7-1 Small Group Discussion: memos that describe the contingency plan you are creating for your final project:

Question

In your initial post, you will submit the following memos that describe the contingency plan you are creating for your final project:

  • An example memo to be sent to the internal staff, using communication strategies to create buy-in and engage the stakeholders
  • An example memo to be sent to the external resources, using communication strategies to create buy-in and engage the stakeholders

In response to your peers, evaluate your peers’ use of communication best practices, providing notes on what was done well and where there was room for improvement. Specifically, look for how the memos employed communication best practices (e.g., persuasion or negotiation), encouraged collaboration, engaged stakeholders, and created buy-in. To complete this assignment, review the Module Seven Small Group Discussion Guidelines and Rubric6-1 Discussion: Common Gaps in Contingency Planning

Answer

Subject: New Contingency Plan

This memo is to inform you of the new contingency plan that will soon be put into place within Shoreline Health System. The goal of this plan is to ensure the organizational and individual preparedness in the event of a crisis. This plan will help with elements such as communication, continuation of workflows, regulatory compliance, patient and staff safety, and more. This plan will benefit all departments

Starting next month, we will implement this contingency plan and begin training. This contingency plan includes use of a cloud system for data entry and management on a day-to-day basis, disaster recovery steps/goals, emergency mode priorities and operation procedures, and communication policies for crisis. With this will also come bi-yearly testing of this plan. Changes will be made as needed to ensure the plan meets necessary guidelines/standards and applies staff feedback. Without this contingency plan we risk workflow slowdowns or down time, compliance violations, miscommunication, and safety problems. The contingency plan is our way of taking the initiative to protect all stakeholders of this organization. The contingency plan takes into consideration the protection of the staff, employees, and organization as a whole.

We hope that all the changes shall be adhered to by every employee, and everyone will help make the new system successful. We apologize for any inconvenience.

Thank you for your continued support, and we look forward to the benefits this new plan will bring for all.

Best regards,

6-2 Milestone Three: Crisis Communication Plan

Question

In this milestone, you will submit the crisis communication plan. You will outline the training needs of the clinical and nonclinical staff, explaining how you will develop trainings to meet these needs. You will also outline the key people in the incident command, describe their key roles and responsibilities, and explain how this command will ensure all stakeholders stay informed.

To complete this assignment, review the following documents:

Answer

It is crucial to determine the clinical and non-clinical staff’s training needs to ensure the seamless running of Shoreline Health System during downtimes. There are several training needs for clinical staff.  Clinical staff should be instructed on efficiently using toolkits for downtime documentation. These resource packages are essential for gathering pertinent data during unanticipated downtimes and avoiding information gaps. Also, training sessions are essential to make sure that communication channels are properly used, facilitating effective information flow between various departments.

Additionally, clinical staff should receive training on how to communicate non-diagnostic information to other departments in an efficient manner, as this is crucial for preserving coordination and continuity of treatment during downtime. To ensure that clinical staff members have the knowledge and ability to record patient information in such circumstances appropriately, it is equally crucial to provide clinical documentation training during planned and unforeseen downtimes (Amatayakul, 2017). Additionally, instruction should be given on finding essential healthcare information from alternative sources since conventional electronic media records might not be accessible during outages. Another crucial need is having the technical team engage with the clinical staff to decide the best time to schedule downtimes. Teamwork is essential to minimize interference with patient care and ensure that downtimes are planned and carried out in the least disruptive way to clinical operations.

Regarding the non-clinical staff, several training needs should be addressed to ensure the smooth running of the healthcare enterprise. Firstly, downtime drills should be carried out during several shifts as a practical approach to crisis training. Both clinical and non-clinical employees can gain practical experience from these drills and become better equipped to handle scenarios that may arise during downtime. Besides, training on an incident command structure with a clear outline is critical to avoid information gaps and promote effective coordination during downtimes (Djalali et al., 2014). Non-clinical staff should receive training on downtime documentation toolkits like the clinical staff. These toolkits are crucial for obtaining pertinent data during unanticipated downtimes and avoiding information gaps. Additionally, non-clinical staff need to be trained in efficient communication methods to guarantee a seamless and effective flow of information across various departments.

Lastly, frontline doctors and non-clinical personnel should receive contingency plan training to prepare for unforeseen events. Through this training, they will be better equipped to react to unforeseen circumstances and maintain patient care during downtime. Shoreline Health System can improve its clinical and non-clinical staff members’ readiness and capacity to manage downtime circumstances by attending to these training requirements, thereby enhancing patient safety and the efficient operation of the healthcare institution.

Clinical staff needs training on effectively using toolkits for downtime documentation, documenting clinical work during downtimes, and finding vital clinical information from other sources. Also, training is required to ensure accurate and thorough recording and information retrieval to maintain patient care standards. On the other hand, the training requirements for non-clinical workers emphasize the incident command structure, proper downtime recording tools use, communication channels, and general preparedness for unforeseen events. These training requirements aim to establish a seamless information flow, coordinate activities, and guarantee operational continuity during downtime. Clinical and non-clinical staff need the training to use downtime documentation toolkits effectively, but different issues need to be covered for each group. The incident command structure and general preparation must be covered in training for non-clinical staff, whereas clinical staff must get training in clinical record keeping and accessing vital clinical information.

The clinical staff at Shoreline Health System require several training approaches to efficiently train on meeting various needs. First, the clinical staff will be exposed to simulated scenarios called scenario-based training that imitate scheduled or unplanned downtimes as part of one approach (Walsh et al., 2020). Role-playing exercises or virtual simulations are ways of achieving this kind of training. Also, clinical staff can practice clinical recording, put their training to use in real-world circumstances, and learn how to find crucial information from additional sources by participating in these scenarios. This method allows clinical staff to acquire the abilities and information to manage downtime scenarios successfully.

