Health Law, Ethics, and Policy

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Business Finance

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Week 1 Ethical Theories, Dilemmas, and Decision-Making As a healthcare executive, you need to understand and be fully prepared to apply ethical theories properly and effectively (e.g., deontology, utilitarianism, consequentialism) when confronted with ethical dilemmas. A framework based on ethics provides you with the tools to analyze ethics-related issues that you will encounter. A foundation in theory, principles, and decision-making will enhance the ability to reason and enhance your role as a professional in healthcare, as well as ensure the sustainability of the organization you lead. The healthcare executive must be fully prepared to effectively apply ethical theories to guide decision-making when confronted with ethical dilemmas. Healthcare executives have leadership responsibilities to define and model ethical behavior as an example for an entire organization (Nelson, 2020). Being grounded in ethics provides an administrator with the tools for analyzing ethics-related issues that they will encounter. Four ethical principles as outlined by Pozgar (2016) serve as an ideal framework for ethical decision making in healthcare settings: beneficence, non-maleficence, respect for autonomy, and justice. Having a foundation in theory, principles, and decision-making will enhance your ability to reason and improve your role as a professional in healthcare, as well as ensure the sustainability of the organization you lead. Figure:1 Principles of Ethics Ethical principles are derived from ethical theories and “provide a generalized framework within which particular ethical dilemmas can be analyzed” (Pozgar, 2016). Often the difficult decisions that are made in healthcare involve having to choose between conflicting ethical principles. The ethical principles of healthcare are autonomy, beneficence, justice, and non-maleficence. Principle Definition Example Autonomy Also called the Seeking informed principle of human dignity; Autonomy is Latin for self- rule. It pertains to the respect for the decisions made by consent from the patient for lab work, examination, or procedure. patients concerning their own lives and healthcare. Beneficence Going beyond non- Performing the maleficence to tasks of daily ensure a patient’s living for patients well-being, who are unable to demonstrating kindness, showing do so compassion, and independently. helping. Justice Providing patients Triaging of with whatever they patients in an deserve or are emergency owed, and treating department to them fairly, equally, ensure those and impartially. whose needs are most urgent receive care first. Non- Defined as an Not administering Maleficence obligation not to a medication if the harm others, as patient is likely to exemplified in the have an allergic common phrase, reaction. "First, do no harm." If harm cannot be avoided, minimize harm as much as possible. References: Ananth, M. (2017). Clinical decision-making: The case against the new casuistry. Issues in Law & Medicine, 32(2), 143–171. Making ethical decisions. (2015). A six-step process should guide ethical decision making in healthcare. Healthcare executive, 30(4), 46-48. Accessed December 13, 2020. Pozgar, G. D. (2016). Legal and ethical issues for health professionals (4th ed.). Jones & Bartlett Publishers. ……………………………………………………………………………………………… Week 1 Assignment: Explain Decision-Making Processes for Ethical Dilemmas By now, you have read about the various ethical theories and principles, as well as ways to solve ethical dilemmas through decision-making models. You will also need to use the self-assessment resource provided this week to complete your self-assessment and examine the code of ethics that is expected to be upheld by members of the American College of Healthcare Executives. Incorporate the self-assessment in your discussion. The purpose of this assignment is to explain how decision-making processes may be applied when faced with an ethical dilemma. You will review and reflect on your own personal values and beliefs that influence how you view and analyze ethical issues, solve dilemmas, and make personal and professional decisions. Reflecting on your personal ethics provide a framework to assist in a greater understanding of the multitude of viewpoints regarding ethics and their cultural and societal influences. Be sure to include speaker notes for each slide. Create a presentation in which you address the following: Include any influences in your life that you believe have shaped your position on ethics in relation to the theories of utilitarianism, deontology, and virtue-based ethics that are presented in your readings. Discuss each of the three ethical theories and provide your agreement or disagreement with the theory based on your own value system. Describe how your background influenced your personal value system (i.e., religion or absence of religion, education, culture, ethnicity, family, and community). Discuss the results of your ACHE Ethics Self-Assessment and include your perspectives on the results in your slides. Describe a challenging ethical or moral dilemma you have faced in the past. The dilemma could have occurred in either a personal or a professional environment. Explain how you would address the dilemma differently now that you are familiar with various ethical theories and decision-making strategies, and a professional code of ethics. If you currently work in a healthcare setting, you may also want to consider your employer’s corporate culture and ethical stance. Length: A minimum of 8 slides (not including title page and reference page) References: Include a minimum of 5 scholarly resources to support