Risk Management, Quality Improvement, and Patient Safety.
Case Scenario Analysis: you have been hired in the CAO’s newly created position (Chief
Administrative Officer) for a regional medical center. The responsibilities have been broken
away from the COO (Chief Operational Officer) to focus primarily on all business and revenue
generation activities.
You are a member of the hospital’s executive management team (Chief Executive Officer, Chief
Operational Officer, Chief of the Clinical Staff (medical and nursing), Chief Information Officer,
Chief Compliance Officer, and Chief Quality and Risk Management Officer, and legal counsel.
The hospital is a nonprofit. The services provided within the hospital include cardiac
rehabilitation, emergency department, radiology, pediatrics, same-day surgery, a retail
pharmacy, ophthalmology and optical, oncology, limited physical rehabilitation, and physical
therapy, patient education, substance abuse, renal dialysis, and obstetrics. The Joint
Commission accredits the hospital with recertification in 2 years.
In your initial and informal strategic assessment, you felt several areas warranted further review,
both under the Chief Compliance Officer. You were not because of any dereliction of
responsibilities by the Chief Compliance Officer. The foundation discussed was exclusively
business and fiscally based:
1. The separated responsibilities of risk management, patient safety, and quality improvement
from a business perspective.
2. The limited or defined methods and practices to minimize medical malpractice within the
organization. Of specific concern were medical errors, adverse events, and hospital infections,
even though there was no medical malpractice claim filed against the organization or any
clinical provider.
In your discussion with the CEO, she asked for an inclusive memorandum of record back to her
to address the following from a business case assessment. You have been there long enough to
know the CEO is thorough and bases her decisions on collaboration, data, facts, and legal
authority with the two primary objectives of high quality of care minimizing risk to the
organization. Hence, she expects your proposal to utilize supporting evidence.
1. Examine the responsibilities of process improvement, risk management, patient safety, and
quality improvement in a healthcare organization from a business case perspective. The CEO is
explicitly asking, since there is a Chief Compliance Officer, how these responsibilities could be
(or should be) the responsibility of both members of the C-suite or remain under the Chief
Compliance Officer.
2. Propose specific risk reduction strategies to mitigate medical malpractice, medical errors, and healthcare-associated infections (HAI’s) from a business assessment. Again, use supporting evidence in your proposal to the CEO.
3. Knowing that these two responsibilities are multidisciplinary, recommend a C-suite and upper
management ad hoc team by hospital positions to exam the items above for recommendations
for process improvement teams. Support your recommendations with justification for industry
standards or best practices