Additionally, regular use of downtime drills is another crucial training approach. These exercises are crucial for ensuring that all parties, including the clinical team, are educated, and kept up to date on the precise downtime protocols and the realities of a crisis. The team can practice and improve communication strategies by simulating downtime scenarios during various shifts, ensuring that the chosen channels efficiently facilitate information flow (Dunlap & Ellerbe, 2016). Downtime drills also allow the billing team to get billing information from the clinical staff and manually document it during downtime to maintain business operations.

The clinical staff also needs hands-on workshops as another training approach. These are interactive sessions/workshops that provide attendees with the chance to participate actively. Clinical staff practice using downtime documentation toolkits through group exercises, case studies, and simulations. By actively practicing throughout these courses, the clinical team will receive practical expertise in recording pertinent information during downtimes. With this strategy, staff members can better use the documentation toolkits when faced with downtime since they can learn by doing.

Some training strategies will be used at Shoreline Health System to meet the training needs of the non-clinical staff. Downtime drills are one such approach. These activities test how well the backup plans and downtime procedures work. The personnel can test and improve their comprehension of the downtime procedures by completing these drills (Walsh et al., 2020). Additionally, they will receive instructions on manually scanning paper documents and saving the results in a secure location. Through this training, the non-clinical employees will be prepared to handle downtime circumstances and be able to access vital information in the future, supporting the continuity of operations.

Training in communication skills is another crucial component of non-clinical personnel training. Effective communication is essential to maintain efficient and smooth information flow across various departments during downtimes. Through this training, Staff members will learn active listening, accurate message delivery, and communication approaches (Dunlap & Ellerbe, 2016). The non-clinical staff can communicate non-diagnostic information to other departments accurately and efficiently if their communication skills are improved. This approach will make coordinating and maintaining operations during downtimes easier, ensuring that crucial information is efficiently communicated.

The incident command team at Shoreline Health System consists of key employees assigned to specific command roles. The Chief Executive Officer assumes the role of the incident commander, responsible for the overall coordination and management of the incident response. They communicate with stakeholders and external agencies, allocate resources, and ensure effective utilization. Besides, the HIM Director is the liaison officer responsible for information control and assisting individuals and organizations involved in the emergency response (Djalali et al., 2014). The Risk Management Officer acts as the safety officer, monitoring, assessing, and managing the risks associated with managing the incident.

The Public Relations Manager takes on the role of the public information officer, responsible for communicating with other agencies, the media, and stakeholders. They also act as a liaison between the organization and the public. Also, the Operations Manager serves as the operations section chief, managing and coordinating operational actions and implementing the incident response strategy. The Director of Supply Chain assumes the role of the logistics section chief, responsible for providing all necessary logistics functions, such as moving communication channels, medical care, food, supplies, and other essential resources during an emergency.

Additionally, the Chief Nursing Officer takes on the role of the planning section chief, collecting and analyzing information about the incident and developing and maintaining the incident action plan (Djalali et al., 2014). Finally, the Chief Financial Officer assumes the finance/administration section chief’s role, managing the incident response’s financial aspects, including tracking costs, expenses, and reimbursements.

Designating distinct roles and duties to diverse stakeholders is crucial for effective coordination during downtimes. The technical staff should notify all interested parties before any planned downtimes. This aspect enables individuals to prepare psychologically and physically for the impending emergency. The technical team should also consult the clinical staff to decide the best time to schedule the downtimes. The billing staff should open clear contact lines with the healthcare team to collect and record charge information during operational downtime (Amatayakul, 2017). Additionally, to handle technical issues as soon as possible during unforeseen downtimes, the technical staff department should keep good lines of communication open with system providers.

 

 

 

Amatayakul, M. (2017). Health it and ears: Principles and practice. American Health Information Management Association.

Djalali, A., Carenzo, L., Ragazzoni, L., Azzaretto, M., Petrino, R., Della Corte, F., & Ingrassia, P. L. (2014). Does hospital disaster preparedness predict response performance during a full-scale exercise? A pilot study. Prehospital and Disaster Medicine, 29(5), 441–447. https://doi.org/10.1017/s1049023x1400082x

Dunlap, N. E., Ellerbe, S. (2016). An organizational approach to downtime readiness. Journal of Healthcare Management, 61(2):116-131.

Walsh, J. M., Borycki, E. M., & Kushniruk, A. W. (2020). Effects of electronic medical record downtime on patient safety, downtime mitigation, and downtime plans. International Journal of Extreme Automation and Connectivity in Healthcare, 2(1), 161–186. https://doi.org/10.4018/ijeach.2020010110.

 

 

6-1 Discussion: Common Gaps in Contingency Planning

Question

In this assignment, you will discuss common gaps in contingency planning and best practices to address these gaps. You will base your identification of common gaps and their recommendations on research.

For this discussion, address the following:

  • Identify a common gap that occurs in contingency planning.
  • Provide examples of issues that may arise in healthcare organizations due to the identified gap.
  • Based on your research, provide a recommendation on best practices for addressing the gap.

In response to your peers, consider their initial posts. Do their recommendations adequately address the gaps? Explain. What additional recommendations can you provide? What additional issues can you see arising based on the gap?

To complete this assignment, review the Discussion Rubric.

 

Answer

Common Gaps in Contingency Plans

A common gap in contingency planning includes relying on a single plan or resources in the event of a crisis (Preparis, 2019). Reliance on a sole strategy, technology vendor or support agency in the event of a crisis creates a vulnerability for the organization. If the organization is relying on a single strategy to address a crisis and the strategy is impeded or ineffective, operations will be halted until the need can be addressed. In the event patient care is restricted, the healthcare organization must coordinate with local and national relief organizations to address patient needs. Reliance on local organizations alone may not be sufficient to meet the needs of the organization. If the contingency plan dictates that employees be assigned remote work when unable to use physical locations, remote protocols and accounts should be established and routinely maintained.