the assignment. The completed assignment should address all of the assignment requirements, exhibit evidence of concept knowledge, and demonstrate thoughtful consideration of the content presented in the course. The writing should integrate scholarly resources, reflect academic expectations and current APA standards. ………………………………………………………………………………………… Week 2 The U.S. Legal System for Healthcare Administration Healthcare organizations are often faced with threats to their overall mission and bottom line due to violations of ethical, legal, and regulatory guidelines and requirements. Unethical behavior contributes to a lack of trust and satisfaction among patients and other stakeholder groups. For example, healthcare workers who are not guided by a strong personal and professional ethics are more likely to avoid their responsibilities, be absent from work, embezzle funds, or exhibit inappropriate attitudes or behaviors toward patients (Serneels & Lievens, 2018). De Vries and colleagues (2017) confirmed earlier studies that identify corrupt corporate environments as a precursor to unethical behavior. Both primary stakeholders (employees, consumers) and secondary stakeholders (regulatory agencies, accrediting organizations, civic organizations) can exert pressure on an organization in the event of a major ethical failure, which is a decision(s) that intentionally or unintentionally breaks laws, regulations, or an organization’s code of conduct. As a healthcare executive, you may be tempted to focus on the secondary stakeholder (e.g., a government agency) because the secondary stakeholder has the authority to immediately shut down a healthcare facility. However, you must also be careful not to neglect the primary stakeholders, who can contribute to an organization’s demise more gradually through lack of satisfaction or low morale. Ethical failures can also lead to legal problems. For example, lawsuits have been recently filed against one state’s department of corrections due to the failure to meet a reasonable standard of care. The lawsuit cited injury or untimely inmate deaths because of physician negligence or “deliberate indifference” (Robbins, 2018, para. 2). This same state ranks 43 out of 49 for prison health system funding. The lower level of funding was presumed to be the reason why less qualified physicians are more likely to be recruited into the system. It could be argued that a failure to address ethical issues such as distributive justice, beneficence, and non-maleficence (which will be covered in more detail later in this section) led to the multimillion-dollar lawsuits. This case illustrates why the healthcare administrator must also be familiar with laws and regulations to avoid civil and criminal penalties and lawsuits, for yourself individually and your organization. Last week, you explored ethical theories and principles, as well as your personal and professional ethics. This week, you will research the foundation of the U.S. legal system. As you can see in Figure 2, there exists a relationship between ethics and the law. Although they often overlap, ethics and the law are not interchangeable. It is possible for an action to be legal, but unethical (e.g., selling a Food and Drug Administration approved pharmaceutical that could cause addiction), or illegal, but ethical (e.g., certain actions taken during the Civil Rights Movement). Nevertheless, what is usually illegal is usually unethical (e.g., knowingly billing a patient incorrectly for financial benefit). In essence, laws are codified standards of what a society has deemed ethical behavior. Figure 2: De Silva, J. (n.d.). Business ethics: The basics. To appropriately lead healthcare organizations, it is critical that you have a working knowledge of the legal system. As an executive who understands how laws are created, you will be able to understand and anticipate changes to the healthcare landscape that will impact your organization more clearly. In addition to knowing the sources of the law (constitutional, statutory, and common/case), classification of laws (civil and criminal), the concept of checks and balances, and the trial process, you must also be familiar with legal precedents and any rules and regulations that stem from laws. It is customary for the executive leadership team to develop an organization’s policies and procedures based on federal, state, or local laws, rules, and regulations. The classifications of law, and any related regulations—as well as its implications for policy on the national, state, local or organizational landscape—will be explored further in subsequent weeks. As you analyze legal decisions you may encounter legal terms with which you are not familiar. Use the Glossary from the Elias and Nolo e-text to ensure your accurate interpretation of legal decisions for the cases you select. References de Vries, R. E., Pathak, R. D., van Gelder, J. L., & Singh, G. (2017, October 15). Explaining unethical business decisions: The role of personality, environment, and states. Personality and individual differences, 117, 188-197. Robbins, D. (2018, December 28). Settlements in prison doctor lawsuits top $3 million; could go higher. Serneels, P., & Lievens, T. (2018, January 25). Microeconomic institutions and personnel economics for health care delivery: A formal exploration of what matters to health workers in Rwanda. Human Resources for Health, 16, 1–22. ………………………………………………………………………………………. Week 2 Assignment: Analyze Legal Cases Pertaining to Healthcare Administration Issues. As a healthcare executive working in the United States, you must be familiar with the laws that govern the U.S. healthcare system. There are instances when a case arises due to a violation of a previous ethical or legal precedent. Assignment Instructions: