Policy Analysis: Hahnemann University Hospital's Fall Prevention Policy
Introduction
Organizational policy alignment and adherence to laws and regulations are critical for overall corporate compliance and to decrease organizational risks (patient falls, medication errors, cyber hacks and PHI data breaches, infection control, et cetera). In this assignment, you will select, evaluate, and update one health care provider's policy related to a significant regulatory risk to the health care organization.
use the Hahnemann Falls Policy Links to an external site. to complete this assignment, following these instructions:
As you can see, this policy was written in 2012. Now, imagine you are a health care administrator working at the health care organization where this policy originates from.
Analyze the policy, taking into consideration the changes in HIPAA and PHI since 2012.
Evaluate what information and where that information would need to be updated for a current revision of this document.
Locate the areas where you would update or add information to this 2012 version. Propose revisions that are based on current identified standards and/or new guidelines that you have researched in the text or identified in other high-quality sources (that is, journals, government websites, and the like).
Analyze the significance of the selected policy updates as it relates to potential litigation. (Why did the policy need updating? What threats do these changes help avoid?)
Summarize your perspective on the revisions as well as any additional changes that should be considered.
Present your work as an executive summary suitable for distribution to your organization's board members.
Your paper should be 3-5 pages long and should include a title page and references, for a total of 5-7 pages.
-Analyze a problematic or dated health care policy, explaining its primary purpose and effectiveness.
-Determine the issues the selected policy poses as it is written and any related ramifications.
-Research the changes needed to update and align the policy with current standards and guidelines.
-Propose revisions that are based on current identified standards and/or new guidelines.
-Analyze the significance of the selected policy updates as it relates to potential litigation.
-Summarize personal perspective on the revisions as well as any additional changes that should be considered
Policy Analysis: Hahnemann University Hospital's Fall Prevention Policy
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Policy Analysis: Hahnemann University Hospital's Fall Prevention Policy
Introduction
Patient fall remains one of the most significant challenges in patient safety, despite being avoidable. Patient falls present an economic burden to patients and healthcare organizations (LeLaurin & Shorr, 2019). Healthcare organizations also face potential litigations when patients experience injuries or death following a fall. To this end, many healthcare organizations have implemented fall prevention programs or policies. The policies provide healthcare professionals with guidelines on preventing falls and responding in the event of a fall. However, the effectiveness of the fall policies is influenced by how current the policy is, especially because the more recent the policy, the more evidence-based it is and the more it incorporates current changes in regulations. This executive summary analyzes Hahnemann University Hospital's fall prevention policy by identifying issues in the policy, proposing revisions, and discussing the legal significance of the proposed revisions. It also offers a personal perspective on the revisions.
The Policy
Hahnemann University Hospital's fall prevention policy was written in 2002 and has only been revised once, in 2013. This means that the hospital has been using the same policy for fall prevention for almost ten years without considering changes in regulation and current evidence. The policy’s primary purpose is to establish the guidelines for patient fall prevention, patient fall risk assessment, healthcare professionals’ actions in the event of a fall, and staff responsibility for patient safety (Hahnemann University Hospital, 2013). The policy effectively defines terms pertaining to patient falls, such as intentional and accidental falls. It also identifies the key factors that increase the risk of patient falls, including those associated with secondary diagnoses.
Further, the policy describes the procedure for the initial risk of fall assessment, performed by the admitting registered nurse using the Morse Fall Scale Risk Screening Tool (Hahnemann University Hospital, 2013). It also provides the procedure for follow-up assessment and medication-related fall assessment. As part of the medication-related fall assessment, the policy includes a list of medication classifications that can increase the risk of falls. It also provides guidelines for post-fall management, including injury assessment, radiological studies and tests, the individuals to be notified of the fall, vital signs assessment, and documentation of the fall in the patient’s medical records. All these aspects make the policy effective in fall prevention. However, several issues hinder its effectiveness, especially in light of current regulations and evidence. These issues are discussed in the section below.
Issues Identified in the Policy
One of the primary issues identified is in relation to HIPAA and PHI. Specifically, the policy does not address HIPAA compliance in patient referrals. It indicates that for patients with low and moderate risk of falls, one of the interventions should be "referral to appropriate disciplines such as physical therapy (Hahnemann University Hospital, 2013).” Referrals to such disciplines require healthcare professionals to share information with specialists. The policy must ensure that these patient referrals comply with HIPAA. According to Tariq and Hackert (2023), the medical records shared during referrals contain PHI, covered under HIPAA. Healthcare professionals don't need to obtain consent from the patient, but they must ensure that the person receiving the records is the referral provider. The policy does not provide guidelines on how healthcare professionals can ensure HIPAA compliance when referring patients at risk of falls to appropriate disciplines/practices.
Another key issue in the policy is the lack of utilization of electronic health records (EHR) in identifying or assessing the risk of falls. According to Moskowitz et al. (2020), an assessment tool incorporating patients' EHR is more effective in assessing a patient’s risk of falls than the Morse Fall Scale Risk Screening Tool. Such a tool does not require additional data collection because it relies on new data documented in the patient's EHR. A different study found that EHR data, especially those obtained from nurses' progress notes, contain a clinical judgment aspect that is helpful in the assessment of the risk of falls (Bjarnadottir & Lucero, 2018). This clinical judgment aspect is absent in existing fall-risk assessment tools. The fall assessment tool used in Hahnemann University Hospital’s fall policy lacks this aspect too.
Also, the policy does not incorporate the training of healthcare professionals concerning patient falls. Although the policy shares the guidelines that the staff can use to assess the risk of falls and the...