Regulatory Environment – Executive Summary

Create a 3–4-page executive summary of tools and best practices for quality improvement, risk management, and learning guidelines. 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:
  • Identify metrics for measuring or monitoring the risk-management issue.
  • Propose how you will make use of the outcome data for organizational improvement.
  • Organizational Improvement: State how you will encourage voluntary reporting.
  • 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.

    Additional Requirements

    • Written communication: Written communication should be free from errors that detract from the overall message. (You must include the Executive Summary Table as an appendix to your report.)
    • Length of paper: 3–4 double-spaced pages for the written portion of the assessment.
    • Number of resources: A minimum of three resources.
    • APA Format: Use appropriate APA format for clear, concise presentation of information. Communicate information and ideas accurately, utilizing peer-reviewed sources, including proper APA reference citations.
    • Font and font size: Times New Roman, 12 point.

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