You will select three cases from the list of 15 recent legal cases (in the resources provided for this week) considered to have significant legal implications according to the American Medical Association (2019). Prepare a legal analysis for each case. Your analysis will include the title of the case, a discussion of legal precedent, a summary of the legal opinion, and a specific discussion of how the case applies to healthcare administration decision making within the context of your own professional practice. Be sure to discuss whether each case is based on constitutional, statutory, or common law. Length: 5 pages (not including title page and reference page) References: Include a minimum of 5 scholarly resources to support the case analysis paper. The completed assignment should address all of the assignment requirements, exhibit evidence of concept knowledge, and demonstrate thoughtful consideration of the content presented in the course. The writing should integrate scholarly resources, reflect academic expectations and current APA standards. ……………………………………………………………………………………………… Week 3 Criminal and Civil Law in Healthcare Delivery Malpractice can be described as professional misconduct and/or the failure of the healthcare professional to meet a reasonable standard of care, usually due to negligence, which results in harm to the patient (Corsica, 2019). Malpractice can be best understood in the context of the healthcare provider’s scope of practice, limits of liability, and (if not an independent contractor) the responsibility of the organization which employs that individual. Figure 3 In Week 2, you learned how laws are created. This week, you will focus more specifically on criminal and civil law. To promote justice, laws are established to punish certain behaviors in a consistent manner. In healthcare, punishable behaviors could include failure to provide a reasonable standard of care, deliberate actions such as improper coding and billing for services provided, or failure to obtain consent for medical procedures. Punishments include fines and/or imprisonment. Violations of criminal law are public cases between the government and an individual or group (e.g., “The People vs…”). A criminal case can also arise from violations of administrative laws, which are regulations established by government agencies. Criminal cases are commonly known as either a felony—a serious crime requiring a minimum of a year of imprisonment—or a misdemeanor, a less serious crime requiring fines and time served up to one year. Civil law pertains to disputes between one entity and another. The two major categories in civil law are tort (harm done to others) and contract law. A tort can result from intentional acts such as battery or fraud, or through unintentional and careless acts such as negligence. A contract is an oral or written agreement between two or more parties. Violations of contract law can occur from failing to uphold one’s part in an agreement, otherwise known as a breach of contract. Civil cases can be initiated by private as well as public parties (Erstad, 2018; Legal Information Institute, n.d.). It is becoming more common for cases to involve both criminal and civil proceedings. The U.S. Department of Justice began pursuing criminal investigations by paralleling civil investigations in cases of corporate fraud. An example of a case where both criminal and civil charges were sought is when Tenet Healthcare Corporation hospitals paid kickbacks to Hispanic Medical Management for maternity referrals. The structure of the referral process resulted in improper Medicaid eligibility determination and billing practices (Schencker, 2015). Take advantage of the excellent resources this week to become familiar with examples of civil and criminal law specific to the healthcare sector. You learned in the first week that the organizational environment can either discourage or encourage unethical actions—actions that could lead to civil or criminal sanctions. Competent, ethical, and engaged chief executive officers (CEOs) are essential to “developing a culture that fosters employee voice and upward communication” (Adelman, 2012, p. 133). Adelman (2012) asserts CEOs who prioritized consistent visibility and availability to employees encourage open communication and trust- and relationship-building. CEOs are also key players in promoting a corporate culture of continuous improvement that centers on transparency of information, especially when it comes to encouraging employees to share difficult information (Adelman, 2012). Therefore, through fostering communication and a willingness to report adverse events and near-misses in healthcare settings, executives can help create a culture that reduces the likelihood of criminal and civil violations. References: Adelman, K. (2012). Promoting employee voice and upward communication in healthcare: The CEO’s influence. Journal of Healthcare Management / American College of Healthcare Executives, 57(2), 133–147. Erstad, W. (2018). Civil law vs. criminal law: Breaking down the differences. Legal Information Institute: Cornell Law School. (n.d.). Criminal law. Schencker, L. (2015). Tenet fraud probe signals feds' growing interest in criminal cases. Modern Healthcare, 45(20), 14. ………………………………………………………………………………… Week 3 Assignment: Recommend Strategies to Mitigate Risk of Negligence Litigation Within Healthcare. In Weeks 1 and 2, you read about the impact on an organization when it has a culture of hiding allegations of misconduct, failing to respond to complaints quickly or at all, and not addressing negligence or incompetence. As a healthcare executive, you want to avoid the potential loss of trust, erosion of consumer satisfaction, and low employee morale that results from a corporate culture that