and analyze the causes of falls and the possible solutions.

The JC also recommends Failure Mode and Effects Analysis (FMEA) which is crucial for identifying weakness within the clinical services and high-risk procedures (MIPAA, 2019). The FMEA measures and recommendations also enable the hospital to identify risks based on various procedures and how weaknesses of the various services can lead to fall risks. The JC recommends special resources and expertise such as the patient safety officer (PSO), whose role is to ensure excellent patient care and services. The PSO can help the hospital identify various risks related to patients that can increase the chances of falling.



Administrative personnel and their roles in enforcing risk management protocols

Managers play a significant role in risk management in the hospital. Their main duty is to oversee the risk analysis and prevention measures to ensure they are updated and effectively accomplish the desired objectives. The procurement and risk management managers and departments ensure the hospital has the necessary resources to mitigate the risk (Hendrich, 2018). They ensure the hospital has special facilities such as movement-assisted devices, which are crucial for achieving safety and quality standards set by the Joint Commission.

The risk manager and his team are responsible for organizational risk identification and analysis. They analyze all the processes and services to identify potential sources of risks. They also collaborate with other members from various departments to ensure the hospital can identify factors contributing to the rising risks in the hospital (Hendrich, 2018). The risk management department, led by the various managers, oversees risk evaluation to ensure the organization takes instant measures to deal with the risks. The risk manager also files a risk assessment report and presents it to the organization’s management board to seek instant action.

The human resources department ensures the hospital has the right personnel to enforce risk management procedures. This includes employing competent and enough nurses and other medical personnel to improve medical care serves delivered to patients. The measure also increases the patient-nurse ratio, reducing risks due to lack of adequate nursing care and assistance (Hendrich, 2018). The human resources department is also responsible for training the medical personnel to ensure they have the necessary skills to implement and enforce various risk prevention standards set by the hospital.