Compliance Initiatives/5 Whys Process/Root Cause Analysis

Competency 1: Determine best practices for health care compliance and privacy programs.
Competency 2: Synthesize the policy enforcement and communication strategies of regulatory bodies across the health sector.
Competency 3: Analyze the role of risk management in ensuring ethical practices and driving organizational growth in the health sector.

Reflect on the following questions in a minimum of 500 words:

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Question 1: How could you utilize a matrix to identify ways to meet major compliance initiatives in your current organization? (HOSPITAL SETTING) How could you apply finding trends in graphs and charts to identifying insights for your current position? Provide an example, either within your work environment or in society at large, of when using the Five Whys process or root cause analysis could illuminate an issue you are facing.
Question 2: What specific assignments or learning activities from this course did you find particularly beneficial? What do you feel could’ve improved or added to your learning experience in this course?

Submit your reflection.

Sample Answer


Compliance Initiatives/5 Whys Process/Root Cause Analysis

Question 1

A matrix can be useful for identifying ways to meet major organizational compliance initiatives. By looking at the various elements of the matrix, it is possible to identify which areas need improvement and which are already meeting compliance standards (Dunzer et al., 2019). The first step is identifying the major compliance initiatives relevant to the organization. These might include patient safety, infection control, and medication management initiatives for a hospital setting. Once the relevant initiatives have been identified, the next step is to assess the current state of compliance in each area by looking at data from audits, reviews, and other sources.

Identifying areas where improvements need to be made is the next step. This can be done by looking at the data from the assessment and identifying areas where the organization is not meeting compliance standards. Then develop a plan for improving compliance in those areas, which should be tailored to the organization’s specific needs and available resources. Finally, implement the plan and monitor the results by tracking the data from audits and reviews to see if there is a change in the organization’s compliance rate. Additionally, it is important to periodically assess the plan to see if it is still effective and to make changes as needed.

There are a few ways that finding trends in graphs and charts can help identify insights for a hospital setting. The first is by looking at the overall trends of the hospital (Hallam & Contreras, 2018). Doing so can help identify areas that may need improvement, such as increasing the number of patient admissions or reducing the number of readmissions. Looking at trends over time can also help identify any seasonality in the hospital’s data. For example, if there are more admissions in the summer months, this could be due to an increase in tourist traffic.

Another way to use trends to identify insights is by looking at specific departments or units within the hospital (Hallam & Contreras, 2018). This can help identify areas that may be underperforming or overperforming and those that may need more resources. For example, if the emergency department has a high volume of patients but a low number of beds, this could be an indication that the department is understaffed. Finally, trends can also help identify changes in the hospital’s demographics (Hallam & Contreras, 2018). The latter can be important in understanding how the hospital’s services are being used and whether there are any changes in the patients being admitted. For example, an increase in the number of elderly patients being admitted could indicate a need for more geriatric services.

Medics use the Five Whys process in the work environment to help them understand the root cause of issues. For example, recently, there was an issue with a patient not receiving the proper care they needed. They used the Five Whys process to help them understand why this was happening; Why did the patient experience a decline in their condition? Why was the patient not responding to treatment? Why did the patient develop complications? Why was the patient not able to recover? Why did the patient die? By asking why five times, medics can drill down to the root cause of the problem and develop a plan to address it.

Question 2

The assignments that required me to research and analyze the compliance programs of different organizations were most beneficial. It was helpful to see how different organizations approached compliance and to compare and contrast their strategies. Lessons on risk management were also helpful. It was beneficial to learn about the different types of risks that can affect an organization and develop a management plan. The course could have been improved by including more assignments that required students to research and analyze regulatory bodies’ policy enforcement and communication strategies.

In conclusion, a matrix can be a useful tool for identifying ways to meet major organizational compliance initiatives. The Five Whys process and Root Cause Analysis can also be used to identify trends and problems in an organization. By looking for patterns in the data, it is possible to identify ways to improve care and compliance in a hospital setting. This course was beneficial in teaching students about compliance and risk management.



Dunzer, S., Stierle, M., Matzner, M., & Baier, S. (2019, June). Conformance checking: a state-

of-the-art literature review. In Proceedings of the 11th international conference on subject-oriented business process management (pp. 1-10).

Hallam, C. R., & Contreras, C. (2018). Lean healthcare: scale, scope and sustainability.

International journal of health care quality assurance.

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