Identifying Risks
Analyze a health care organization’s strengths, weaknesses, opportunities and threats (SWOT analysis) in relation to privacy and security risks and HIPAA compliance. Write a risk report (3-4 pages) providing background information on privacy and security and summarizing SWOT analysis findings.
Health care has advanced tremendously over the years, and so have privacy and security issues. As health care becomes more complex, the interaction between the law and health care continues to increase. This interaction includes legal violations, such as malpractice and other litigation, and privacy breaches through electronic access. Federal legislation, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires health care organizations to protect health information. HIPAA also provides data privacy and security provisions for safeguarding medical information. While no official, prescribed HIPAA compliance training program exists, health care organizations typically offer training to employees to ensure adherence to HIPAA guidelines and regulations. Requiring internal training is one way organizations can lower the risk of HIPAA violations occurring.
Many roles within the health care industry, including physicians, nurses, ancillary health professionals, and security and compliance professionals, are required to conduct themselves according to a set of professional ethics. These ethical standards are designed to ensure that patients feel safe sharing their private medical issues without fear of having those issues shared inappropriately or indiscriminately. Health care professionals face ethical dilemmas because of their access to this confidential information. For example, health care professionals may have access to health records for neighbors, friends, or family members. Adhering to a professional code of ethics and creating an environment of privacy and confidentiality is critical to adhering to the spirit of HIPAA laws. One way to assess risks and HIPAA compliance is to analyze the organization’s strengths, weaknesses, opportunities, and threats in relation to privacy and security. This is called a SWOT analysis. A SWOT can be an effective business tool to use as a starting point to improve business practices.
For this first course assessment, you will assume the role of a HIM analyst for Valley City Regional Hospital, part of the Vila Health system, in North Dakota. One of your major tasks is to create the hospital’s privacy and security plan. As part of that task, the hospital’s director of quality assurance has asked you to prepare a SWOT analysis and report.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
- Competency 1: Describe the purposes and scope of the Health Information Portability and Accountability Act (HIPAA).
- Describe HIPAA’s purpose and scope.
- Distinguish between privacy and security risks in health information management.
- Competency 2: Integrate privacy rules and regulations into health information management processes.
- Explain the purpose and benefits of identifying security and privacy risks.
- Competency 3: Analyze the relationship between security and privacy in health care.
- Compare/contrast privacy and security characteristics.
- Competency 4: Analyze legal and ethical implications related to Health Information Management.
- Determine professional, ethical, and legal risks in health information management.
- Competency 5: Communicate effectively in a professional and ethical manner.
- Create documents that are clear, well organized, professional, and generally free of errors in grammar, punctuation, and spelling.
- Follow APA style and formatting guidelines for citations and references.
Preparation
To prepare for this assessment you will need to view this media piece: Vila Health: Identifying Risks. Based on your findings from the media piece, you will perform a SWOT analysis. Next, you will prepare a report that supplies the narrative to accompany your SWOT analysis.
Instructions
In this first assessment, you will assume the role of a HIM analyst for Valley City Regional Hospital, part of the Vila Health system, in North Dakota. One of your major tasks is to create the hospital’s privacy and security plan. As part of that task, the hospital’s director of quality assurance has asked you to prepare a SWOT analysis. To help you complete your SWOT analysis, the director of quality assurance has arranged for you to meet with the risk management manager to gather information about the risk audit the hospital recently completed.
This assessment consists of two parts.
Part 1: Conduct a SWOT analysis based on your findings from the Vila Health: Identifying Risks media piece.
You will be able to create a PDF document of your SWOT analysis within the media piece. In accordance with HIPAA law, professionalism, and ethical standards, your SWOT analysis will need to focus on Valley City Regional Hospital’s strengths, weaknesses, threats, and opportunities related to protecting the privacy and security of health information.
Within the weaknesses and threats quadrants of your SWOT analysis, be sure to answer these questions:
- What health information management privacy and security risks did you identify for Valley City Regional Hospital?
- What health information management professional, ethical, and legal issues did you identify for Valley City Regional Hospital?
Part 2: Prepare a risk report that provides introductory information about privacy and security in health information and summarizes key SWOT analysis findings.
In your risk report, please be sure to include the following headings and address the questions under each heading:
HIPAA’s Purpose and Scope (1/2 page)
- What is HIPAA?
- What is its purpose?
- What is its scope?
Privacy vs. Security (1/2 page)
- What does privacy mean in health information management?
- What does security mean in health information management?
- How are privacy and security alike?
- How are they different?
Purpose and Benefits of Identifying Privacy and Security Risks (1/2 page)
- Why do health care organizations want to identify privacy and security risks?
- What are the benefits of identifying these risks?
- Who benefits from health care organizations identifying privacy and security risks?