Best Practice Recommendation

The best practice recommendation for addressing dependency on a single plan or strategy is redundancy (Preparis, 2019). Coordination with technology vendors to develop backup plans addressing system downtime or lack of access can reduce restoration wait times. Multiple contingency plans addressing a single situation creates options for the organization. Contingency plan redundancies can reduce the risk to the organization and increase preparedness to adverse events (Preparis, 2019).

Reference

Prepares. (2019 August 12). Common Gaps in Enterprise Business Continuity Plans. Preparis. https://www.preparis.com/article/common-gaps-enterprise-business-continuity-plans

5-2 Short Paper: Examine how healthcare organizations evaluate contingency plans and the relationship of this evaluation to regulatory requirements.

Question: examine how healthcare organizations evaluate contingency plans and the relationship of this evaluation to regulatory requirements.

In this assignment, you will examine how healthcare organizations evaluate contingency plans and the relationship of this evaluation to regulatory requirements.

Submit your assignment here. Make sure you’ve included all the required elements by reviewing the guidelines and rubric.

4-2 Milestone Two: Downtime Procedures and Resources

 

Answer

 5-2 Short Paper: Evaluating Contingency Plans

Evaluating Contingency Plans

Organizations require contingency plans for them to be ready for unforeseen occurrences or emergencies and remain resilient. These plans can only be assessed or evaluated effectively after a thorough review procedure. This analysis examines common approaches for evaluating contingency plans, the importance of such reviews, the period for doing them, and the connection between evaluations and regulatory agencies.

Approaches

Scenario testing is one of the approaches for evaluating contingency plans. This approach considers the effectiveness of a strategy by simulating hypothetical emergencies. Also, it determines the strengths and weaknesses of a strategy by analyzing how well it handles various scenarios. Another approach is performance metrics, which evaluates the effectiveness of a contingency plan quantitatively by setting up precise metrics and performance indicators (Safer contingency planning, 2021). These measures include communication efficacy, general operational efficiency, response time, and resource allocation.

Tabletop exercises are an approach that gathers critical stakeholders to discuss emergency scenarios. These exercises of important stakeholders allow for controlled discussion and analysis of hypothetical emergencies to develop feasible solutions. In this approach, the feasibility of the contingency plan is assessed, loopholes are identified, and response strategies to the crisis are improved (Martins, 2022). Finally, after-action reviews are thorough analyses conducted immediately after an incident or emergency. To improve future response efforts, they involve analyzing the measures that have been completed, finding areas for improvement, and documenting lessons learned.

Value

Evaluating contingency plans helps identify strengths and weaknesses. Evaluation enables businesses and organizations to pinpoint the advantages and disadvantages of their backup plans (Lister, 2016). With this knowledge, they may improve their overall preparedness and reaction skills by building on their strengths and addressing their deficiencies. Besides, evaluating contingency plans makes it possible to continue the continuous improvement cycle.  Organizations can improve their capacity to efficiently manage future catastrophes by identifying areas that need improvement or correction (Safer contingency planning, 2021).  As a result, routine or continuous evaluations foster a proactive and adaptable attitude to emergency management.

Contingency evaluation helps in risk reduction. Businesses can find hazards and vulnerabilities they have not seen by evaluating their environment. This information makes it possible to take preventative mitigation steps, which lessens the impact and possibility of upcoming calamities (Lister, 2016). A sound risk management approach benefits from evaluations. Lastly, evaluating contingency guarantees adherence to legal obligations, business norms, and best practices. Adherence to best practices builds trust with stakeholders and regulatory bodies by displaying an organization’s dedication to accountability and comprehensive risk management. Evaluations show that rules and regulations are followed.

Timeline

The timeline necessary to evaluate contingency plans relies on several variables, such as the organization’s structure, the complexity of the plan, and the frequency of potential emergencies. Some common evaluation timelines are triggered evaluation, post-incident evaluation, and periodic or annual evaluation. A post-incident evaluation is conducted immediately after an incident or emergency. In this evaluation, the emphasis is on determining the effectiveness of the response, highlighting strengths and faults, and documenting lessons gained while they are still fresh in participants’ minds (Safer contingency planning, 2021). Triggered evaluations of contingency plans apply if significant organizational alterations occur, such as relocating, adopting modern technology, or updating regulations. Post-incident evaluation is another timeline that is conducted following an emergency or event. The main goals of this evaluation are to rate the success of the answer, pinpoint its advantages and disadvantages, and record any lessons discovered while they are still fresh in participants’ thoughts.

Relationships

The requirements and expectations of regulatory agencies frequently cross paths with the evaluation of contingency plans.  Government bodies, auditors, insurers, the board of directors, and internal stakeholders are some stakeholders interested in assessing these evaluations. Firstly, governmental entities like occupational safety and health administrations, environmental agencies, or industry-specific regulatory bodies may require health organizations to submit evaluations to assure conformity with regulations and standards (Martins, 2022).  These organizations are crucial in ensuring that efficient contingency preparations are conducted in a way that safeguards public safety, environmental sustainability, and employee well-being.

Also, the healthcare organization’s internal stakeholders have a stake in how well its contingency preparations are evaluated. The organization’s senior management, risk management divisions, and legal and compliance teams work to ensure it is both emergency- and law-compliant. They rely on evaluation reports to determine the efficacy of risk mitigation techniques and to make defensible choices that will increase organizational resilience (Safer contingency planning, 2021). Finally, as part of their monitoring duties, the board of directors and shareholders may be interested in evaluations of contingency plans. They rely on these analyses to evaluate the organization’s risk management plans, operational toughness, and regulatory compliance. Investors worry about the company’s capacity to safeguard their capital and uphold long-term stability. 

