HCS/456 v5 Organizational Performance Management Table Choose a health care organization and research it to complete this table, and then share it with your learning team as you collaborate to complete your presentation. Include your tables as appendices in your presentation. 1. Provide a name of or link to a specific health care organization. Summarize the key products or services provided by the organization and identify the primary customers it serves. Organization Overview Cleveland Clinic Link: https://my.clevelandclinic.org/ Key services provided: Some of the key services provided and diseases managed by the Cleveland clinic include primary care services, cancer management, dermatology care, plastic surgery, gastrointestinal diseases management, neurological diseases care, endocrinology and metabolism, urology, ophthalmology, pediatrics, health and wellness promotion, and respiratory disease treatment. Primary Customers: The primary customers served at the facility includes patients from different age groups and their family members, physicians and other healthcare staff, investors, researchers, and medical equipment suppliers. 2. Outline the overall content of the major regulations, accreditation requirements, and other standards that affect the organization. Provide the title, section, parts, or subparts, or the numbering system, etc. of the specific regulations or accreditation requirements. Responses should be at least 100 words. For example: Use of electronic signatures in electronic medical records is equivalent to handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200 Electronic Signature Organization Regulations, Accreditation, and Standards 1. Major regulations: A. Regulation bodies include: a) Federal regulation bodies like U.S. Food and Drug Administration (FDA), Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services, and HealthIT. b) State regulation bodies include Ohio Department of Health and the Ohio Department of Insurance. Copyright 2020 by University of Phoenix. All rights reserved. Organizational Performance Management Table HCS/456 v5 Page 2 of 4 c) Industry related regulation bodies include: American Medical Association B. Regulations provided by the bodies Federal: Regulations associated with the Affordable Care Act (ACA), HIPPA for patient and health information privacy protection, and adherence to health insurance reforms State: Regulations found at http://codes.ohio.gov/oac/ (Ohio department of insurance and Ohio administrative code) 2. Accreditation Requirements a. The Joint Commission b. Ohio Department of Health (ODH) c. Accreditation Council for Graduate Medical Education (ACGME) d. Centers for Medicare and Medicaid Services (CMS) e. National Committee for Quality Assurance (NCQA) Other accreditation bodies (https://my.clevelandclinic.org/departments/patientexperience/depts/quality-patient-safety/accreditation): i American Association of Blood Banks (AABB) ii American Association of Tissue Banks (AATB) iii American Board for Certification Orthotics and Prosthetics (ABC) iii American Society for Bariatric Surgery (ASBS) iv American Standards of Histocompatibility & Immunogenetics (ASHI) v College of American Pathologists (CAP) Other standards that affect the organization Departments, accreditation, clinical risk management, environmental safety, quality control, quality data registries, quality improvement, environmental safety, bioethics, and infection control. 3. Highlight the effect the organization’s regulations, accreditation requirements, and other standards have on risk management functions and activities. Responses should be at least 100 words. Effects on Risk Management Regulations use by the organization: HIPPA, Patient Rights, Informed Consent, and Pension Protection Act of 2006 Copyright 2020 by University of Phoenix. All rights reserved. Organizational Performance Management Table HCS/456 v5 Page 3 of 4 Accreditation and Licensure: The Joint Commission, Ohio Department of Health, Centers for Medicaid and Medicare, American Association of Blood Banks, American Association of Tissue Banks, College of American Pathologists, American Standards of Histocompatibility & Immunogenetics, American Board for Certification Orthotics and Prosthetics, the Ohio Department of Mental Health, and the American Society for Bariatric Surgery. Risk management functions and activities: Clinical risk management, Infection control, proper handling of patients and management of their conditions and reduction in risks of complications or errors, quality improvement of activities conducted in the facility, ensuring that all the staff have the required training and education qualifications, and health insurance issues management. 4. Identify specific components of performance-management systems—policies and procedures, self-audits, benchmarking, complaint management, corrective or preventive action, education and training, communication, and other mechanisms—to be used by the organization. Responses should be at least 100 words. Organizational Performance Management Systems The performance-management systems components involves the use of strategic performance standards and measures, progress reports, and quality improvement efforts. Performance standards: Some of the standards include identifying relevant standards to different departments in the organization, selecting proper indicators, setting goals and objectives, and communicating the information and expectations. Measures of performance: Performance measures include refining of indicators, developing databases, and collecting data. Process: The processes included entails use of clinical data for decision-making, using strategic approaches to address clinical issues, and developing of a learning environment Quality improvement efforts: These measures include use of data for clinical data in decision-making, creating a positive organization culture that supports learning, and using feedback mechanism Policy and procedures: The policies and procedures used by the organization are based on state and federal guidelines and recommendations. Complaint management: Complaints are brought forward through the human resource department or the department affected by the issue related to the complaint Communication: Communication is done