tolerates corruption. Assignment Instructions: Select one of the cases from the four options available in Nexis Uni (in the resources provided for this week) that are provided for this assignment. Prepare an Executive Summary for the board and executive leadership with three parts: 1) Findings of negligence; 2) Summary of specific details about where an organization’s policies and procedures failed, and 3) Conclusions and recommendations for an approach the board and executive leadership of the organization can take to mitigate risk of any similar malpractice litigation in the future. Length: 2 pages, using professional executive summary format and style, not including title page and reference page References: Include a minimum of 3 scholarly resources. The completed assignment should address all of the assignment requirements, exhibit evidence of concept knowledge, and demonstrate thoughtful consideration of the content presented in the course. The writing should integrate scholarly resources, reflect academic expectations and current APA standards. ……………………………………………………………………………………………… Week 4 Responsibilities and Liabilities for Healthcare Administrators In today’s litigious environment, it is important to understand the responsibilities and scope of practice of healthcare administrators and organizations. The healthcare executive who is knowledgeable about the responsibilities and liabilities of an organization and its employees and contractors is better positioned to avoid lawsuits and criminal charges. Arguments in defense of healthcare professionals who have been sued for malpractice include concepts such as respondeat superior. The doctrine of respondeat superior establishes the responsibility of either the physician for their own actions or the responsibility of the employer for the actions of their employees. The borrowed servant doctrine, a derivation of respondeat superior, applies when an employer lends an employee to another organization. These doctrines help to establish who is responsible for the negligent behavior, such as undiagnosed or misdiagnosed health conditions, administration of incorrect medications or incorrect dosages of medications, or not responding in a timely manner to patient complaints of pain or other complications. Legislative bodies such as the U.S. Congress or state legislatures give governmental agencies the authority to create and enforce rules and regulations. For example, the U.S. Department of Health and Human Services (HHS) oversees agencies such as the Food and Drug Administration (FDA), which regulates the development of new pharmaceuticals. Additionally, many healthcare facilities decide to go beyond the legal and regulatory requirements of government agencies, choosing to pursue and maintain healthcare accreditation. The Joint Commission accredits and certifies over 22,000 health care organizations and programs in the United States. Accreditation and certification are recognized nationwide as symbols of quality that reflect an organization’s commitment to meeting performance standards (Morgan, 2020). Organizations must likewise be prepared to prevent lawsuits or provide a successful defense against lawsuits. For example, organizations assume liability when regulatory standards have been violated (e.g., when an accident occurs in a clinic that has not adhered to safety regulations). In addition to lawsuits from patients or their families, potential suits can also arise internally. Organizations have been sued by employees, citing harassment and discriminatory practices against those in a protected class (e.g., age, disability, gender, race, religion, or sexual orientation). One way to avoid lawsuits is to establish diversity, equity, and inclusion initiatives so that employees from various backgrounds have fair representation and feel equally valued within an organization. Anti-discrimination and anti-harassment policies, and subsequent mandatory training on such policies, demonstrate an organization’s commitment to a safe working environment and will help prevent or mitigate the effect of a lawsuit. Be sure to review this week's resources carefully. You are expected to apply the information from these resources when you prepare your assignments. References Morgan, J. (2020). The Joint Commission pilots virtual surveys during pandemics. Health Facilities Management, 33(6), 8. Week 4 Assignment: Explain the Process of Professional Licensure, Certification, and Liability……. As a healthcare executive, you must be familiar with the rules that govern professional responsibility and liability not only for the health executive, but for those healthcare professionals that you employ. Additionally, you must be aware of the potential impact that lack of compliance in these areas can have on your organization. Assignment Instructions: Using Kaltura, you will create a 5-minute formal and persuasive presentation for a healthcare organization in your selected state that outlines the professional licensure process for a minimum of two types of professionals. Select a specific U.S. state and at least two types of healthcare professionals (e.g., physician assistant, physical therapist, respiratory therapist, CRNA, pharmacist, physician, nurse, etc.). Research the state’s regulations and statutes for licensure, registration, credentialing, and/or certification for the chosen professional. You must be prepared to discuss the licensure processes required of the healthcare professional to legally practice in that state. Include a summary of actions the board and executive leadership should take to protect the organization from failures to protect patients from providers with licensing or credentialing issues and to avoid discrimination lawsuits from providers who are not hired or credentialed to