References

 

Lister, J. (2016). Importance of Contingency Planning in Strategy Evaluation Results. Small Business – Chron.com. https://smallbusiness.chron.com/advantages-disadvantages-financial-risks-within-companies-16048.html

Martins, J. (2022). Steps to create and evaluate a contingency plan. Asana. https://asana.com/resources/contingency-plan

Safer contingency planning. (2021). Safer contingency planning. SAFER Guides | HealthIT.gov. https://www.healthit.gov/topic/safety/safer-guides

 

5-1 Discussion: Training Best Practices

Question:5-1 Discussion: Training Best Practices

In this discussion, you will reflect on your personal experience in trainings (professional and/or educational) and discuss what worked well and what did not work so well. You will then recommend some best practices to implement, based on research.

To begin, reflect on an experience you have had of either providing or attending a training. This training can be professional and/or educational.

Then, in your initial post, address the following:

  • What worked well during the training?
  • What could have been improved?
  • Based on your research, recommend some best practices that you would implement to improve the training.

In response to your peers, provide real-life situations in which you experienced positive outcomes with the training approach. Elaborate on how you can incorporate the training approach into your daily work.

To complete this assignment, review the Discussion Rubric.

1-1 Discussion: Vulnerabilities in the Flow of Information

Answers

Working in the healthcare field provides many opportunities for various trainings. These trainings can be geared specifically towards your job performance, as well as organization-wide trainings that everyone may be required to complete. A training module that comes to mind is specific to my job duties. I am responsible for sponsoring personal identification badges for employees within my department. This basically means that I am to initiate the process of when an ID badge is needing to be provided to a new employee, or when a current employee’s badge is needing to be renewed due to expiration.

The training was very detailed, and the great part about the module was that it was descriptive of what exactly should be done to process the requests. Screenshots of how to process requests were present throughout the entire module, which helped tremendously with understanding. The downside to the module was that it was not specific to possible scenarios that could potentially occur that would be outside of normal processing procedures. Ironically, that is what happened when I processed my very first request. I had to not only lean on my training, but also reach out to someone for help with the task. This module can be improved by advising of possible issues that are not within normal processing. The module could advise reaching out to certain individuals for help if needed.

The best practices that I would implement for this training would be conducting regular assessments for ways of improving and asking employees to detail their learning needs. It is important to assess trainings to evaluate their validity and effectiveness. Assessments can be given, and employees may provide insight on personal experiences that may help improve the trainings. These trainings are created for employees, so their needs and concerns should be considered. “You develop training programs for employees, so you want them to benefit the most. And to achieve that your courses should closely match your employees’ needs” (2022, August 11).

 

References

Piper, D. (2022, August 11). Best practices in training and development. Dennis Piper. https://blogs.oregonstate.edu/piperde/2022/08/11/best-practices-in-training-and-development/

4-2 Milestone Two: Downtime Procedures and Resources

Question: Downtime Procedures and Resources

In this milestone, you will identify the key stakeholders and their needs, develop downtime procedures for accessing and storing patient information, identify organizational tools and external resources to support these procedures, and explain how the procedures protect the privacy and security of patient information.

To complete this assignment, review the following documents:

3-1 Discussion: Downtime Interoperability

Answers

4-2 Milestone Two: Downtime Procedures and Resources

Internal Stakeholders And The Impact of The Crisis onThem

When ransomware attacks a healthcare organization and creates a crisis, several key stakeholders across the healthcare organization will be affected. As a result, multiple responsibilities arise that must be addressed to mitigate the impact on patient care and the organization’s overall operation. Some common stakeholders that the crisis will impact include the HIM director, physicians and nurses, IT staff, patients, the CEO, the chief information officer (CIO), and medical records staff.

The HIM Director is one of the common stakeholders in charge of safeguarding patient health information’s security and privacy and ensuring that all legal and regulatory standards are met. As a result, personal patient health information may be exposed without authorization, violating legal and regulatory standards. In a crisis, they may struggle to safeguard patient privacy and security. To reduce these risks, the HIM Director requires tools and resources, including incident response plans, regular risk assessments, backup and recovery systems, and more. These tools and resources will help the director monitor the crisis and lessen its effects on patient health information.

Physicians and nurses are other stakeholders responsible for treating and feeding patient data to electronic health records (EHRs). Their ability to obtain patient health information may be compromised in a crisis, affecting the care they deliver to patients. These health professionals require access to patient health information to guarantee appropriate care and make informed clinical decisions. IT staff is another stakeholder responsible for maintaining and managing the EHRs that transmit and store patient health information. When dealing with a crisis, they could delay maintaining and restoring electronic systems, resulting in more downtime and subpar patient care. To lessen these risks, they require cybersecurity vendors, the Health Cybersecurity and Communications Integration Center (HCCIC), incident response plans, backup and recovery systems, and personnel training and awareness to recognize and address the problem quickly.

Patients are also stakeholders impacted by the crisis in the healthcare organization. For them to make informed decisions about their care, they require access to their health information and high-quality care from the healthcare institution. They could have trouble accessing their medical records in a crisis, which affects the standard of care they get. They require access to their medical records and confirmation from the healthcare institution that the information is secure and safe from unauthorized persons. Besides, the CEO ensures the healthcare enterprise functions and operates effectively and is impacted by the crisis because patient care would be compromised, the healthcare system would be dysfunctional, and operational and financial stability becoming unstable. They require a quick-to-implement contingency plan and cybersecurity suppliers who can offer an incident response, network monitoring, and threat intelligence to reduce these risks.

