Organizational Compliance: Financial and Regulatory Impact Report

This report provides a comprehensive analysis of organizational compliance within the healthcare sector, focusing on its financial and regulatory implications. The report discusses the importance of professional standards, training programs, and performance measure metrics in enhancing patient safety and care quality. It highlights the impact of compliance on hand hygiene practices, infection control, and the reduction of medical negligence costs. The study compares compliance rates at Daffodils Hospital with national averages, identifies areas for improvement, and proposes strategies for implementing changes, including electronic data management and staff training. The report also addresses the challenges faced during implementation, such as funding and staff cooperation, and emphasizes the role of stakeholders, including hospital staff, patients, and their families, in ensuring successful compliance and improved healthcare outcomes. The report includes references to relevant literature and an appendix with a Gantt chart for compliance monitoring.

Running head: ORGANIZATIONAL COMPLIANCE
Organizational Compliance
Name of the student
University name
Author’s note

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Executive Summary (refer to appendix)
The current report discusses the financial and regulatory impact of organizational
compliance with professional standards. The enhancement in performance of the healthcare
staff could be brought about by implementing sufficient training programs. Some of these
training programs help the workforce in being industry ready along with improving the
quality of care. As commented by Brubakk, Vist, Bukholm, Barach & Tjomsland (2015), a
well trained healthcare staff also means that specialized care services to the patients admitted
within the hospital could be delivered. A workforce which is compliant with the industry
standards helps in ensuring that the safety standards are met and prevents the occurrence of
legal breaches.
The implementation of a performance measure metrics plays a pivotal role in the
maintenance of the professional standards. Some of these have been described with reference
to financial regulations. The Institute of Medicine (IOM) has taken performance evaluation in
healthcare as one of the major objectives of professional standards maintenance. Some of the
key areas focused upon as per the current regulation are- diabetes, depression, pain control in
advanced cancer stages. The 100,000 lives campaign was implemented in the year 2005 with
a vision to reduce the mortality rates in hospitals. The protecting 5 million lives from harm
were implemented with a view to reduce the chances of occurrence of central line-associated
bloodstream infection in hospitals (Anthony, Appari & Johnson, 2014).
As suggested from figures and stats the cost of medical negligence in US is around
$55.6 billion a year, which accounts to 2.4% of the nation’s entire healthcare expenditure
(Flodgren, Gonçalves‐Bradley & Pomey, 2016). In this respect, abiding by the healthcare
regulations can help in ensuring effective patient safety and care. Some of the policies which
could be mentioned over here are –Patient Protection and Affordable Care Act, 2010, Health

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Insurance Portability and Accountability Act (HIPPA) etc. Therefore, compliance with these
measures can help in regulating the excess charges generated on annual healthcare due to
medical negligence (Brubakk et al., 2015).
In this respect, some of the changes which could be implemented for facilitation in
compliance monitoring within my current healthcare have been discussed over here. This
could be done by installing an electronic database in the current healthcare setup, where the
performance charts of each and every healthcare staff is recorded and evaluated over time. As
commented by Duncan, Thorne & Rodney (2015), a well motivated staff had less turnover
rates compared to less engaged staff.
In this respect, the compliance rates with professional working standards of the
Daffodils hospital could be compared with the overall compliance rates of the US based
hospitals. With the emergence for antibiotic resistant organisms hand hygiene had become of
utmost importance. An overall compliance rate of 81% has been achieved for hand hygiene
for the US based hospitals. The internal survey conducted in the Daffodils hospital combining
the ICU and the non-ICUs received a score of 56%, which is relatively low compared to
overall state standards. High rates of readmission due to post operative secondary infections
were observed for the daffodils hospital. Therefore, following up of the professional
standards would help in ensuring that the hygiene standards are maintained within the
perioperative care. As commented by Greenfield et al. (2016), this prevents the unnecessary
admissions and the controls the additional healthcare costs.
Hand hygiene is one of the most important factors for the prevention of infections
within an acute healthcare setup. In this respect, the methods which are most commonly used
by the Daffodils hospital are – direct observation, self reporting by healthcare workers,
calculation based upon hand hygiene product usage. After conducting a one year study, it was

