Hospital Compliance of University of California San Francisco Medical Center
Research a real-world hospital in the United States for the organization's compliance or governance plan. It is suggested that a national or a large healthcare delivery system be considered, as some smaller or regional hospitals may not meet the assignment content requirements listed below. Also, depending on the organization, the content may be prominent on their website, use different terminology for compliance or governance, or be within the organizational strategic plans. Dig deep within the organization's website or use appropriate external sources.
Examine how the plan(s) minimizes organizational liability and risk while supporting compliant business and clinical operations. The lens of this analysis should be that of a healthcare administrator in the C-suite.
The following topics are required and should be presented, in this order, within the body of an APA paper – see additional formatting requirements. Students are welcome to add other topics supporting a comprehensive organizational review for compliance and governance.
Explain the hospital's senior leadership organizational structure by position vs. name. Depending on the hospital's selection, this may include the board of directors, the C-suite, or an executive team.
In addition, create an organizational chart that includes the executive management team's positions (not individual leadership names).
Describe the hospital's licensing and certification status. Include any specific federal or state regulations that are acknowledged on the organization's website to guide these programs.
Also, identify who, by position, has direct responsibility for the compliance or governance program(s). From your learned knowledge, is this sufficient for the organization? Please explain.
Present the hospital's accreditation status, including which organization(s) they are accredited by, and explain its accreditation standing. Students may need to go to the accrediting agency's website to review if not included on the hospital's website.
Collectively, evaluate the organizational compliance or governance program(s) and demonstrate how they reduce the hospital's liability and promote sound business operations. If you feel the program(s) does not do one or both, provide a solid counter-argument with specifics on how the organization could improve.
Grading Criteria
Student writing should be at the academic level, unbiased language in the third person, and proper healthcare and legal vernacular.
Assigned papers will require APA formatting (most current edition), including the title and reference pages. If you are unsure how to format using APA style, please see the Writing Center or Learning APA Style.
Excluding the APA title and reference pages, the papers should be between 1,000 - 1500 words in the body. The word count requires the substance to be concise, robust, logical, and demonstrate complete knowledge of the weekly content. Although not in proper APA formatting, please include the word count for the paper's body at the very bottom of the title page. For assistance with determining the word count, please see the following Microsoft Word resource.
The body of the paper should include first level APA headings for all content or topics when required. Having the required content as first-level headings will support students in meeting the content requirements and the paper's focus on the required subjects. Students are welcome to add subheadings at the second or third levels, but the first level is required. The APA Citation Guide can assist with formatting, including headings.
All sources used within the paper's body (directly and paraphrased) must be cited in the body of the paper and on the required reference page per APA requirements and should not exceed 20%. Content from other sources that exceed 20% could indicate a lack of originality or possibly plagiarism and will be addressed following the Academic Integrity Policy noted below.
Third-party plagiarism software, such as Turnitin, may be used to assess the originality of a student's work in any assignment, papers, and quizzes, or exams to rule out plagiarism. NOTE: a link is provided in the course for students to submit a DRAFT Turnitin submission for a pre-review before submitting for grading to meet course and SU requirements.
The quality of the content will be assessed using the attached rubric. All criteria in the category must be met to earn the full points. See attached rubric.
Hospital Compliance
Student's Name
Institutional Affiliation
Instructor's Name
Date
The University of California San Francisco Medical Center
The real-world hospital chosen for this analysis is the University of California San Francisco Medical Center (MC). As a Major college medical facility, UCSFMC is situated in San Francisco, California. It is a University of California San Francisco Medical Center and Clinics (UCSF) component (Shete et al., 2020). It is a significant supplier of emergency, outpatient, and inpatient services to patients in northern California. As a sizable healthcare delivery system, UCSFMC gives a wide range of patients comprehensive medical care. The hospital is dedicated to delivering exceptional patient care, conducting ground-breaking research, and training the upcoming generation of healthcare professionals. It has achieved national recognition for its excellence in patient care, research accomplishments, and teaching excellence (Shete et al., 2020). UCSFMC has implemented a robust compliance and governance program to minimize its risk and liability while promoting compliant business and clinical operations as part of its commitment to excellence.
Senior Leadership Organizational Structure
At UCSFMC, the senior leadership organizational structure consists of a Board of Directors, a C-Suite, and an Executive Team. The Board of Directors is in charge of establishing the hospital's overarching direction and policies. Executive officers, clinical leaders, and other community members comprise the group, which is presided over by a person with extensive experience in healthcare, finance, and law. Chief Operational Officer, Chief Nursing Officer, Chief Medical Officer, Chief Financial Officer, Chief Information Officer, Chief Risk Officer, and Chief Quality Officer make up the C-Suite. The C-Suite provides operational oversight and strategic guidance to ensure the hospital meets its goals and objectives. The Executive Team comprises Vice Presidents from all departments within the facility and is responsible for developing and implementing strategies to achieve excellence in patient care, research, and teaching.
UCSFMC's Chief Quality Officer (CQO) is responsible for the organization's compliance and governance program. An internal compliance officer and the department of quality, patient safety, and risk management support the CQO. The Internal Compliance Officer oversees the implementation of CMS regulations and the facility's Quality Improvement Program. The Quality, Patient Safety & Risk Management Department monitors and manages risk and quality programs and oversees the investigation and resolution of patient complaints.
Organizational Chart
The organizational chart for the executive management team at UCSFMC is as follows:
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132588022860000330708024574600319277921336000UCSFMC Organization Structure
21240753416300-276225330200
45910503048000The C-Suite Board of Directors Executive Team
64769932386002948941609600053816257048600
Chief executive officerExecutive OfficersVice Presidents
Chief Operating OfficerCommunity Members
Chief Nursing OfficerClinical Leaders
Chief Medical Officer
Chief Financial Officer
Chief Information Officer
Chief Risk Officer
Chief Quality Officer
Licensing and Certification Status
The California Department of Public Health (CDPH) grants UCSFMC licenses and certifications, and the Joint Commission Accreditation of Healthcare Organizations (JCAHO) (Schmaltz et al., 2011). It has also received accreditation from the American College of Radiology, the Commission on Accreditation of Rehabilitation Centers, and the College of American Pathologists. The California Medical Association and the California Nursing Association both acknowledge the hospital. The Centers for Medicare and Medicaid Services (CMS) criteria are fully met by UCSFMC. The CMS administers the Children's Health Insurance Program (CHIP), Medicaid, and other programs. This government organization is a part of the U.S. Department of Health and Human Services.
Several state and...