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Hospital Compliance Executive Summary

Hospital Compliance Executive Summary

The purpose of this paper is to present an executive summary that identifies and examines the Magnet report results received from the American Nurses Credentialing Center (ANCC) for Saint Louis Medical Center (SLMC) to the board of directors. The healthcare sector plays a critical role in the society. It is through an effective and efficient healthcare sector that society will be able to realize sustainable development. In relation to this view, policymakers in the healthcare sector are usually concerned about improving the sector through relevant strategies to help healthcare organizations rise above these challenges, such as the poor, which is also the main concern for Saint Louis Medical Center. In 2014, Saint Louis Medical Center was in the limelight for the wrong reasons. Despite being one of the VA hospitals, the hospital was accused of being marred with poor service delivery for military veterans (Bogan, 2016). It is worth noting that the role of leaders and managers is huge, as society believes it is their primary role to ensure that the healthcare organizations that they lead not only meet the patient’s needs by providing affordable, quality, and patient-centred care but are also self-sustainable. Essentially, leaders are required to be cognizant of both the external and internal challenges that may prevent the organizations from achieving the set goals. Given the complexity and novelty of the leadership challenges at Saint Louis Medical Center, addressing the hospital’s current and future leadership needs requires effective leadership strategies. Transformational leadership is widely acknowledged as the most effective style of leadership. Transformational leadership involves acknowledging the emotional needs of employees (Cox, 2016; Roussel, 2013).

According to the Magnet report, the Saint Louis Medical Center’s board of directors were asked to come up with recommendations for relevant incentives, which may be adopted to improve the leadership capacity at the hospital to assure quality and patient-centred care, especially following the organizational politics that have compromised service delivery. The Saint Louis Medical Center has developed three recommendations:

Recommendation 1: The facility has the responsibility of providing quality medical services. To achieve this mission, the hospital must have organized medical staff teams operating under leaders approved by the hospital’s board. The leaders should be selected based on the criteria set out by standards to determine the suitability of individual members based on the information on training and education backgrounds, experience, current competence, licensing, and character are vital in the accreditation to these professional standards. It is important for the information to be verified by trusted sources on which to base a reasoned decision in the selection and appointment of the leaders.

Recommendation 2: The report also recommends that the hospital and its partners immediately undertake to promote proper leadership in the form of transformational leadership.

Transformational leadership is a form of organizational leadership in which the leaders work with their followers to realize the set goals. In essence, the role of the transformational leader entails inspiring the followers to realize positive change. It is worth noting that transformational leaders play a vital role in fostering employee motivation, boosting employee morale and enhancing job performance. These goals are achieved through a wide range of means, such as serving as role models, building collective identity, challenging the subordinates to own up their actions, setting the vision, empowering other people around them and being good listening partner. To effectively serve in this position, the leaders need to own different leadership personalities, such as being good listeners and communicators, showing empathy, commitment, and selflessness, among other qualities (Cox, 2016). Applicants for the positions of staff leaders are supposed to be able to lead the hospital in developing quality assessment and performance improvement programs that include clinical assessments in all units in the hospital, diagnostic procedures that involve all departments in the hospital system, such as the pharmacy, laboratories and therapeutic interventions by leading and supervising the team in order to achieve the goals of these programs and outcomes as appropriate to medical staff functions.

Recommendation 3: If Saint Louis Hospital supports the directives, the report recommends that appropriate actions involving training and technical assistance should be provided to the managers or leaders. The medical staff needs to be accountable to the healthcare organizations’ governing bodies and well organized for the quality of care that is provided to be assured.

Ideally, the medical staff should be well organized in accordance with the approved standards of the governing body. The doctors of medicine should constitute a large percentage of any medical staff committee. The responsibility for conduct or behaviour of the medical staff and organization should only be assigned to osteopaths or doctors, doctors of dental medicine or dental surgery with permission from state laws with regard to the hospital location, or doctors of pediatric medicine in instances where the state laws permit such actions (Clayton & Miller, 2017; Al- Sawai, 2013).

Nevertheless, the medical staff is called upon to directly report to the organization’s management about the organizational proposals, including revisions related to rules, Bylaws, medical staff officers, and regulations. Moreover, they are also required to exercise accountability to governance in relation to a report of the findings from current evaluations of the clinical work of the medical staff. In addition, members of the medical staff are also required to collaborate with governance and administration concerning institutional planning, appropriate utilization of the organization’s resources, and budgeting, among other roles.


Al-Sawai, A. (2013). The Leadership of Healthcare Professionals: Where Do We Stand? Oman Med J. 2013 Jul; 28(4): 285–287.

Bogan, J. (2016). The new leader of St. Louis VA tries to stabilize an embattled healthcare agency. Retrieved from va-tries-to-stabilize-embattled/article_89703dc3-0f43-5388-b651-4aa017f1afe8.html

Clayton, J. & Miller, K. (2017). Professional and Regulatory Infection Control Guidelines: Collaboration to Promote Patient Safety. AORN Journal 106. Vol. 106 (3): 201-210

Cox, J. (2016). Leadership and Management Roles: Challenges and Success Strategies. AORN Journal. Vol. 104(2): 45-49.

Roussel, L. (2013). Management and Leadership for nurse administrators. (6th ed.). Burlington, MA: Jones and Bartlett Learning. Print ISBN: 9781449614928.


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Your healthcare organization has had several small compliance incidents in the past two years, and the organization is now motivated to update its compliance program. Your executive leadership team asked you to review 2 healthcare compliance programs from similar organizations to determine how they constructed their compliance program and what aspects your organization should adopt.

Hospital Compliance Executive Summary

Hospital Compliance Executive Summary

Select the type of healthcare organization you want to be represented in this assignment (e.g., family practice, hospital, urgent care, or nursing home).

Locate 2 compliance program documents from comparable healthcare organizations using your Internet search engine.

Read both compliance program documents and examine the similarities and differences between them 2.

Create a matrix that compares how both organizations execute the following compliance components:

How internal monitoring and auditing are conducted
How compliance and practice standards are implemented
The designated compliance officer (or a person designated to be the contact for compliance matters), who that person reports to, and their relationship to the organization’s governing board
How employees are trained and educated to model compliant behaviours
How violations or offences are detected, reported, and corrected
How lines of communication with employees are developed
How disciplinary standards are enforced

Write a 525- to 700-word executive summary that informs your executive leadership about the matrix you created and offer your opinion as to which best practices the organization should adopt for its own compliance program.

Cite your sources according to APA guidelines.

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