through a top-down approach and departmental approaches, which aims at addressing issues affecting the organization 5. Provide several links to relevant sources that will be useful as your learning team completes the paper. Additional Links Copyright 2020 by University of Phoenix. All rights reserved. Organizational Performance Management Table HCS/456 v5 Page 4 of 4 Links: Health IT Legislation. (2020, May 19). Retrieved from HealthIT.gov: https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislation Department of Health and Human Services. (2020, June12). Retrieved from HHS.gov: www.hhs.gov US Department of Labor – Occupational Safety & Health Administration. (2017, January 10). Retrieved from OSHA.gov: https://osha.gov/SLTC/healthcarefacilities/standards.html Cleveland Clinic. (2020, June 10). Retrieved from Cleveland Clinic.org: http://my.clevelandclinic.org/ Copyright 2020 by University of Phoenix. All rights reserved. HCS/456 v5 Organizational Management Performance Table Brandee Spector Risk Management/HCS235 University of Phoenix June 22, 2020 Qiana Amos Copyright 2020 by University of Phoenix. All rights reserved. Organizational Performance Management Table HCS/456 v5 Page 1 of 3 Organizational Performance Management Table Choose a health care organization and research it to complete this table, and then share it with your learning team as you collaborate to complete your presentation. Include your tables as appendices in your presentation. 1. Provide a name of or link to a specific health care organization. Summarize the key products or services provided by the organization and identify the primary customers it serves. Organization Overview The Mayo Clinic is a non-profit organization that provides quality health care services to patients. The organization has three locations that offer a wide variety of health care services such as cancer care, gastroenterology, surgery, pediatrics, and gynecology. The organization offers health care services for pediatric, adult, and geriatric patients. Link: https://www.mayoclinic.org/ 2. Outline the overall content of the major regulations, accreditation requirements, and other standards that affect the organization. Provide the title, section, parts, or subparts, or the numbering system, etc. of the specific regulations or accreditation requirements. Responses should be at least 100 words. For example: Use of electronic signatures in electronic medical records is equivalent to handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200 Electronic Signature Organization Regulations, Accreditation, and Standards The Mayo Clinic is affected by many regulations, standards, and accreditation requirements for patient safety and the delivery of high -quality care. The Mayo clinic received Magnet Recognition for their nursing program from the American Nursing credentialing center. The Mayo clinic adheres to the federal regulatory- Agency for Healthcare Research and Quality Patient Safety Indicators(PSI) which consist of 26 indicators to assess the facility’s compliance in patient safety. The Mayo clinic follows the HIPAA Privacy Rule, the EMTALA Act regarding the anti-dumping in patient emergency situations and the HITECH Act regarding the meaningful use of health information technology. The Mayo Clinic is accredited by the Joint Commission. Rules and Regulations: Copyright 2020 by University of Phoenix. All rights reserved. Organizational Performance Management Table HCS/456 v5 Page 2 of 3 Agency for Healthcare Research and Quality 26 Patient Safety Indictors (PSI) Health Insurance Portability and Accountability Act (HIPAA), Privacy Rule (2000), Pub. L. No. 104-191 (42 U.S.C. § 1320d-2 note) 45 C.F.R. Part 160 and Subparts A and E of Part 164 Meaningful use of Health Information Technology, Health Information Technology for Economic and Clinical Health Act(2009), Pub. L. No. 111-5, 123 Stat 115. Emergency Medical Treatment and Labor Act (1986), 42 CFR Parts 413, 482, and 489 [CMS-1063-F] RIN 0938-AM34 Health care Reform Patient Protection and Affordable Care Act 2010, Public Law 111-148, HR 3590 3. Highlight the effect the organization’s regulations, accreditation requirements, and other standards have on risk management functions and activities. Responses should be at least 100 words. Effects on Risk Management The Mayo Clinic’s success is dependent on the capability to adhere to the federal regulations and accreditation standards set forth by agencies. Patients have a high level of expectations regarding their care and expect facilities such as the Mayo Clinic to be in compliance. Stakeholders Risk management teams must understand and monitor the regulatory and accreditation requirements in addition to, performing risk analysis assessments and demonstrate willingness throughout all aspects of the facility to make improvements. As these regulations and requirements drive the policies and procedures of risk management. Utilization of the Enterprise Risk Management core domains and drivers will greatly assist in formulating structured processes throughout all levels of the organization to further enhance patient safety and outcomes. 4. Identify specific components of performance-management systems—policies and procedures, self-audits, benchmarking, complaint management, corrective or preventive action, education and training, communication, and other mechanisms—to be used by the organization. Responses should be at least 100 words. Organizational Performance Management Systems There are important components of performance management systems that can be utilized by organizations such as the Mayo Clinic in order to identify potential risks, make necessary improvements, and achieve compliancy. For instance, conducting patient satisfaction and employee surveys to measure results for areas of focus and improvements. Another component is the use of information technology applications that can electronically report any “near miss” or incidents within the facility. If a patient safety event occurs, conducting an interview to determine the risk and the correct course of preventive action. Another aspect is continual education and training for employees regarding compliance and risks. The Mayo Clinic organization has an Audit and Compliance Committee that conducts self-audits