BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan

Issue Summary

BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan: At Vila Health, a significant incident involving a HIPAA violation occurred during the evening shift, involving a medication error between two patients with similar names and dates of birth. The next morning, patient B. Moore’s mother was at the facility’s main desk when she overheard the unit secretary and a nurse from another unit discussing the event. The nurse stated that she would study the EHR later to gather information regarding the incident. This occurrence was a blatant breach of HIPAA standards since the personnel communicated protected health information (PHI) in public without patient authorization (HIPAA Journal, 2022).

HIPAA, the Health Insurance Portability and Accountability Act of 1996, is a federal statute that prevents patients’ information from being shared without their permission. The HIPAA Privacy Rule establishes guidelines for how patients’ PHI should be managed, giving them the right to know and decide how their information is used or shared (Edemekong et al., 2024). In this instance, hospital employees violated HIPAA by discussing a patient’s situation in public and engaging professionals who were not directly accountable for the patient’s treatment (Tariq & Hackert, 2023). 

To avoid such accidents, numerous precautions must be adopted. To begin, all staff members should be retrained on HIPAA rules and standards to ensure that they understand the requirements for patient privacy and confidentiality. Second, any talks about confidential patient care should take place in private and only between staff members who are actively involved in the patient’s care. Lastly, staff training should highlight that only direct care professionals have access to patient medical records.

Related Assessment:
BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure
BHA FPX 4004 Assessment 1 Address a Patient Safety Issue

Institute for Healthcare Improvement Triple Aim

In ‘BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan’ The IHI Triple Aim framework is critical for developing a healthcare leadership strategy that improves system performance. The Institute for Healthcare Improvement (IHI), a non-profit organization created in 1991, works to improve healthcare quality for both patients and professionals (Institute for Healthcare Improvement, 2024). The Triple Aim concept is built around three core principles: enhancing the patient experience, lowering per capita expenditures, and promoting population health.

Implementing the Triple Aim framework can considerably improve mistake detection and solution creation for future occurrences, resulting in better-coordinated care and a lower burden of sickness. This leads to a healthier population overall. Higher quality healthcare can lower costs, freeing up community funding for other critical expenditures (Institute for Healthcare Improvement, 2024). By concentrating on these three goals, healthcare companies may build a more efficient, effective, and sustainable healthcare system.

Regarding the incident at Vila Health in ‘BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan’, following the IHI Triple Aim will greatly improve patient care quality while lowering drug mistake costs. By enhancing the healthcare system to reduce mistakes and HIPAA breaches, the hospital can provide excellent treatment with fewer occurrences. The IHI standards stress HIPAA compliance by incorporating components that assist reduce breaches caused by incorrect management of patient information. This involves teaching personnel how to access patient files, how to avoid improper discussions about patient information, and how to properly destroy sensitive patient information.

Only direct care professionals should have access to a patient’s file, and doing so out of curiosity breaches both the patient’s rights and HIPAA requirements. Patient information should be communicated confidentially, either with the patient or with those directly involved in their treatment. Proper disposal of sensitive medical information is critical to avoiding HIPAA breaches and protecting patient data. It is critical to establish clear procedures for the correct disposal of protected health information (PHI) and make sure that all workers are aware of them. Regular training is recommended to reinforce these behaviors (Tariq & Hackert, 2023). These strategies will not only minimize errors and potential HIPAA breaches but will also lower per capita expenses while improving overall patient care quality. 


A safety culture is a framework in which a company prioritizes high standards, values, beliefs, and attitudes toward safety (Naji et al., 2021). The HIPAA infractions at Vila Health jeopardized patient safety, emphasizing the necessity for a strong safety culture. Maintaining a safety culture necessitates trust-based communication, effective preventative actions, mutual understanding, and shared beliefs about the value of safety (Naji et al., 2021). Organizations must learn from negative occurrences in order to avoid such instances in the future, with an emphasis on progress over punishment. While accountability is critical, the focus should be on retraining and creating higher practice standards to prevent recurrences.

The Joint Commission promotes ongoing development in safety culture and proposes eleven criteria for achieving it. These principles include developing policies that support safety culture, reporting adverse events, eliminating intimidating behavior, recognizing care team members who report errors, establishing a baseline measure of safety culture, analyzing survey results, developing and implementing unit-based quality and safety improvements, incorporating safety culture training, and providing training as frequently as necessary (Joint Commission International, 2023)


Identification errors affect every aspect of the healthcare system. To reduce these errors, the hospital’s risk management team and all nursing departments must work together to design policies, implement remedial measures, and teach clinical personnel. The risk management department takes an active role in averting scenarios that might result in liability or losses. These losses or liabilities may result from privacy violations, patient medication mistakes, dangerous circumstances, or diagnostic errors (Rodziewicz, 2023).

At Vila Health, numerous nursing departments are divided into specialties, but the core objective of each profession is patient safety. Vila Health’s clinical and non-clinical colleagues are all responsible for implementing adjustments to prevent identification mistakes. Three essential persons will be involved and accountable for carrying out the action plan: the hospital’s Chief Compliance Officer (CCO), a Clinical Nurse Specialist, and a nurse assigned to the focused floor.