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found that the hand hygiene compliance rate was 23% at baseline for intensive care units and
31% for non-ICUs (Smiddy, O'Connell & Creedon, 2015). There is no fixed protocol for
measuring the compliance rates of hand hygiene within an acute care setup. It varies with
each and every organization where some organization would focus upon whether the action
was performed before and after in the intensive care unit. As commented by Tschudin-Sutter,
Sepulcri, Dangel, Schuhmacher & Widmer (2015), linking actions of hand hygiene with the
indications for hand hygiene described in the professional guidelines. In this respect, use of
maximal barrier precautions during central line insertions can also reduce the rate of
infection.
The economic implications of changing the hand hygiene practices are unclear. It has
been confirmed further that there is a cost saving to standardize practice. The physicians have
reported regarding reduced costs on prescribing antibiotics, following cystitis treatment
guidelines (Duncan, Thorne & Rodney, 2015). Data had been gathered for annual costs on
hand hygiene products from product purchase orders. The daffodils hospital used the cost per
100 beds as standard unit of measurement based upon the usage of soap, paper towels and
alcohol rubs. Per 100 beds a cost of almost 100 us dollars were noted, which could amount to
a huge figure when taken on an additive basis. In order to further measure the compliance
rates of hand hygiene a simple calculation was used by the daffodils hospital were the
number of actual hand hygiene episodes were divided by the total indications for hand
hygiene. To estimate the ratio of alcohol rub usage, the number of hand hygiene which
occurred with alcohol was divided by the number of episodes which occurred with soap and
water. The results were obtained on the higher side which further proved that alcohol was
more effective than soap and water (Chassin, Mayer & Nether, 2015).
A number of steps could be undertaken for implementing changes within my current
organization for maintenance of the professional healthcare standards are:

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 Conducting internal performance survey
 Changing with past records and histories of medical negligence
 Working out a training plan
 Imparting training to the employees
 Exposure to in house practical session
Thus, working in accordance with the professional nursing standards can help in
enhancing accountability on the part of the healthcare professionals, which can reduce the
chances of error within an emergency and trauma care.
Some of the prime stakeholders who would be affected by the change are the hospital
staffs, the patients and their respective families. As commented by Greenfield et al. (2016), a
more responsible and accountable staff would help in raising the standards of the healthcare
services along with reducing unnecessary healthcare costs. The changes within the
Thus, working as a healthcare inspector some of the challenges could be faced by me
during implementation of the changes within the Daffodils regional institute of healthcare due
to lack of sufficient finances and effective cooperation from the healthcare staff. The
installation of effective electronic data management systems requires huge amount of
investment on the part of the hospital. However, the lack of sufficient funds might hinder the
progress of my current healthcare organization compared to others. However, as argued by
Coventry, Maslin‐Prothero & Smith (2015), installation of such software improves the
workflow system within the healthcare set up.
Therefore, proposing a detailed and well researched plan to the stakeholders can help in
generating sufficient and the required amount of finances. As commented by Duncan et al.
(2015), educating the healthcare staff on the benefits of following the performance
regulations which can reduce chances of accidents due to medical negligence.

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References
Anthony, D. L., Appari, A., & Johnson, M. E. (2014). Institutionalizing HIPAA compliance:
Organizations and competing logics in US health care. Journal of health and social
behavior, 55(1), 108-124.
Brubakk, K., Vist, G. E., Bukholm, G., Barach, P., & Tjomsland, O. (2015). A systematic
review of hospital accreditation: the challenges of measuring complex intervention
effects. BMC health services research, 15(1), 280.
Chassin, M. R., Mayer, C., & Nether, K. (2015). Improving hand hygiene at eight hospitals in
the United States by targeting specific causes of noncompliance. Joint
Commission journal on quality and patient safety, 41(1), 4-12.
Coventry, T. H., Maslin‐Prothero, S. E., & Smith, G. (2015). Organizational impact of nurse
supply and workload on nurses continuing professional development
opportunities: an integrative review. Journal of advanced nursing, 71(12),
2715-2727.
Duncan, S., Thorne, S., & Rodney, P. (2015). Evolving trends in nurse regulation: What are
the policy impacts for nursing's social mandate?. Nursing inquiry, 22(1), 27-38.
Flodgren, G., Gonçalves‐Bradley, D. C., & Pomey, M. P. (2016). External inspection of
compliance with standards for improved healthcare outcomes. The Cochrane Library.
Greenfield, D., Hinchcliff, R., Hogden, A., Mumford, V., Debono, D., Pawsey, M., ... &
Braithwaite, J. (2016). A hybrid health service accreditation program model
incorporating mandated standards and continuous improvement: interview study of

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multiple stakeholders in Australian health care. The International journal of health
planning and management, 31(3).
Smiddy, M. P., O'Connell, R., & Creedon, S. A. (2015). Systematic qualitative literature
review of health care workers' compliance with hand hygiene
guidelines. American journal of infection control, 43(3), 269-274.
Tschudin-Sutter, S., Sepulcri, D., Dangel, M., Schuhmacher, H., & Widmer, A. F. (2015).
Compliance with the World Health Organization hand hygiene technique: a
prospective observational study. infection control & hospital
epidemiology, 36(4), 482-483.
Appendix
Attributes 0-4 months 5-8 months 9-12 months
Conducting internal
performance survey

Developing a
training plan along
with assessment of
the training costs

Presentation of the
plan to the
supervisors and
gathering of funds

Imparting in-house
training to the


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employees
Evaluation of
performances

Gantt chart for compliance monitoring
(Source: Author)