Introduction
When speaking about the healthcare field, one can surely understand the main goal is to deliver quality care and improve patient outcomes. However, in order to achieve such outcomes, healthcare organizations must prioritize regulatory and accrediting compliance in each department. Thus, for the department to enhance patient safety and quality of care, it is essential to address the gaps of insufficient training, poor documentation, and a lack of standardized processes and find a program that would help ensure compliance with standards.
Gap Analysis
Approaching Regulatory or Accreditation Compliance
To approach regulatory or accrediting compliance, the healthcare department should implement a comprehensive process that consists of several steps. The first step of the process involves conducting regular internal audits. Internal audits are utilized to assess the quality management system using standards (Hut-Mossel et al., 2021). To ensure impartial judgment, internal audits are performed by internal auditors within the hospital’s own organization, which might include quality officers or medical specialists from a different department than the one being reviewed (Hut-Mossel et al., 2021).
Another step in the process is to establish specific rules and guidelines that align with regulations and accreditation standards. Such approaches will help create documents to ensure compliance (Young & Smith, 2022). Finally, the department should focus on the implementation of proper education and training initiatives. According to Wu and Busch (2019), education can enhance patient safety and healthcare quality. Training on ethical standards and safety protocols can significantly improve both patient safety and care quality (Wu & Busch, 2019). Therefore, the department should follow a comprehensive process.
Current or Potential Gaps in Compliance
There are several potential gaps in compliance that are worthy of mentioning. For example, the first gap is poor documentation that might not adhere to regulations and standards. In cases of inadequate documentation, risks of litigation might follow (Kasaye et al., 2022). Moreover, nurses’ commitment to patient safety guidelines is necessary for the enhancement of care quality and the avoidance of clinical errors (Vaismoradi et al., 2020).
In this case, whenever there is a lack of standardized processes, there might be inconsistencies in the delivery of care, which can lead to negative outcomes. Consequently, medical errors and variations in patient care can follow. Finally, inadequate training can be considered a significant gap in compliance. Inadequate training programs can result in a lack of regulatory and standard awareness (Bigdeli et al., 2021). Without paying close attention to such gaps, it is impossible to ensure efficiency in a healthcare setting.
Recommendations
Corrective Action Strategies
When discussing recommendations and corrective action strategies, several can be highlighted. The first corrective action strategy is to implement an Electronic Health Record (EHS) system. Existing literature has emphasized the advantages of deploying EHR, including better patient safety policies, better patient outcomes, and lower costs (Upadhyay & Hu, 2022).
Moreover, the department should establish specific procedures and protocols for clinical processes. For example, these can involve surgical site verification, medication administration, and infection control (Beauchemin et al., 2019). Finally, sufficient attention should be paid to the education and training programs implemented in the department. For instance, the programs can focus on ethical guidelines, documentation practices, and patient safety protocols.
Implications of Non-Compliance
At the same time, it is crucial to understand that failure to comply with the mentioned gaps can have significant implications for the department. For example, the most obvious implication of non-compliance is legal action and financial penalties (Leslie et al., 2021). Meanwhile, such penalties can result in decreased trust from partners and patients.
Another implication associated with non-compliance can be seen in the compromised health of the patients. In instances when there is a lack of training and poor process standardization, medical errors can jeopardize the health outcomes of individuals (Rodziewicz et al., 2023). Therefore, the implications that stem from non-compliance pose both monetary and non-monetary risks.
Establishing an Accreditation or Compliance Program
Finally, it is crucial to establish a compliance program within the department to ensure effective outcomes. First, in order to choose the optimal program, it is necessary to focus on the design of the program and outline its main components, such as goals, scope, and others. This will additionally involve focusing on programs that are unique to the department’s specialty. Moreover, another step in the adoption of the program is its implementation.
On the one hand, the department will have to assign specific staff members to manage the program. On the other hand, it will be essential to establish communication channels to address concerns and training. Finally, an ongoing evaluation will be a significant part of the adoption of the program. Ongoing collection and analysis of feedback and performance indicators will be vital.
Conclusion
In summary, addressing the gaps of inadequate training, subpar documentation, and a lack of standardized processes is crucial for the department to improve patient safety and the standard of care. Among the potential gaps in compliance are poor documentation, a lack of standardization processes, and training. The recommendations involve paying attention to training staff, establishing procedures and protocols, and implementing the EHR systems. Implications of non-compliance in such circumstances can be legal actions and risks to patient health outcomes. The program that should be established by the department should focus on the key components of the program, its control, and evaluation.
References
Beauchemin, M., Cohn, E., & Shelton, R. C. (2019). Implementation of clinical practice guidelines in the health care setting: A concept analysis. Advances in Nursing Science, 42(4), 307–324. Web.
Bigdeli, S., Arabshahi, S. K. S., Sohrabi, Z., & Zazoly, A. Z. (2021). Exploring the challenges of educational accreditation of teaching hospitals and providing the solutions. Journal of Education and Health Promotion, 10, 1-8. Web.
Hut-Mossel, L., Ahaus, K., Welker, G., & Gans, R. (2021). Understanding how and why audits work in improving the quality of hospital care: A systematic realist review. PloS One, 16(3), 1-25. Web.
Kasaye, M. D., Beshir, M. A., Endehabtu, B. F., Tilahun, B., Guadie, H. A., Awol, S. M., Kalayou, M. H., & Yilma, T. M. (2022). Medical documentation practice and associated factors among health workers at private hospitals in the Amhara region, Ethiopia 2021. BMC Health Services Research, 22(1), 1-13. Web.
Leslie, K., Moore, J., Robertson, C., Bilton, D., Hirschkorn, K., Langelier, M. H., & Bourgeault, I. L. (2021). Regulating health professional scopes of practice: comparing institutional arrangements and approaches in the US, Canada, Australia and the UK. Human Resources for Health, 19(1), 1-12. Web.
Rodziewicz, T.,Houseman, B., & Kipskind, J. (2023). Medical error reduction and prevention. National Library of Medicine. Web.
Young, M. & Smith, M. A. (2022). Standards and evaluation of healthcare quality, safety, and person-centered care. National Library of Medicine. Web.
Upadhyay, S., & Hu, H. F. (2022). A qualitative analysis of the impact of electronic health records (EHR) on healthcare quality and safety: Clinicians’ lived experiences. Health Services Insights, 15, 1-7. Web.
Vaismoradi, M., Tella, S., A Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ Adherence to Patient Safety Principles: A Systematic Review. International Journal of Environmental Research and Public Health, 17(6), 1-15. Web.
Wu, A. W., & Busch, I. M. (2019). Patient safety: a new basic science for professional education. GMS Journal for Medical Education, 36(2), 1-15. Web.
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