practice within your organization. Make sure you examine any regulations related to facility accreditation and Joint Commission requirements. Keep your target audience and purpose in mind for this presentation to set the tone and visual professional experience of your presentation. Be sure to explain the following: The process the healthcare professional must follow to achieve licensure and/or certification. The legal and extra-legal requirements. The civil complaint steps consumers or patients can follow in a case of alleged incompetence or misconduct. Credentialing processes to protect the organization from lawsuits from providers who are not hired and credentialed to practice within the organization. The process that the state’s responsible regulatory agency(ies) follows to investigate allegations and, if necessary, implement sanctions or other disciplinary actions. The possible risks of criminal liability due to incompetency, abuse, or misconduct that the organization must be prepared to prevent in their credentialing process for licensed providers in their organization. Additionally, you will create written script for your formal presentation using APA format and include this as part of your assignment along with your Kaltura presentation. Length: A minimum of 5 minutes and no more than 6 minutes References: Include a minimum of 3 scholarly resources to support the professional responsibility of the healthcare administrator to protect the organization from failures in the validating of credentials who practice in their organization. The completed assignment should address all of the assignment requirements, exhibit evidence of concept knowledge, and demonstrate thoughtful consideration of the content presented in the course. The writing should integrate scholarly resources, reflect academic expectations and current APA standards …………………………………………………………………………………………. Week 5 Federal and State Policies and Regulatory Guidelines in Healthcare Settings. In Week 1, you reviewed concepts such as distributive justice as an ethical principle. Some ethicists would argue that healthcare is a right, and it should not be administered from merely a business perspective. Regardless of your perspective, as a healthcare executive, you must give priority consideration to the top legal and regulatory issues that directly impact organizations and their decisions related to access to care and resource allocation. As an executive with significant decision-making responsibilities, you have the responsibility of stewardship of the resources (financial, human, facilities, etc.) that have been given to the organization through various stakeholders. You will need to ensure adherence to regulatory requirements and balance the sustainability and viability of your organization against its core mission to provide healthcare services to your client populations. According to the Centers for Medicare and Medicaid Services (2018), healthcare expenditures are nearly 18% of the U.S. gross domestic product (GDP), which is higher than any other nation in the world. Despite the high percentage of healthcare spending and recent policy shifts to incentivize value-based pay, organizations are challenged to meet regulatory requirements in ways that effectively utilize resources. Be sure to review this week's resources carefully. You are expected to apply the information from these resources when you prepare your assignments. References: Centers for Medicare and Medicaid Services. (2018). National health expenditure data: Historical. Fitzgerald, M. P., Bias, T. K., & Gurley, C. T. (2017). The Affordable Care Act and consumer well-being: Knowns and unknowns. Journal of Consumer Affairs, 51(1), 27– 53. ………………………………………………………………………… Week 5 Assignment: Create Standard Operating Procedures Addressing Impact on Resource Allocation and Organizational Performance Assignment Instructions: Begin with a one-page Executive Summary to introduce and summarize the six top legal issues that organizations face as listed below. Next, using the SOP template provided, you will select the Stark Law option and two additional issues of your choice, for a total of three from the six issues listed below. You will prepare three SOP documents to address the Stark Law plus the two additional issues you choose from a policy and organizational resource allocation perspective. Create SOPs that will provide policy and processes to prevent violations for each of the three issues. Each of your three SOP documents will be 1-2 pages. Choose Stark Law plus two more from the six issues below: Stark law Fraud and Abuse Equal Employment Opportunity laws Anti-kickback laws Medical malpractice Changes in reimbursement Length: 3-6 pages, plus a 1-page Executive Summary References: Include a minimum of 3-5 scholarly resources to support the content of your SOP documents. The completed assignment should address all of the assignment requirements, exhibit evidence of concept knowledge, and demonstrate thoughtful consideration of the content presented in the course. The writing should integrate scholarly resources, reflect academic expectations and current APA standards. …………………………………………………………………………………. Week 6 Impact of Technology on Legal and Ethical Aspects of Healthcare Delivery. With the adoption of technological advances come legal and ethical issues pertaining to health informatics, passive health monitoring tools, electronic health records, artificial intelligence, telemedicine, social media, and other emerging trends. Recent interviews with C-Suite leaders from Inter-Mountain Health System, JFK Health System, and others revealed a focus on resolving challenges to securely share patient information and enhance patient-centric technology applications as key priorities (Wider, 2018). Healthcare