The Chief Compliance Officer (CCO) will manage the action plan, give guidance, and make recommendations for improvements. The CCO’s monitoring ensures that the plan adheres to The Joint Commission’s compliance rules and requirements for patient identification (Dawson, 2023). The Clinical Nurse Specialist will demonstrate evidence-based ways to improve patient identification and prevent misidentification, guaranteeing patient safety. Finally, two nurses assigned to the impacted floor will be in charge of reinforcing and strategizing with unit counterparts to avoid patient misidentification (Romano et al., 2021).

Failure to involve all departments in safety and quality improvements creates weaknesses in a health system culture and stifles professional growth. If corrective actions for clinical safety and quality improvement are not implemented, sentinel occurrences will continue and undermine departmental activities. To address this, all departments must work together to solve the patient identification problem and improve the hospital’s culture.

One effective strategy is to create a full health system workshop that lasts a week and focuses on training and teamwork. This training would involve team-building exercises, forums for department heads, and roundtable talks with top management. These actions would be primarily focused on aligning with the hospital’s aim of decreasing and eliminating patient identification errors while also building a culture of safety and continuous improvement (Medicine (US) et al., 2019).

Team-building activities can improve communication and collaboration among staff members from various departments, reducing silos and developing a cohesive approach to patient safety. Departmental leaders should use forums to share best practices, address issues, and establish unified plans to enhance patient identification procedures. Roundtable conversations with top leadership allow for direct contact with hospital administrators, ensuring that frontline employees’ perspectives and concerns are heard and addressed.

Leadership Strategies

A HIPAA compliance program includes several critical components. First, adopting security rules is critical for securing patient information and ensuring that all employees understand the necessity of protecting sensitive data. Regular risk assessments help uncover possible weaknesses and allow the firm to address them proactively.

Training is another important aspect of the HIPAA compliance program. Regular training sessions should be held to educate workers on HIPAA requirements, the importance of patient privacy, and the proper management of patient data. This training should be obligatory for all workers and customized to specific hazards recognized by the organization.

Implementing processes to ensure compliance is also necessary. This includes developing explicit protocols for accessing and exchanging patient information, ensuring that only authorized staff have access, and enforcing stringent controls over patient data management. Monitoring compliance through frequent audits and assessments ensures that these processes are followed and enables the early detection and rectification of any problems.

Leadership and Collaboration Strategies

Evidence-based leadership and collaboration strategies are critical for creating a safe and quality culture in healthcare organizations. These tactics entail enlisting important organizational leaders to collaborate toward a common objective. Addressing the HIPAA breach event at Vila Health needs a collaborative effort led by the compliance officer, with assistance from the nursing and office administrators.

When a HIPAA violation is discovered, the compliance officer must promptly alert the unit’s nurses and office personnel. This announcement should be made in person to ensure that the gravity of the situation is conveyed clearly. Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) have access to patients’ protected health information (PHI) via records, thus they must understand the restrictions on accessing and sharing patient data. The educational training should highlight that PHI access is only granted on a need-to-know basis and that discussions regarding patient care must follow this approach.

The training session should be posted on the facility’s learning portal so that all staff members can access it, ensuring complete knowledge. This strategy enables the compliance officer to reach a larger audience while emphasizing the significance of following privacy standards. The compliance officer should work with nursing and office administrators to ensure compliance in their respective areas. These administrators may assist ensure that employees respect privacy requirements and keep accurate records of employee training, compliance, non-compliance reports, and corrective measures.

The compliance officer must do regular follow-ups to verify that policies are followed consistently. This involves regular check-ins with department managers to ensure compliance and resolve any issues or concerns. The compliance officer should also schedule frequent meetings with department administrators to review any modifications and give further training as needed. Keeping employees informed about current developments and best practices reinforces the significance of keeping the workplace safe and compliant.

Opportunities to Enlist the Governing Board’s Aid

To establish a fair and just culture within a healthcare company, the governing board must be actively involved. This board, which is normally made up of trustees, is in charge of developing and evaluating the hospital’s overall mission and strategy. While the board does not have direct control over hospital policy, its role in leading and supporting the formation of a fair culture is critical. It is vital to encourage employees to communicate critical safety-related information while also rewarding reporting and learning in an environment where leaders and human resource policies coincide with these objectives.

The board of trustees is responsible for advising and offering input on management policies, procedures, and decisions. This inspection ensures that department administrators properly apply policies that promote a fair and just culture. Every employee in the business is obligated to create an equal and just workplace. Employees are required to act in ways that safeguard patients from harm, report serious incidents, and participate in the investigation of adverse events to determine what went wrong and how to prevent it in the future.

Leadership responsibilities are critical to promoting a just culture. Leaders must establish high-performance expectations, teach staff to improve performance and offer the tools and resources required for a safe work environment. Leaders are also held accountable for keeping these standards, setting a good example for all workers, creating a fair and just culture, and ensuring that everyone behaves respectfully. This entails fostering an environment in which employees feel comfortable reporting problems without fear of repercussions and are encouraged to engage in issue solutions.