The healthcare organization’s information technology infrastructure is controlled by the chief information officer (CIO), who is vulnerable to the crisis’ impacts. The CIO may have trouble coordinating the IT response to the attack in a crisis and re-establishing the IT infrastructure. Clear instructions on managing IT operations, security precautions like firewalls, access controls, intrusion detection systems to safeguard patient data, and backup systems to restore IT systems are all required to reduce these risks. Lastly, medical records staff who maintains the accuracy and completeness of patient health information would lack access to patient health information during the crisis, thus affecting the accuracy of the medical records. They need paper-based records, physical security measures for paper-based records, and adequate training on managing patient information to ensure the continuity of patient care.

Comparison of Stakeholders

Although each stakeholder in a healthcare organization has unique or specific roles and responsibilities, they all work toward the same objective of giving patients high-quality treatment and care. All parties involved must have access to patient health information to make informed decisions and deliver the proper care to patients. Nevertheless, each stakeholder has unique needs depending on their roles within the organization. For instance, the HIM director oversees maintaining the privacy and security of patient health information, while physicians and nurses need immediate access to patient information to offer prompt care. Moreover, the contingency plan is essential to address the needs of all stakeholders in a crisis. The contingency plan can assist stakeholders in reducing the crisis’ impact on patient care and resuming normal quickly by offering clear instructions, resources, and tools.

Alternative Solution for Essential Patient Information

A secure cloud-based electronic health record (EHR) system can be an effective alternative for giving staff members access to crucial patient information during a crisis. This solution will enable healthcare workers to view patient records or information from any place with internet access to maintain continuity of treatment even when staff members are not physically present in the clinic or hospital (Liao et al., 2019). With this alternative approach, staff members will have immediate access to patient information, such as test results, medical histories, and medication lists, which are crucial for delivering high-quality treatment.

The cloud based EHR system will meet HIPAA regulations, guaranteeing patient data security and privacy. Furthermore, adopting strong EHR system security measures such as frequent security audits, multi-factor authentication, and data encryption will provide a secure environment for storing and sending patient data. In order to prevent data breaches and ensure the proper management of patient information, staff employees will receive the necessary training on how to use EHR systems and data security processes (Xie et al., 2018). Healthcare organizations can maintain continuity of service and ensure that patient information is secure and confidential during a crisis by implementing this alternative solution.

Alternative Solution to Capture and Store Patient Information

An alternate solution to capture and store patient information is implementing a secure, web-based portal that allows patients to feed and update their medical information. The patient’s vital information, including medical background, present prescriptions, allergies, and emergency contacts, would be captured via the portal and safely stored in a central database accessible to authorized healthcare professionals to prevent cyberattacks (Boycki et al., 2019). It is worth noting that the web-based portal will allow staff to manage patient care effectively during the crisis by enabling them to access patients’ medical information remotely from any location with internet connectivity. As a result, staff will have access to the information required to deliver quality care even if they are not physically present in the hospital or clinic.

Additionally, the web-based portal will be built with robust security features, like password protection, data encryption, and safe data transmission to the centralized database, to protect patient information’s privacy and security and comply with HIPAA laws. The healthcare organization will inform patients about safeguarding their private health information. They will also receive detailed instructions on how to use the portal safely. The staff members will be trained on the proper use of the web-based portal and data security procedures to protect the privacy and security of patient health information. Lastly, the organization will conduct regular security audits of the database to find any flaws or potential dangers to patient information and fix them (Shickel et al., 2018). By putting these procedures in place, Shoreline Health System will ensure that patient data is securely obtained, saved, and accessed following HIPAA rules, even during the crisis.

Information Management Tools

Information management tools are crucial in healthcare organizations for ensuring the security and privacy of patient information. A password manager is one of the tools that healthcare organizations can use to securely manage and store user passwords and prevent unauthorized access to confidential patient information (Ghezzi & Masciadri, 2017). Another crucial tool for safeguarding patient health information is a firewall, which can be used to regulate access to a network and assist in preventing illegal entry. Besides, theft or loss of health information during a crisis can be avoided using data loss prevention software to restrict and monitor data transfer.

Another essential tool is encryption software, which can encode data and guarantee that only authorized users can access it. It prevents cyberattacks and access to private patient health information by malicious individuals. Also, multi-factor authentication is an information management tool that can prevent unauthorized access to sensitive data like health records by requiring users to present several forms of identification (Kuo & Rajan, 2017). Systems for data backup and recovery are crucial tools for safeguarding against data loss and ensuring that health data is accessible in times of emergency.

By establishing a secure connection between two sites on the internet, virtual private networks are information management tools that can protect sensitive health information during data transfer to avoid any information loss (Ghezzi & Masciadri, 2017). In addition, systems for controlling user identities and information access are crucial for ensuring that only authorized users can access private health information to make informed clinical decisions. Lastly, a network can be protected against data breaches and cyberattacks using intrusion detection and prevention systems, which can identify and prevent illegal access (Kuo & Rajan, 2017). In conclusion, information management tools are crucial to maintaining the confidentiality and security of patient data in healthcare organizations so that they store sensitive patient data and adhere to legal obligations.

External Resources

The healthcare organization will use several external resources to help with contingency plans and keep PHI private and secure during the crisis. In the event of natural disasters and fires in my location (Hooksett), the Hooksett Fire-Rescue Department will offer emergency medical assistance while maintaining the security and privacy of PHI. The EMS personnel will receive training on responding to emergencies while maintaining patient confidentiality and protecting patient information. Similarly, the Hookset Police Department will support emergency medical response, secure the emergency scene, and uphold order while guaranteeing the security and privacy of PHI.