technology professionals within healthcare institutions must adapt to rapid changes. Organizations report that issues with data security are the impetus for changes in their institutions (Yelton & Schoener, 2020). Concerns revolve around risks due to cyberthreats that impact strategies, operations, and roles. In Week 1, you examined ethical decision-making, primarily from an individual perspective. This week, you will research options for decision-making from an organizational perspective. Historically, since 1992, the Joint Commission on the Accreditation of Health Care Organizations required hospitals to establish mechanisms to provide resolutions to ethical dilemmas resulting from patient care. Most hospitals responded to this requirement by forming ethics committees (Zivot, 2020). Be sure to review this week's resources carefully. You are expected to apply the information from these resources when you prepare your assignments. References: Wider, J. (2018). C-Suite innovators discuss advances in technology, cybersecurity, interoperability, analytics, and more (cover story). Health Management Technology, 39(3), 6–9. Yelton, S. J., & Schoener, B. (2020). Research: The evolution of healthcare technology management in leading healthcare delivery organizations. Biomedical Instrumentation & Technology, 54(2), 119–124. Zivot, J. B. (2020). Useful ethics committees: No mandate required. Critical Care Medicine, 48(6), 928–929. …………………………………………………………………………………… Week 6 Assignment: Facilitate a Poster Presentation for First-Time Managers… Your organization has created a task force consisting of several new managers. They are charged with exploring the impact of technology adoption within your organization and providing recommendations to the Ethics Committee for guidelines they will develop. This task force is part of your organization’s approach to succession planning and identifying high performing managers to fast-track to expanded leadership responsibilities, so you have a big responsibility to prepare the task force for success. You have been asked to prepare an educational poster presentation to inform the task force on key issues as part of their kick-off planning retreat. Your organization has recently made a significant investment in the acquisition and adoption of new technology to enhance organizational performance and the patient experience and the Ethics Committee is looking forward to the recommendations from this task force. Be sure your poster presentation is engaging and effective at preparing the task force to assume a thorough and comprehensive approach in their efforts. Your presentation will inform that task force on the role of the Ethics Committee as well as the key issues that technology adoption poses for the Ethics Committee’s work. Assignment Instructions: create an engaging and informative poster presentation for the task force as part of their kick-off retreat to inform them of the role of the Ethics Committee and emerging issues related to technology adoption (i.e., mobile devices, patient portals, telemedicine/telehealth, artificial intelligence (AI) systems). You will address the role of the Ethics Committee and a minimum of two specific legal and ethical implications, including relevant regulatory guidelines, for at least three types of technology in your poster presentation. Statutes and regulations related to privacy, patient’s rights, and responsibilities. Statutes and regulations related to data protection and privacy. Current principles of patient consent. Health information management and confidentiality. Organizational strategies for data breach or disaster recovery. References: Include a minimum of 5 scholarly resources to support the content of your poster. The completed assignment should address all of the assignment requirements, exhibit evidence of concept knowledge, and demonstrate thoughtful consideration of the content presented in the course. The writing should integrate scholarly resources, reflect academic expectations and current APA standards. …………………………………………………………………………… Week 7 Corporate Compliance, Fraud, and Abuse. At its very core, the purpose of healthcare is to bring vital services to patients so that they can enjoy good health and, thus, a better quality of life. The individuals who provide these services should be able to perform their activities in an environment that is safe and allows them to operate at the top of their profession. In some geographic regions, the healthcare market is saturated, and competition for potential clients is stiff. The healthcare organization that delivers consistently high-quality value to its constituents is the one that will differentiate itself from its competition. It is your responsibility as a healthcare executive to ensure that your organization is scandal-proof—free from negative news coverage, poor patient outcomes, low customer satisfaction, and employee morale issues. It is not possible to separate the ethical operation of an organization from its ability to avoid legal difficulties. Fraud and abuse are a threat not only to individual healthcare organizations but also to the national healthcare system. In the fiscal year 2016, the U.S. Department of Justice (DOJ) recovered about $4.7 billion in settlements and judgments from civil cases involving fraud and false claims. Over half of that amount, $2.5 billion, was from cases related to the healthcare industry (DOJ, 2016). Throughout the last decade, the media has often reported on major healthcare scandals. For example, in 2009, 60 Minutes had an episode that described how Medicare was fraudulently billed $60 billion for services or products that were never provided or delivered. The Centers for Medicare and Medicaid are required to pay claims within a short time, either 15 or 30 