BHA FPX 4006 Assessment 1 Compliance Program Implementation and Ethical Decision-Making

BHA FPX 4006 Assessment 1 Compliance Program Implementation and Ethical Decision-Making


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Capella university

BHA-FPX4006 Health Care Regulation and Compliance

Prof. Name



Assuming the role of a risk management and quality improvement professional at Vila Health’s community-based hospitals, situated in Minnesota and Wisconsin, the task at hand involves addressing a recent compliance breach. An employee inadvertently disclosed protected patient health information without prior authorization, constituting a privacy breach and a violation of HIPAA regulations.

Privacy Breach—HIPAA Violation

During routine duties, an employee at Vila Health mistakenly shared a patient’s protected health information while seeking pre-authorization for a surgical procedure. This action contravened HIPAA regulations, established in 1996 to safeguard patient data (Chen & Benusa, 2017). Failure to adhere to HIPAA standards not only compromises patient privacy but also exposes Vila Health to legal ramifications, particularly under the HITECH Act (D’Arrigo, 2019).

Seven Essential Elements of an Effective Compliance Program

Compliance programs in healthcare facilities are pivotal for ensuring patient privacy and safety. Seven essential elements underpin an effective compliance program, including standards and procedures, designation of a compliance officer, and education initiatives (D’Arrigo, 2019).

Privacy Breach Consequences

HIPAA violations can lead to severe legal and financial penalties for healthcare facilities and their leadership, necessitating immediate corrective action to mitigate risks (D’Arrigo, 2019).

Evidence-Based Recommendations

Integrating Human Resources in investigating privacy breaches and conducting GAP analyses can bolster Vila Health’s compliance efforts and safeguard patient information (Stuart, 2019).

Ethical Decision-Making Framework for Health Care Leaders

Healthcare leaders must employ ethical decision-making frameworks to address conflicts effectively and ensure compliance with regulations (Nelson, 2015).


The incident underscores the importance of robust compliance measures in healthcare settings to uphold patient privacy and adhere to regulatory standards. By implementing evidence-based practices and ethical decision-making frameworks, Vila Health can mitigate risks and prevent future breaches.


Chen, J. Q., & Benusa, A. (2017). HIPAA security compliance challenges: The case for small healthcare providers. International Journal of Healthcare Management, 10(2), 135–146.

D’Arrigo, T. (2019). HHS Adjusts Penalties for HIPAA Violations. Psychiatric News, 54(13), 23–40.

Doyle, A. (2014). Are you aware of HIPAA breach notification standards? PsycEXTRA Dataset, 1(1), 15–23.

BHA FPX 4006 Assessment 1 Compliance Program Implementation and Ethical Decision-Making

Nelson, W. (2017). Making Ethical Decisions. A Guide to Sociological Thinking, 89–102.

Stuart, L. (2019). Guidance for Psychologists on HIPAA Breach Notification Rule. PsycEXTRA Dataset, 10(1), 10–20. doi: 10.1037/e562802011-002.

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