Part Two of the Risk Management Plan Analysis

This is a summary of the risk management strategy that the ECRI institution designed and put into practice. It covers the Joint Commission's responsibilities in quality management by organizations, the responsibilities of pertinent employees in risk management, and the connection between risk management and moral principles.

The joint commission

The joint commission is a nonprofit organization that was founded in 1951 with the goal of enhancing the general welfare of the populace by pressuring healthcare companies to deliver high-quality, safe care. By working with other health care sector partners, it assesses the standard of care provided in health organizations. The commission has set aside standards that need to be adhered to in evaluation processes by healthcare organizations to improve their performance on matters related to health. The organization is responsible for accrediting more than 21000 healthcare facilities and organizations. The standards applied in the accreditation process signify high levels of quality, safety, and performance. The joint commission ensures that healthcare organizations meet quality standards through the following ways:

Setting standards

The Joint Commission set aside standards that help all healthcare organizations to assess measure and evaluate the extent to which quality performance is met in their operations and dealings with patients. These standards are focused patient, resident care, and organization functions that are significant in the provision of high-quality care. When setting standards, the commission allows inputs from all healthcare providers including professionals, experts, consumers, and government agencies to ensure that they are of high quality. These standards are then developed and all healthcare service providers that are accredited and certified by the commission are educated on how to comply with the new standards and are given a manual containing the standards (The Joint Commission, 2016). All accredited healthcare service providers are expected to comply with the standards as they are a measure of quality. Organizations are expected to apply every aspect of quality standards in their operations and those who fail to conform to these standards risk being discredited.

Enhancing patient safety

The Joint Commission monitors patient safety in all healthcare organizations and evaluates the extent to which organizations conform to patient safety criteria. Patient safety is important in every healthcare facility and the commission collaborates with patient safety bodies to improve the quality of national safety. The commission helps organizations to facilitate patient safety by putting in place quality processes and structures to ensure that all patients are safe.

For instance, ECRI institute risk management plan will incorporate all the standards by the Joint Commission to enhance patient safety.

The Sentinel Event Policy and Patient safety programs

This is a policy established in 1996 and revised in 2014 that deals with the occurrence of sentinel events. During such occurrences, healthcare organizations should undertake through analysis of the situation, identify causes and make improvements to reduce any future risks associated with it and evaluate the effectiveness of the improvements. The joint commission provides support to accredited organizations during a sentinel event and evaluates the organizations’ processes to see whether they conform to standards of quality.

The commission also receives reports on safety from patients, government agencies, and other concerned individuals. It then uses the information received to make improvements on quality in accredited and certified organizations, to ensure that they comply with quality and safety standards.

Administrative Personnel Roles Relevant To Operational Policies Focused On Employer-Employee Risk Management Policies

Administrative personnel play important roles in risk management and over the past few years, their roles have evolved greatly due to the changing environment which presents many risks and uncertainties. The various administrative personnel include the risk managers, healthcare administrators, and health service managers. These play crucial roles in risk management which include:

Identifying risks

The planning committee with the help of other administrative personnel is responsible for identifying and analyzing the various risks that are inherent in the organization. This is done by undertaking surveys and studying current changes in technology and the general market environment to ensure that any unforeseen risks are covered. All the risks are identified and planning is done on how to deal with the risks. Examples of risks that the organization may face include healthcare infections, telemedicine resulting from advancements in technology, strikes and alarm fatigue. After all potential risks are identified; they are entered into the risk management tool by the appropriate risk managers.

Establishing risk management policies and procedures

The administrative personnel are also responsible for establishing necessary operational policies and procedures relevant to manage the identified risks. These policies clearly define who is responsible for what and who the risk managers report to. The healthcare managers in setting the policies also ensure that they conform to risk management standards of quality as outlined by the Joint Commission. The administration also conducts a frequent review of the policies and evaluates them accordingly to ensure that they fully analyze and communicate any risks imminent in organizations. The risk managers report to the healthcare managers the status of the policies and their influence in mitigating risks. The healthcare managers then inform all the stakeholders involved about the statues of the risk management policies and any challenges encountered in risk management.

Performing risk assessments and evaluation on policies

Healthcare risk managers perform risk assessments before they occur and establish practices to mitigate the risks. The set policies are evaluated on a regular basis to analyze whether they are effective in managing risks. They also explain the policies to all the staff involved in the operations of the organization and create standard practices that should be adhered to.

Relationship of Risk Management Programs and Compliance with Ethical Standards

For any healthcare organization, the standards for managing risks must be in line with the ethical standards set by the Joint Commission and their ethical duty to the society to provide high-quality patient care. The risk management policies and procedures should contribute to the high quality of service delivery to patients and all stakeholders (JoAnn and Welsh, 2011). Over the years, various researchers have questioned the practice of risk management in healthcare, whether it is ethical at all since the maintenance of accountable healthcare institutions is critical to the whole population.

All the individuals involved in the risk management practices should have moral integrity and be consistent with the adherence of all ethical principles.

The ethical principles involved in healthcare and that should be a part of risk management practices include: principle of justice, principle of beneficence, principle of autonomy, and non-maleficence.

Principle of justice

This principle in healthcare states to equal and fair distribution of organizational resources and to treat everyone as equal. All patients have an equal right to be treated and served at a medical facility regardless of where they come from or who they are. This implies that risk management practices should be fair to all. For instance, the risk of medication errors should be fully prevented to ensure that no patient gets the medicine intended for another and to promote fairness (Butts, 2008).

Autonomy principle

This principle entails respecting other people's rights in conducting independent decision-making processes. For instance, all patients have freedom of choice regarding the kind of treatment to be administered to them. Risk management policies should be aimed at respecting everybody's rights and wishes.


This principle states that harm or hurt should be avoided at all costs. This entails ensuring that your activities do not cause any harm to others. For instance, risk managers may use untested machinery to extend the life of a patient to avoid death. The policies used by risk management to prevent risks should not have the potential for harm or damage to those using them.

Beneficence principle

The beneficence principle states the desire to do good to others and all risk management procedures should be aimed at doing good. Healthcare providers should always do right by their patients.


Butts, J. B, & Rich, K.L. (2008). Nursing Ethics across the Curriculum and into Practice. Sunbury, MA: Jones and Bartlett, pp21-22, 2nd ed,

Denise, G. (2010). Study finds no progress in safety at hospitals. Retrieved on June 9, 2017 from

JoAnn B. R and Robin, W. (2011). Ethics and managing risk. The Nursing risk management series. American Nurses Association.

The Joint Commission (2016). Facts about joint commission standards, retrieved from dition-standards/html on June 9, 2017

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