days. The payment turnaround made it difficult to investigate false claims. However, the DOJ, the FBI, and several state attorneys general have taken on investigating these claims. Medicare has taken steps to make enrollment more stringent so that phony companies are less likely to be able to commit fraud in the future (CBS News, 2009). Such cases of fraud cause great harm to the taxpayers, whose dollars go into a public trust to administer two of the largest direct health services programs in the world. However, it is the smaller cases of fraud that go almost unnoticed and not reported by the media that result in a similar degree of harm to the U.S. healthcare system. Abuse, providing unnecessary services, and overbilling for services are also detrimental to the system of healthcare. As stated in Week 3, cases of fraud and abuse result in both criminal and civil charges. In the face of such large-scale corruption in 1991, the U.S. Sentencing Commission (USSC) adopted guidelines that provided rules and principles for the sentencing of organizations that commit fraud and abuse. Moreover, the Thompson Memorandum, otherwise known as Principles of Federal Prosecution of Business Organizations, established guidelines that U.S. attorneys can use in determining whether to bring an enforcement action against an organization (U.S. Sentencing Commission, 2015). These guidelines and principles have been updated in keeping with the changes in the corporate climate, with the latest proposed changes announced in late 2018 (U.S. Department of Justice, 2018). In response, leaders of healthcare organizations began to establish corporate compliance programs to prevent and mitigate the effects of fraud and abuse. The U.S. Department of Health and Human Services’ Office of the Inspector General (OIG) is responsible for disseminating compliance guidance to healthcare organizations. As you learned in Weeks 1 and 3, the environment of an organization can determine whether ethical behavior is encouraged or discouraged, and the leadership of an organization directly impacts the environment. Executives must go beyond fostering the right environment and establish policies and procedures to ensure that their organizations do not commit acts of fraud and abuse. References: CBS News. (2009). Medicare fraud: A $60 billion crime. U.S. Department of Justice. (2015). U.S. States Attorney’s Office, District of New Jersey: Compounding pharmacist sentenced to 20 months in prison for paying kickbacks for referrals, health care fraud. U.S. Department of Justice. (2016). Justice Department recovers over $4.7 billion from False Claims Act cases in Fiscal Year 2016. U.S. Department of Justice. (2018). Principles of Federal Prosecution of Business Organizations. U.S. Sentencing Commission. (2015). Chapter eight: Sentencing of organizations. In 2015 guidelines manual. Author. …………………………………………………………………………….. Week 7 Signature Assignment: Create a Corporate Compliance Plan for a Healthcare Organization. Assignment Instructions: Note: As you prepare your Signature Assignment this week, please keep in mind that for your Week 8 Assignment, you will review and respond to the feedback provided for the Week 7 Signature Assignment. Next week, in Week 8, you will also reflect on the course content, concepts, and course competencies, and critically analyze and document how these elements impact and/or advance your career interests and degree program pathway. Use an annotated bibliography to support your ideas. Signature Assignment: Using relevant state regulations and the Federal Guidelines developed by The Office of Inspector General (OIG) for healthcare organizations, you will develop a comprehensive, organization specific, Compliance Plan, including key relevant policies and procedures to support organization wide compliance. Use relevant resources and models of compliance program documents from other healthcare organizations to inform the design and content of your Compliance Manual. Length: A minimum of 5 pages organized with headers and formatted in the style of a resource manual that can be understood by all employees in the organization, not including the title page and reference page. References: Include a minimum of 3 scholarly resources to support the creation of the Compliance Plan. The completed assignment should address all of the assignment requirements, exhibit evidence of concept knowledge, and demonstrate thoughtful consideration of the content presented in the course. The writing should integrate scholarly resources, reflect academic expectations and current APA standards. ………………………………………………………………………….. Week 8 Utilize Feedback Through Self-Reflection and Literature Review. Throughout this course, you have studied the theoretical underpinnings of ethics and the laws and regulations associated with healthcare, as well as useful applications for both. In Week 1, you read about the costs of unethical behavior. This week, you will review cases, based on actual events that further explore the level of damage due to unethical and illegal actions in healthcare settings. In Week 2, you gained an understanding of the sources and function of U.S. law. This week, you will need to revisit those concepts to determine whether there are legal precedents and legal opinions for cases like the ones presented below. In Week 3, you learned about legal violations, whether they were civil (i.e., contracts, torts, and specifically, medical negligence) and/or criminal law (i.e., misdemeanors, felonies) and ways to avoid such violations. Similarly, this week you will provide recommendations to help prevent future violations. In Week 4, you researched the roles, responsibilities, and possible liabilities of healthcare professions and healthcare organizations. Now, you need to