Additionally, the healthcare organization will receive guidance on effectively communicating any updates on PHI’s privacy and security during the crisis from the Manchester-based Cookson Strategic Communications agency. This public relations specialist will offer instructions on keeping lines of communication with patients and staff regarding safety measures. During the crisis, The Grady Law Firm in Hooksett will offer legal assistance and advise the healthcare organization on PHI security and privacy laws. This legal firm will support the healthcare organization in adhering to all legal standards for safeguarding PHI and assist in reacting to any legal issues that may arise due to the crisis.

To ensure the security and privacy of PHI during the crisis, the New Hampshire Society for Technology in Education in Hooksett will provide IT vendors who will offer technical support for the equipment and systems employed. This approach will guarantee that the IT infrastructure of the healthcare organization is safe and complies with HIPAA regulations. 

References

Borycki, E. M., Kushniruk, A. W., Armstrong, B., Joe, R., Otto, T., & Ho, K. (2019). Patients’ perspectives on web-based patient-controlled health record systems: A literature review. Journal of medical systems, 43(7), 170.

Ghezzi, P., & Masciadri, A. (2017). Information security and privacy in healthcare: managing healthcare information. IEEE Access, 5, 15567-15587. https://doi.org/10.1109/ACCESS.2017.2712021.

Kuo, Y. F., & Rajan, S. S. (2017). Information technology applications for healthcare: A review of the literature. Journal of Medical Systems, 41(8), 130. https://doi.org/10.1007/s10916-017-0772-0.

Liao, C., Chen, R., Chen, T., & Chen, J. (2019). A cloud-based electronic health record system: Development, implementation, and analysis of a hospital-wide proper consent form. Journal of medical systems, 43(2), 26. doi: 10.1007/s10916-018-1145-1.

Shickel, B., Tighe, P. J., Bihorac, A., & Rashidi, P. (2018). Healthcare predictive analytics: strategies for predicting readmissions. Artificial Intelligence in Medicine, pp. 88, 22–35.

Xie, B., He, D., & Mercer, K. (2018). Implementation of cloud-based electronic health records and its effect on clinical outcomes and satisfaction of patients and healthcare providers: A systematic review. Journal of medical systems, 42(7), 133. doi: 10.1007/s10916-018-0992-0.

4-1 Worksheet: Incident Command

Question: 4-1 Worksheet: Incident Command

In this worksheet, you will create a matrix of the key roles in the incident command, describe the roles, and outline their responsibilities.

To complete this assignment, review the following documents:

3-1 Discussion: Downtime Interoperability

Answer

HIM 680 Module Four Worksheet

Incident Command

 

Incident Command Person Description of Role Key responsibilities in a crisis People in the Organization That Might Take This Role
Commander Responsible for overseeing all the aspects of the response effort and management of the incident.

 

The commander allocates resources and makes strategic decisions to ensure the situation is resolved safely and as soon as feasible.

Authorizing personnel and the use of resources.

 

Monitoring the progress of the response effort and making adjustments where necessary.

 

Developing priorities and objectives for the response effort.

 

Ensuring effective coordination and communication between all parties involved in the response effort.

 

Determining the strategy for responding to the incident.

Chief Operating Officer

 

Chief Executive Officer

Liaison officer Serves as a point of communication for other agencies or groups taking part in the incident command and response effort.

 

 

They ascertain that all stakeholders can access pertinent data and that actions and resources are coordinated appropriately.

Ensuring that external agencies understand the healthcare organization’s priorities and objectives.

 

Maintaining and establishing communication with external parties in the incident command and response effort.

 

Coordinating personnel and the use of resources between external agencies and the healthcare organization.

 

Facilitating information sharing between external agencies and the incident command.

Community Outreach

 

Director of Government Relations

Safety officer Ensures the safety of the public, environment, and every response team member. Giving workers instructions and training on safety procedures.

 

Determining and evaluating any possible risks or hazards related to the incident.

 

Making and putting into action plans to lessen risks or hazards that have been identified.

 

Monitoring the workplace to ensure everyone is safe, including the general public.

Safety Manager

 

Director of Occupational Health and Safety

Public information officer In charge of overseeing all interactions with the media, other stakeholders and the general public during the response effort. Giving workers direction and instruction on communication norms and processes.

 

Creating and providing the public, media, and other stakeholders with accurate and timely information.

 

Managing enquiries and information requests from the public, the media, and other parties.

 

Coordinating with the incident command to ensure that all message is uniform and in line with the goals and priorities of the healthcare organization.

Public Relations Manager

 

Director of Communications

Operations section chief Overseeing all operational aspects of the response effort, including coordinating the employment of personnel and resources to deal with the incident command. Guiding and instructing on operational protocols and procedures for personnel.

 

Formulating and implementing operational strategies and protocols to deal with the situation.

 

Keeping track of the response’s development and making any necessary modifications.

 

Coordinating the utilization of personnel and resources to make response operations efficient and successful.

Emergency Preparedness Coordinator

 

Director of Operations

 

Facilities Manager

 

Clinical Operations Manager

Finance/admin section chief Manages the incident command’s administrative and financial elements.

 

They ensure proper allocation and tracking of resources such as supplies, personnel, and equipment.

 

Offer the incident command team administrative and financial support.

Support the incident command team’s administrative needs.

 

Make and keep the incident budget.

 

Maintain and control incident records and documentation.

 

Keep tabs on all expenses and charges related to the occurrence.

 

Maintain and monitor the time and attendance records of the staff.

 

Control purchasing and contracting operations.

 

Give the incident command team logistical support.

Logistics Coordinator

 

Chief Financial Officer

 

Administrative Assistant

 

Budget Analyst

 

Procurement Specialist

 

3-1 Discussion: Downtime Interoperability

Question: Downtime Interoperability

In this assignment, you will discuss approaches that healthcare organizations can take to address patient care during downtime interoperability.