in consultation with the Chair of Risk management to investigate any improprieties of the organization. Copyright 2020 by University of Phoenix. All rights reserved. Organizational Performance Management Table HCS/456 v5 Page 3 of 3 5. Provide several links to relevant sources that will be useful as your learning team completes the paper. Additional Links https://www.nursingworld.org/organizational-programs/magnet/ – Magnet recognition program https://www.ahrq.gov/cpi/corecompetencies/index.html- Agency for Healthcare Research and Quality https://www.qualityindicators.ahrq.gov/modules/psi_resources.aspx AHRQ quality indicators https://www.hhs.gov/regulations/index.html – Regulations for health care organizations https://www.hhs.gov/regulations/additional-regulations/index.html https://www.qualitycheck.org/quality-report/?keyword=mayo%20clinic&bsnid=369946 -Joint Commission Accreditation. https://www.healthit.gov/sites/default/files/privacy-security/federal-privacy-laws-table2-26-10-final.pdf https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/Downloads/CMS-1063-F.pdf https://www.mayoclinic.org/documents/audit-and-compliance-committee-charter/doc-20462821 -Audit and Compliance Officer committee of Mayo Clinic Copyright 2020 by University of Phoenix. All rights reserved. HCS/456 v5 Organizational Performance Management Table Choose a health care organization and research it to complete this table, and then share it with your learning team as you collaborate to complete your presentation. Include your tables as appendices in your presentation. 1. Provide a name of or link to a specific health care organization. Summarize the key products or services provided by the organization and identify the primary customers it serves. Organization Overview Houston Methodist Orthopedics & Sports Medicine in Nassau Bay. The key services is rehabilitation as far as physical therapy, rehabilitation therapy and speech therapy. Primary customers are those that have musculoskeletal system issues and those that have impairments preventing them from moving efficiently. 2. Outline the overall content of the major regulations, accreditation requirements, and other standards that affect the organization. Provide the title, section, parts, or subparts, or the numbering system, etc. of the specific regulations or accreditation requirements. Responses should be at least 100 words. For example: Use of electronic signatures in electronic medical records is equivalent to handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200 Electronic Signature Organization Regulations, Accreditation, and Standards Some of the regulations that must be adhered to are the Antitrust laws (the Sherman Act, the Federal trade Commission Act (FTC) and the Clayton Act, the Health Insurance Portability and Accountability Act (HIPAA) Privacy rule located at 45 CFR Part 160 and Subparts A and E Part 164, the patient safety and Quality Improvement Act of 2005 Statute and Rule subpart C pursuant to section 922, HIPAA’s security rule found at 45 CFR 160, 162, and 164, HIPAA’s privacy and Security Framework, HIPAA’s personal health records and the submission notice of a breach in 45 CFR Part 164.408. There are also standard within their own facility in relation to accuracy of records, charts and other documents, retention and disposal of records, charts and other documents, information security and confidentiality, computer passwords, medical and billing records and personnel records. 3. Highlight the effect the organization’s regulations, accreditation requirements, and other standards have on risk management functions and activities. Responses should be at least 100 words. Copyright 2020 by University of Phoenix. All rights reserved. Organizational Performance Management Table HCS/456 v5 Page 2 of 2 Effects on Risk Management The regulations and standards mentioned in section 2 play a major role on the effects of risk management. These regulations and standards allow the organization to have things in place that must be adhered to in order to ensure the safety and security of patients while performing tasks with the patients, but also the information that they input electronically related to the diagnosis and progress of the patient. It helps to safeguard their personal information. Another thing that the regulations and standards does is that it sets the tone for the culture of the organization which embeds risk management in every step of the process that they do from discussing the diagnosis of the patient to their billing information , etcetera. 4. Identify specific components of performance-management systems—policies and procedures, self-audits, benchmarking, complaint management, corrective or preventive action, education and training, communication, and other mechanisms—to be used by the organization. Responses should be at least 100 words. Organizational Performance Management Systems Lets look at promotions and transfers. In order for an employee to be promoted they must meet the minimum experience, background and education requirements, have a minimum of six months of active employment in current role, have n formal counseling record for misconduct in the last six month, complete a formal online application notify current manager prior to attending a scheduled interview with hiring manager and immediately notify their current manager upon acceptance of the internal transfer offer. They are given the opportunity of reporting questionable practices which can be kept anonymous. There is a hotline number and email provided which helps to keep performance management systems intact. There are values that assist with performance which are integrity, compassion, accountability, respect and excellence (ICARE). 5. Provide several links to relevant sources that will be useful as your learning team completes the paper. Additional Links https://www.houstonmethodist.org/-/media/pdf/hr/Employee_Handbook https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/HIPAAACA/StatutesandRegulations?gclid=EAIaIQobChMIvLqr96L6gIVycDACh0IZwYdEBYYASAAEgLQOvD_BwE https://www.hhs.gov/hipaa/for-professionals/breach-notification/breach-reporting/index.html Copyright 2020 by University of Phoenix. All rights reserved.

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