determine who was at fault of the violations that occurred in the cases you will read about in this week’s resources. In Week 5, you analyzed a national policy related to the allocation of resources and access to care. This week, you will consider how these cases impacted the issues of resource allocation and access to care. In Week 6, you explained the issues that may arise because of advanced health technology, and in Week 7, you developed a tool to assess organizational readiness for corporate compliance. This week, you will decide if your organization has the structure and systems in place to address the challenges that result from bioethics and possible fraud and abuse violations. ……………………………………………………………………….. Week 8 Assignment: Utilize Feedback Through Self-Reflection and Literature Review.. In Week 7, you integrated and applied elements of the course content in the Signature Assignment, which allowed you to address a significant question or issue (i.e., through creative thinking, critical thinking, problem-solving, inquiry, and analysis, etc.). Using the feedback from your Week 7 assignment, you will have the opportunity to complete a self-reflection and respond accordingly. Reflect on and respond to how the feedback provided can help you improve your academic performance and contribute to your professional growth. In addition to your self-reflection, you will also conduct an independent literature review of relevant scholarly, peer-reviewed sources. Choose sources that support your ideas for enhancement of the course competencies and content areas where you have identified opportunities for improvement. For example, if your professor indicated you need improvement in team leadership, select sources that would enhance your knowledge and skill base in this area. Your Week 8 assignment has two parts. Part 1: Self-Reflection Complete a self-reflection using the Feedback Review Template. The Feedback Review Template is in this week’s Course Resources area. To complete your self-reflection, seek clarity from your professor about the areas you did not understand or areas that require improvement. Then, schedule a one-to-one meeting with your professor to discuss the feedback provided and to inform your responses. Use the Feedback Review Template to address the following themes: How you developed and demonstrated the course competencies tied to this course. The practical relevance of the course concepts and course competencies to your professional growth and career interests. Future considerations (e.g., key trends or challenges) to keep in mind as related to the topics covered in this course. Be sure to comprehensively address the feedback provided by the professor for your Week 7 Signature Assignment. As you complete the template, you will be asked to address the following questions: What are the areas in which your professor indicated you did well? Why do you think you did well in this (these) areas? What are the areas in which your professor indicated you need to improve? What can you do to improve in this (these) areas? How did your professor’s feedback help your mastery of the course subject matter? How did the Week 7 Signature Assignment and this course help you to develop the course competencies? What aspects of this assignment can you take forward into your professional career and why? How did this course contribute to your understanding of possible trends and/or challenges related to the profession of health administration in the future? What do you need to consider regarding the course topic and why? Part 2: Annotated Bibliography You will prepare an annotated bibliography of five scholarly, peer-reviewed resources to enhance your knowledge base related to selected course competencies and that is informed by your self-reflection and professor feedback. The resources must be current, published within the past 3-5 years. Each annotated bibliography should be no less than three robust paragraphs. Use feedback from your professor to identify scholarly, peerreviewed sources that can help you improve in the areas noted (e.g., assignment enhancement, personal and/or professional growth, topic of further interest prompted by the course content). Use the annotated bibliography guide from Academic Success Center (ASC)* to ensure that your annotated bibliography meets all requirements. *For this assignment, remember that each annotated bibliography should be no less than three robust paragraphs. Assignment Requirements Your assignment will be submitted in one single document with two parts: Part 1 will be your Self-Reflection using the Feedback Review Template. Part 2 will be your Annotated Bibliography. To complete this assignment successfully, be sure to include the following: Title page Part 1: Based on the completion of your Feedback Review Template, provide a selfreflection summary on how this course contributed to your professional growth and your understanding of future trends and/or challenges related to your profession (2 pages minimum). Include your Feedback Review Template. Part 2: An APA-formatted annotated bibliography of 5 scholarly, peer-reviewed resources addressing any one or all of the following areas: Enhancement of the Assignment Personal/Professional Growth and Development Topic of interest for further investigation based on course content References (additional to the annotated bibliography) The completed assignment should address all the assignment requirements, exhibit evidence of relevant scholarly, peer-reviewed research, concept knowledge, and demonstrate thoughtful consideration of the content presented in the course. The writing should integrate scholarly, peer-reviewed resources, reflect academic expectations, and current APA standards.
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