Steps in the Process of Risk Management in Healthcare


Risk management is essential for any enterprise, but for healthcare organizations, it has even greater significance because, frequently, people’s lives are at stake. Risk is defined as “a probability or threat of damage, injury, liability loss that is caused by vulnerabilities and that may be avoided through pre-emptive actions” (Alam, 2016, p. 118). The essence of risk management consists in identifying, assessing, and reducing possible threats to patients, visitors, personnel, and resources of the organization (Alam, 2016).

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This paper will analyze a risk management plan of Jackson Health System (JHS), a net of medical centers and hospitals in Miami. The analysis shows that the organization’s plan complies with the standards established by the superior regulatory agencies.

Summary of the Risk Management Plan

The type of risk management plan elaborated by JHS is community-focused and centered on patient safety. The rationale for selecting this example is that it is a large set of hospitals, some of them being considered the best in the country. Therefore, this organization is sure to manage risks successfully to guarantee the safety of a great number of patients, visitors, and employed healthcare professionals.

The purpose of JHS is to provide citizens of Miami with high-quality healthcare regardless of their income levels. It has a wide range of medical services to offer to its patients, such as urgent and primary care, rehabilitation and behavioral health centers, as well as outpatient services. Risk management plays a significant role in these settings since there is always a possibility of a medical error, equipment malfunction, and patients’ deaths (Jackson Health System [JHS], 2016). Consequently, the organization should assess the probability of these risks and develop a strategy of preventing or addressing them.

Standard Administrative Processes

While preparing a risk management plan, a healthcare organization relies on standards accepted by the regulatory agencies. There are five basic stages of the risk management process: establishing the context, identifying risks, analyzing them, evaluating, and managing them (Alam, 2016). While establishing the context, risk managers should pay primary attention to intensive care units, operation and emergency rooms, as well as blood transfusion services and medication management (Alam, 2016).

Communication with personnel and patients, as well as various reports and survey results, are used to identify risks (Alam, 2016). Analyzing levels of risks and their underlying causes are required to prioritize them and assess which of them should be managed in the first place (Alam, 2016). The final step requires defining the necessary actions, resources, responsible persons, and timeframes (Alam, 2016). The risk management plan of JHS follows all five steps.

Florida Statutes provide a more specific list of requirements for a healthcare organization’s risk management plan. According to Florida Statute 395.0197, healthcare organizations should educate their nonphysician personnel about risk prevention annually (Jones & Slosburg, n.d.). However, it is unknown whether JHS provides such training for its staff since there is no information about it in the risk management plan.

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Florida Statutes also prohibit unauthorized personnel from attending patients alone and require healthcare employees to reports all the adverse incidents to the risk manager (Jones & Slosburg, n.d.). The risk management plan of JHS conforms to these rules since it includes these requirements and provides a detailed explanation of the process of reporting incidents.

Key Regulatory Organizations

The major organization regulating the administration of safe healthcare in Miami is the Joint Commission. It is a federal agency that gives accreditation to other healthcare organizations. Being accredited by the Joint Commission means that a hospital or a medical center meets the standards of medical care, patient safety, and healthcare professionals’ competence. Another organization that oversees the risk management process is the Florida Department of Health.

It passes legislation as to the procedures of risk management, which all the healthcare organizations in the state should follow. The Florida Agency for Health Care Administration (AHCA) is the third agency that supervises healthcare organizations. Its aim is to license and regulate medical care providers, as well as inform citizens of the quality of healthcare services.

Compliance with the Standards of the Joint Commission

The corresponding MIPPA-approved accrediting body of JHS is the Joint Commission. According to its standard relevant to privacy, healthcare organizations must maintain the confidentiality of patients’ information (The Joint Commission, 2016). It requires employees working with patients’ personal data to sign a confidentiality statement and to keep records out of sight of unauthorized individuals (The Joint Commission, 2016).

The JHS risk management plan claims that incident reports are confidential, but it does not provide any information about the privacy of other patients’ documents (JHS, 2016). As for worker safety, the Joint Commission’s standards expect employees to wear gowns to avoid contamination and require them to undergo health screenings (The Joint Commission, 2016).

The risk management plan of JHS does not contain any information about worker safety; rather, it is focused on patient safety and reporting incidents. As for patient safety, the Joint Commission requires healthcare organizations to place emergency call buttons in hospital rooms and be aware of who enters the buildings (The Joint Commission, 2016). JHS meets the requirement as to the emergency call button but does not contain information about admitting strangers to hospitals.


To sum up, the risk management plan of JHS complies with the majority of standards established by the regulatory organizations. However, some recommendations may be given to improve the risk management program. For example, the organization could develop a set of rules to ensure worker safety since the current plan does not contain any requirements as to this issue. It could also state in the plan the necessity of risk management training for employees to conform to the requirement of Florida Statutes.

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Alam, A. Y. (2016). Steps in the process of risk management in healthcare. Journal of Epidemiology and Preventive Medicine, 2(2), 118-122.

Jackson Health System. (2016). JHS – Risk management. Web.

The Joint Commission. (2016). Standards interpretation frequently asked questions. Web.

Jones, S., & Slosburg, D. (n.d.). Florida risk management and related regulations (3rd ed.). Web.

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