SWOT Analysis Findings (1 to 2 pages)
- How would you headline the key findings from each of the four quadrants of your SWOT analysis?
Conclusion (1 to 2 paragraphs)
- What are the two to three most important points you want the director of quality assurance to remember from your risk report and your SWOT analysis?
Additional Requirements
- Length: 3 to 4 double-spaced pages plus the SWOT PDF.
- Format: Times Roman, 12-point font.
- APA: Follow APA style and formatting guidelines for citations and references. Include a separate works cited page for your references.
- Writing: Create clear, well-organized, professional documents that are generally free of errors in grammar, punctuation, and spelling.
Resources: SWOT Analysis
- Allscripts Healthcare Solutions. (2018). SWOT analysis. MarketLine, 1–8.
- Capella University Health Care Administration Undergraduate Library Research Guide.
- Please consult this guide as needed to conduct independent research on course topics. This resource will direct you to scholarly, peer-reviewed, and authoritative resources.
- Skillsoft. (n.d.). Using SWOT analysis to identify risks [Job Aid].
- SWOT Analysis | Transcript.
- Resources: Privacy and Ethics
- AHIMA. (2018). Ethics. Retrieved from
- Anonymous. (2018). Social media violating patient privacy. Health Care Collector: The Monthly Newsletter for Health Care Collectors, 31(9), 8–9.
- Chapman, S. (2017). Make patient privacy a priority. For the Record, 29(2), 18–21.
- Goodwin, M. (2016). Vulnerable subjects: Why does informed consent matter? Journal of Law, Medicine & Ethics, 44(3), 371–380.
- Oachs, P. K., & Watters, A. L. (Eds.). (2016). Health information management: Concepts, principles, and practice (5th ed.). Chicago, IL: AHIMA Press. Available from the bookstore.
- Chapter 2, “Legal Issues in Health Information Management,” pages 42–75.
- Appendix C, “AHIMA Code of Ethics.”
- Appendix F, “Sample Consent Form.”
- Resources: E-discovery
- Lamont, J. (2017). Emerging content formats challenge e-discovery. KM World, 26(8), 28–30.
- Melnik, T. (2016). Beyond HIPAA: Privacy and security due diligence in health care transactions. Journal of Health Care Compliance, 18(1), 45–48.
- Organization of Legal Professionals. (2014). E-discovery in healthcare: What legal and healthcare professionals need to know [Video] | Transcript. Retrieved from
Expert Solution Preview
Introduction:
Health care organizations must comply with federal legislation, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), to protect private medical information. One way to identify privacy and security risks and HIPAA compliance is by conducting a SWOT analysis. As a HIM analyst for Valley City Regional Hospital, part of the Vila Health system, in North Dakota, conducting a SWOT analysis is a major task in creating the hospital’s privacy and security plan. The following provides a risk report based on the findings from the SWOT analysis conducted.
1. Describe HIPAA’s purpose and scope.
HIPAA’s purpose is to ensure that protected health information (PHI) is appropriately secured and protected while allowing for its appropriate use and disclosure. The scope covers a wide range of health care providers, health plans, and healthcare clearinghouses. HIPAA also applies to business associates, which include entities that provide services to covered entities, such as IT companies that store PHI. HIPAA provides data privacy and security provisions for safeguarding medical information.
2. Explain the purpose and benefits of identifying security and privacy risks.
Identifying security and privacy risks helps health care organizations protect patient privacy, prevent data breaches, and ensure regulatory compliance. By understanding the risks, organizations can implement appropriate safeguards and controls to minimize those risks and maintain the confidentiality, integrity, and availability of PHI. Identifying these risks provides organizations with an opportunity to prioritize resources and address potential vulnerabilities.
3. Compare/contrast privacy and security characteristics.
Privacy in health information management focuses on protecting patient information from unauthorized access, use, or disclosure. Security in health information management focuses on protecting the confidentiality, integrity, and availability of patient information. Both privacy and security are necessary to ensure patient information is protected and secure from unauthorized access or disclosure.
4. Determine professional, ethical, and legal risks in health information management.
Professional, ethical, and legal risks in health information management include ensuring the confidentiality, integrity, and availability of patient information, and upholding ethical standards to ensure patients feel safe sharing their private medical conditions without fear of inappropriate or indiscriminate sharing of information. Additionally, health care professionals must adhere to regulations and compliance standards related to health information management, such as HIPAA and other regulatory initiatives.
5. Create documents that are clear, well-organized, professional, and generally free of errors in grammar, punctuation, and spelling.
The risk report should be clear, concise, and organized in headings and subheadings related to HIPAA’s purpose and scope, privacy and security, identifying risks, SWOT analysis findings, and a conclusion. The use of appropriate APA style and formatting guidelines for citations and references demonstrates a professional and ethical approach. The report should be free of errors in grammar, punctuation, and spelling to ensure clarity and credibility.
