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

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

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

Student Name

Capella University

BHA-FPX4004 Patient Safety and Quality Improvement in Health Care

Prof. Name


Issue Summary

The incident at Vila Health concerning a breach of patient privacy, violating the Health Insurance Portability and Accountability Act (HIPAA), underscores the significance of safeguarding patient information (Vila Health: Patient Safety, 2021). HIPAA, enacted in 1996, mandates standards to protect patient data (Health Insurance Portability and Accountability Act [HIPAA], 2022;, 2022). The HIPAA Privacy Rule governs the use and disclosure of patients’ protected health information (PHI), emphasizing patient control over their data (HIPAA, 2022; Vila Health: Patient Safety, 2021).

To address HIPAA violations, it is imperative to reeducate staff on HIPAA laws, ensure private discussions about patient care, and limit medical record access to direct care staff only (HIPAA, 2022; Berwick et al., 2008). Implementing the Institute for Healthcare Improvement (IHI) Triple Aim framework, which focuses on patient experience, cost reduction, and population health improvement, can enhance care quality and mitigate errors (Institute for Healthcare Improvement [IHI], 2018).


A safety culture prioritizes values, beliefs, and attitudes to ensure patient safety (Pellegrini, 2017). Trust-based communication and learning from adverse events are essential for fostering a safety culture (Pellegrini, 2017). The Joint Commission recommends principles such as recognizing error reporting and eliminating intimidating behavior to develop a robust safety culture (Berry et al., 2020).


Collaboration between risk management and nursing departments is vital for reducing errors and ensuring patient safety (Berry et al., 2020). By involving various departments and reinforcing patient identification protocols, hospitals can mitigate risks and enhance patient safety (Stevens, 2014).

Leadership Strategies

Effective leadership involves addressing HIPAA breaches promptly and implementing compliance programs (Denham, 2007). Training staff on HIPAA regulations and monitoring compliance are essential leadership strategies (Denham, 2007). Enlisting the support of organizational leaders and utilizing educational resources can reinforce compliance efforts (Denham, 2007).

Opportunities to Enlist the Governing Board’s Aid

To foster a fair and just culture, organizations should involve the governing board in promoting safety and reporting mechanisms (Berry et al., 2020). Leadership responsibilities include setting high standards, coaching employees, and ensuring a respectful work environment (Berry et al., 2020).

Leadership Action Plan

An effective action plan involves internal monitoring, staff training, and policy evaluation (Stevens, 2014). Collaboration between compliance officers and department leaders is crucial for implementing corrective actions and ensuring ongoing compliance (Stevens, 2014).

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


Addressing HIPAA breaches requires a multifaceted approach, including education, policy development, and leadership commitment (Stevens, 2014). Fostering a culture of safety and compliance is paramount for protecting patient privacy and enhancing healthcare quality (Pellegrini, 2017).


Antes, A. L., English, T., Baldwin, K. A., & DuBois, J. M. (2018). The role of culture and acculturation in researchers’ perceptions of rules in science. Science and Engineering Ethics, 24(2), 361-391.

Berry, J. C., Davis, J. T., Bartman, T., Hafer, C. C., Lieb, L. M., Khan, N., & Brilli, R. J. (2020). Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system. Journal of Patient Safety, 16(2), 130-136.

Hofmann, A., & Scordis, N. A. (2018). Challenges in applying risk management concepts in practice: A perspective. Risk Management and Insurance Review, 21(2), 309-333.

Gillam, S., & Siriwardena, A. N. (2013). Frameworks for improvement: Clinical audit, the plan do-study-act cycle and significant event audit. Quality in Primary Care, 21(2), 123-130.

Millar, R. (2013). Framing quality improvement tools and techniques in healthcare. Journal of Health Organization and Management, 27(2), 209-224.

Miranda, S., Jr., & Olexa, G. A. (2013). Creating a just culture. Pennsylvania Nurse, 68(4), 4–10.

Pellegrini, C. A. (2017). Leadership is crucial to establishing safety culture, reducing adverse events. The Bulletin of American College of Surgeons.

Stevens, M. (2014). Just culture: A fairer way to improve care. Healthcare Leadership Review, 33(7), 8–10.

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

The Joint Commission. (2021). National Patient Safety Goals Effective January 2021 for the Hospital Program.

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