Establishing a Culture of Patient Safety

1. Create a 3–4-page executive summary of tools and best practices for quality improvement, risk management, and learning guidelines.
2. Include a summary table that describes the status of an organization’s compliance with regulatory requirements.


Assume you have taken on a new role as the chief operating officer. You are charged with leading system-wide risk-management efforts to identify risk and minimize HACs. Your organization’s financial viability depends on receiving proper reimbursement for services delivered. As the chief operating officer, you must create an executive summary that describes your organization’s compliance with the regulatory requirement, to promptly identify conditions that are POAs and proactively assess and manage risk.


Step One: Executive Summary Table

Select a risk-management issue within a specific health care setting or organization. You will use this issue as a starting point for your work on this assessment. Use the Executive Summary Table from the Required Resources to complete this step.

  1. Issue: Write a brief description of the risk-management issue you selected. Explain why this risk-management issue is important to your organization.
  2. Regulatory Requirements: Compile a list of the applicable regulatory requirements and an explanation of what they mean to your chosen risk-management issue.
  3. Risk-Management Implications: Identify the associated risk-management implications. For example, HACs result in no reimbursement, and poor quality ratings. Also, there is a risk of losing repeat admissions, a risk of losing Joint Commission and Magnet accreditation or excellence, or other negative implications.
  4. Environmental Assessment: Assess the internal versus external environment relative to the risks associated with your chosen risk-management issue. You may use strengths, weaknesses, opportunities, and threats (SWOT) analysis or another suitable tool. Be sure to cite the source.
  5. Resources to Address Issue: Describe any resources or strengths your organization possesses that could aid in addressing the risk-management issue.
  6. Philosophy or Culture Statement: Summarize your organization’s philosophy or culture as it relates to patient safety and error reporting.
  7. Measuring and Monitoring:
    1. Identify metrics for measuring or monitoring the risk-management issue.
    1. Propose how you will make use of the outcome data for organizational improvement.
  8. Organizational Improvement: State how you will encourage voluntary reporting.
  9. Ethics Considerations: Describe legal and ethical implications related to the handling of this risk-management issue.

Utilize established sources of information. Some sources that may be useful to you include the federal register, statutes, discipline-specific peer-reviewed journals, and government agency references.

Step Two: Executive Summary

Using the information assembled in Step One, prepare a 3–4-page executive summary for a written presentation to the management team. Select a format for your summary based on your chosen organization’s standards for executive summaries. (Examples of these types of documents can also be found using an Internet search.) Include the following:

  • A proactive assessment of your organization’s compliance with the regulatory requirement to promptly identify POAs and proactively assess and manage risk based on existing regulations and requirements.
  • Your identification of tools and best practices for monitoring parameters and reducing risk, including organizational structure needed for risk reeducation, as supported by the literature.
  • Your recommendations for quality improvement and organization-specific risk management and learning guidelines.

You must include the completed table from Step One as an appendix to this executive summary.


It is an exciting time in health care as all of us experience the implementation of the Patient Protection and Affordable Care Act of 2010. The change will likely affect your current or future health care job. Leaders in our industry are rethinking how business is to be conducted.

Understanding relevant terminology is an important step in addressing the topics of health care quality, risk management, and regulatory environment.

Read further in the Assessment 1 Context [PDF] document, which contains important information related to the following topics within the regulatory environment:

  • Quality of Services.
    • Potential Risks.
    • Regulatory Requirements.
    • Regulatory Bodies.
    • Benchmarking as a Condition of Participation.

Questions to Consider

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as a part of your assessment.

Questions to Consider

The Regulatory Environment:

  • Which regulatory bodies oversee the subsector of the health care industry in which you currently work or would like to work?
    • How would you figure out which organizations oversee the subsector?
    • How would you determine which laws apply to your setting and what type of data you need to collect and examine?
    • What are the standards of care?
    • How would you locate these standards?
    • How would you know if your organization exceeded those standards and might be in a position to apply for accreditation?

Establishing a Culture of Patient Safety:

  • What is an example of a best practice for establishing a systems-based culture of patient safety?
    • How will you know if your organization was identified as an example of success when best practices are used?


  • What types of processes exist for collecting and analyzing data to identify trends in the performance of your health care setting?
    • Who are some of the health care industry’s best performers in terms of risk management?
    • What types of benchmarking data are important to consider?
    • What roles within your own organization need to be involved in a proactive risk-management program?
    • What are some critical success factors for the establishment of a systems-based risk-management program?
    • What types of considerations or cautions are important to keep in mind when interpreting internal and external benchmarking data?
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