Human resource executives play an important role in developing procedures to assist managers and employees in attaining a fair culture. These systems include leadership development programs based on just culture concepts, as well as performance management systems that assure the effective application of just culture principles. They also set protocols for ensuring a respectful work environment with fair repercussions for everybody.

Leadership Action Plan

In order to solve the Vila Health HIPAA breach and avoid similar instances, many critical procedures and techniques may be implemented:

Effective Internal Monitoring and Audits:

Compliance officers should perform frequent internal monitoring and audits to ensure compliance with HIPAA laws. This involves monitoring access logs, doing spot checks on patient record access, and assessing general compliance with privacy regulations. Audits should be comprehensive and methodical in order to detect any gaps or noncompliance concerns.

Training Management and Staff:

Collaboration between department heads and the staff development coordinator is critical for providing thorough HIPAA training to all workers. Training sessions should focus on the facts of Vila Health’s HIPAA breach, highlighting why it occurred and how such breaches might be avoided in the future. The compliance manager should collaborate closely with department administrators and the staff development coordinator to customize training programs to address the unique needs of each department

Evaluate Policies and Make Necessary Changes:

Based on the results of internal audits and monitoring, the compliance officer should assess current HIPAA policies and procedures. Any discovered flaws or holes should be rectified immediately through policy modifications or updates. Policies should be clear, easily available to all employees, and reviewed on a regular basis to ensure they reflect current best practices and compliance standards.

Monitor and Audit Chart Access:

Access to patient information and other sensitive information should be rigorously limited. The compliance manager is in charge of monitoring and analyzing the frequency and reasons for accessing patient records. Only authorized persons with a valid need should be granted access to patient information. Monitoring and auditing chart access logs can assist in detecting illegal access attempts or violations of confidentiality.

Develop a Remediation Strategy:

In the aftermath of incidents like as the HIPAA breach at Vila Health, a remediation strategy should be developed and implemented ASAP. This approach should include remedial steps for any identified gaps or breaches. It should include comprehensive documentation of corrective steps done, as well as explicit timelines for implementation and follow-up.

Establish Disciplinary Measures:

A policy should be developed that outlines disciplinary consequences for workers who breach HIPAA rules. Disciplinary proceedings should be focused on corrective rather than punitive measures, to educate and reinforce compliance rather than intimidating personnel. Positive appreciation should also be offered to workers who continuously follow HIPAA requirements.

Conclusion – BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan

Addressing the HIPAA violation at Vila Health involves a holistic strategy that includes education, policy modification, and constant monitoring. Vila Health may reduce future instances while maintaining patient confidentiality by retraining personnel on HIPAA rules, improving privacy procedures, and performing frequent audits. Furthermore, developing a culture of openness and accountability, backed by leadership and governance, will be critical to preserving these gains over time. Through these collaborative initiatives, Vila Health can increase its commitment to patient safety and compliance while also fostering an ethical healthcare culture.


BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan: Dawson, J. (2023, December 6). A Roadmap for New Chief Compliance Officers: 10 Essential Steps. Qordata Is a Data-Driven Compliance Platform Provider.

BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan: Edemekong, P. F., Haydel, M. J., & Annamaraju, P. (2024). Health insurance portability and accountability act (HIPAA).; StatPearls Publishing.

BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan: HIPAA Journal. (2022, January 2). The Most Common HIPAA Violations You Should Be Aware Of. HIPAA Journal.

BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan: Institute for Healthcare Improvement. (2024). Improvement Area: Triple Aim and Population Health | Institute for Healthcare Improvement.

BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan: Joint Commision International. (2023). CONFIDENTIAL PROPOSED REQUIREMENTS FOR FIELD REVIEW PURPOSE ONLY DO NOT COPY -DO NOT DISTRIBUTE JCI Accreditation Standards for Hospitals and Academic Medical Centers (AMC), 8 th Edition Draft Standards for Field Review Proposed New Standards and Requirements.

BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan: Medicine (US), I. of, Olsen, L., Saunders, R. S., & McGinnis, J. M. (2019). Synopsis and Overview. In National Academies Press (US).

BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan: Naji, G. M. A., Isha, A. S. N., Mohyaldinn, M. E., Leka, S., Saleem, M. S., Rahman, S. M. N. B. S. A., & Alzoraiki, M. (2021). Impact of Safety Culture on Safety Performance; Mediating Role of Psychosocial Hazard: An Integrated Modelling Approach. International Journal of Environmental Research and Public Health, 18(16), 8568.

BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan: Rodziewicz, T. L. (2023). Medical error reduction and prevention. National Library of Medicine; StatPearls Publishing.

BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan: Romano, R., Marletta, G., Sollami, A., La Sala, R., Sarli, L., Artioli, G., & Nitro, M. (2021). The safety of care focused on patient identity: an observational study. Acta Bio Medica : Atenei Parmensis, 92(Suppl 2), e2021038.

BHA FPX 4004 Assessment 3 Collaborate on Quality: Issue Analysis and Leadership Plan: Tariq, R. A., & Hackert, P. B. (2023, January 23). Patient Confidentiality.; StatPearls Publishing.

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