The hospital systems are not functioning as they should, causing downtime interoperability. To begin, choose one of the following alternate solutions:

  • Health information exchange
  • Health information organization
  • Cloud connectivity
  • Paper processes

Then, in your initial post, answer the following:

  • What are the pros and cons of the solution you chose?
  • Based on your selected solution, identify the possible risks and financial impact to the organization.
  • Support your answer with relevant research.

Respond to peers who selected different alternative solutions from the one you selected. In your response posts, compare your peers’ selected alternative solutions to the one you selected. Based on your comparison, which solution would you suggest to an organization? Explain.

To complete this assignment, review the Discussion Rubric.

2-2 Milestone One: Complete a risk assessment for Shoreline Health System

Answer

In dealing with downtime, backup solutions are required to ensure full interoperability and consistency through all scenarios. Having multiple layers of contingencies built into the daily workflows through various means ensures that in any foreseen and unforeseen circumstances, downtime does not interrupt day to day. In this example, I chose to discuss cloud connectivity.

Although the cloud is not a new idea, the idea of cloud computing and the use of cloud servers has become much more prevalent across information driven industries. In the case of healthcare organizations, cloud computing has a few distinct advantages such as; easier access to data at any location, scalability, and security. Cloud computing also has a few distinct disadvantages in; the inability to fully control the structure and architecture of cloud servers, difficulty migrating existing systems to cloud compatibility, and requiring access to the internet.

In terms of risks, cloud computing solves some of the issues associated with traditional downtime, but also opens up an organization to new ongoing costs, as well as new security risks through a wider and more open network of data storage. Financially, a transition to cloud computing as a backup to traditional downtime challenges does create a new cost for an organization, but will allow for any downtimes not involving severe issues to be overcome by a simple transition on the back end (Galen Data, 2022).

References

Galen Data (2022). 9 Key Benefits of Cloud Computing in Healthcare. Retrieved from https://galendata.com/9-benefits-cloud-computing-healthcare/

 

2-2 Milestone One: Complete a risk assessment for Shoreline Health System

Question: Complete a risk assessment for Shoreline Health System

In this milestone, you will complete a risk assessment for Shoreline Health System. To complete this assignment, you will use the Shoreline Health System case study as your base. In addition, you will provide recommendations on best practices for the identified vulnerabilities.

To complete this assignment, review the following documents:

1-2 Worksheet: risks and practice determining potential areas of noncompliance with HIPAA privacy and security regulations

 

Answers

HIM 680 Final Project Milestone One Worksheet

Risk Assessment

 

In this milestone, you will conduct a risk assessment for Shoreline Health System. To complete this assignment, you will use the Shoreline Health System case study in the Final Project Case Study document as your base. You will also conduct research to supplement the case study information and to determine common vulnerabilities and threats related to ransomware attacks, the departments impacted by these vulnerabilities and threats, the risk to noncompliance, and the likelihood, severity, and risk level of the vulnerabilities. Finally, you will also recommend best practices to address the identified vulnerabilities.

 

The information within the tabs of the Risk Assessment Report file will help you complete this milestone and fill in the assessment located on the next page.

 

Vulnerability Name: Describe particular weaknesses or flaws in your security that could be exploited by a threat source to cause a security violation or breach.

 

Threat Source: Describe the threats that could take advantage of the vulnerabilities. Consider the four categories of threats—adversarial, accidental, structural, and environmental—as well as more specific examples such as external and internal threats, users, visitors, viruses, natural hazards, and so on.

 

Departments Impacted: Identify the departments impacted by the crisis with a brief explanation of how each is impacted.

 

Noncompliance: Explain how the identified vulnerabilities lead to risks of potential noncompliance with HIPAA privacy and security regulations.

 

Likelihood of Occurrence: Determine if the likelihood of occurrence is high, medium, or low, and explain your reasoning.

 

Impact Severity: Determine if the impact severity is high, medium, or low, and explain your reasoning.

 

Risk Level: Determine if the risk level is high, medium, or low, and explain your reasoning.

 

Recommended Best Practice: Give recommendations for the best new safeguard(s) that can reduce further risk from this vulnerability. These safeguards may include policies, procedures, software, and so on.

 Risk Assessment

Vulnerability Name Threat Source Departments Impacted Noncompliance Likelihood of Occurrence Impact Severity Risk Level Recommended Best Practice
Unencrypted data Malware, ransomware, phishing The HIM department

 

IT department

HIPAA requires that all data be encrypted when it is at rest (being at rest means being under storage on a disk or drive) High Medium High Use AES 256-bit encryption, which has been cited as a very strong and robust standard for encryption that is availed to computer users commercially.

 

Ensure all the plain text passwords are in cipher text form; encrypt the plain text with keys

Security logging failure Low instances of logging and monitoring the systems HIM and IT department The healthcare facility is supposed to collect information, handle the information closely and regulate the manner of handling this information. High Medium Medium The medical facility needs to audit its logs frequently and properly; there is a need to compile, store and assess the logs
Sharing of PHI information The hard drives of the company were stolen by outsiders IT Department The question of non-compliance comes from the violation of the privacy rule; the identifiers of patients reach players who are not concerned with the health of the patient. Patient information needs to be kept within the facility and be used by those who oversee the health of the patient Low Medium Medium Requires setting up physical security in which to place the hard drives and prevent them from getting into the hands of external personal
               
               

Modified from HIMSS Security Risk Assessment Guide/Data Collection Matrix with permission of HIMSS.

 

Highest Priority Vulnerability

What is the highest priority vulnerability the organization needs to address to ensure compliance with HIPAA privacy and security regulations?

The highest priority vulnerability is the use of unencrypted data concerning patients in storage drives. The data stolen may end up in the hands of those who may want to cause actual harm to the patients identified by stolen information. For instance, those that took information regarding patients from BlueCross BlueShield of Tennessee (BCBST) used the information for activities other than promoting the health of the patient. If this information finds its way into the hands of an individual who does not care about the well-being of the listed individuals, they may cause more damage than using the information for marketing.

 

 

Use your risk assessment to justify why this is the highest priority:

There are three risks present in the scenario. From the risks that are present, the stolen unencrypted data presented the highest risk priority and impact severity considering that not much is known concerning the possible use of the data stolen from the facility.

2-1 Short Paper: Resources for Contingency Planning

Question

In this assignment, you will discuss the common stakeholders, tools (hardware, etc.), and external resources (mutual aid, affiliates around you, emergency personnel) used in enterprise-wide healthcare contingency planning.

Submit your assignment here. Make sure you’ve included all the required elements by reviewing the guidelines and rubric.

1-2 Worksheet: risks and practice determining potential areas of noncompliance with HIPAA privacy and security regulations

 

Answer

2-1 Short Paper: Resources for Contingency Planning

Common Stakeholders

The Covid-19 pandemic has highlighted the importance of enterprise-wide contingency planning in the healthcare industry. When planning for any healthcare crisis, it is important to consider the various stakeholders involved to ensure an effective response plan. These stakeholders include healthcare providers, patients, patients’ families, government agencies, insurance companies, and suppliers who uniquely manage the crisis and ensure the healthcare system can continue functioning effectively (Trujillo-Fernandez, 2007). Healthcare providers are responsible for caring for patients, diagnosing and treating illnesses, and managing the resources needed to provide care. Besides, patients seek medical attention and require access to quality care, information, and resources to manage their health. Government agencies such as the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) play a crucial role in providing guidelines, regulations, and funding for healthcare contingency planning (Trujillo-Fernandez, 2007). Also, healthcare organizations, including hospitals, clinics, and laboratories, provide the infrastructure and resources needed to deliver patient care. Lastly, community members play an essential role in supporting healthcare providers, sharing information, and adhering to guidelines to prevent the spread of disease.

Tools for enterprise-wide contingency planning

In response to the Covid-19 pandemic, a range of tools are required to combat the spread of the virus, treat those who are infected, and monitor the progression of the disease. One of the most critical hardware tools needed is personal protective equipment (PPE). PPE includes masks, gloves, and gowns for healthcare workers and others who encounter infected individuals (Trujillo-Fernandez, 2007). PPE is necessary to prevent the spread of the virus and protect healthcare workers from becoming infected. Without sufficient PPE, healthcare workers are at a greater risk of contracting and transmitting the virus to others.

Another vital hardware tool needed during the Covid-19 pandemic is medical equipment, such as ventilators and oxygen concentrators. These devices are critical for treating individuals suffering from severe cases of Covid-19 and experiencing respiratory distress. As the number of cases increased during the pandemic, there was a shortage of medical equipment in many areas, leading to a strain on healthcare systems and higher mortality rates (Amatayakul, 2017). Ensuring an adequate supply of medical equipment is essential for improving outcomes for Covid-19 patients and reducing the burden on healthcare workers.

External resources

During a healthcare crisis like the Covid-19 pandemic, it is essential to consider external resources to manage the situation effectively. These external resources can include mutual aid networks, affiliates in the community, and emergency personnel. Mutual aid networks are grassroots community-based organizations that work to aid and support to those in need. In a healthcare crisis like Covid-19, mutual aid networks can play a critical role in helping vulnerable populations access food, medical supplies, and other essential resources. These networks can also provide emotional and social support to individuals struggling during the pandemic. For example, mutual aid groups can help connect individuals in isolation or quarantine with volunteers who can deliver groceries, medication, or other necessities (Trujillo-Fernandez, 2007). Additionally, mutual aid networks can help spread awareness about public health guidelines and encourage community members to follow them. The involvement of mutual aid networks can ease the burden on healthcare systems and contribute to a more effective response to the crisis.

Affiliates in the community, such as community health centers and other healthcare organizations, are also crucial resources during a healthcare crisis like Covid-19. These organizations can provide various services, including testing and treatment for the virus, mental health support, and educational resources.  Community health centers can play a significant role in providing care to underserved populations who may not have access to traditional healthcare services (Trujillo-Fernandez, 2007). These organizations can also help facilitate communication between healthcare providers and public health officials, ensuring that information is disseminated effectively and efficiently.  In addition, community-based organizations, such as food banks and shelters, can partner with healthcare organizations to support those experiencing economic hardship or homelessness during the pandemic.

Emergency personnel, such as paramedics and firefighters, are another important external resource during a healthcare crisis like Covid-19.  These professionals can provide immediate medical assistance to those experiencing severe virus symptoms and may require urgent care. Emergency personnel can also help transport patients to healthcare facilities and ensure they receive medical attention. Additionally, emergency personnel can assist with distributing PPE and other essential medical supplies and provide support in the event of a surge in hospitalizations or other healthcare needs (Amatayakul, 2017). The involvement of emergency personnel is critical to ensuring that healthcare systems can effectively manage the pandemic and provide care to those who need it most.

Conclusion

Healthcare crisis contingency planning requires the consideration of several stakeholders, including employees, customers/patients, government agencies, and suppliers. Organizations need the necessary hardware and software tools to implement such planning effectively, including teleconferencing and health monitoring tools. Finally, external resources such as mutual aid organizations, affiliates, and emergency personnel must also be considered to ensure organizations can respond to the crisis effectively.

 

 

References

Amatayakul, M. (2017). Chapter 12. In Health IT and EHRS: Principles and practice. American Health Information Management Association.

Trujillo-Fernandez, M. J. (D. (2007). Contingency planning for the healthcare industry. https://web.archive.org/web/20150914073901/http://www.drj.com/drj-world-archives/planning-in-other-industries/contingency-planning-for-the-healthcare-industry.html