[Solved] Hospital Risk Management/Health Care Policy

Assignment Prompt & Instructions

**files (5)**

– ## HosptialApplication.docx

– ## HealthCarePolicyAssignment.docx

– ## HospitalRiskManagement_Scenario460.pdf

– ## HealthCarePolicyMemoTemplate.docx

– ## Rubric-HealthCarePolicyandProcedureDevelopment.pdf

**## HosptialApplication.docx**

Within the Allied Health Community media, read the "Hospital: Risk Management Scenario."

In a total of 250-500 words, respond to the questions located in the scenario.

**## HealthCarePolicyAssignment.docx**

Complete the
**Transitional Care Application assignment prior** to beginning this assignment.

Select
one conflict issue from the Transitional Care scenario in the Allied Health Community and write a new policy and procedure related to the issue that identifies methods or practices of rationally and effectively discusses issues and resolving conflict.

**Write a 500-word memo** to your supervisor (you may choose to use the "Health Care Policy and Procedure Memo" sample) that describes this issue and an explanation of how the new policy and procedure will resolve the issue. In the memo, include a draft of the policy and procedure. Be sure to include the research on industry standards that helped you formulate the policy and procedure.

·
**Memo template is attached**

**## HospitalRiskManagement_Scenario460.pdf**

HOSPITAL: Risk Management Scenario

Scenario

A rural country hospital facility provides health care services to over 35,000 citizens, with a high
percentage being older Americans who have retired to this area of the country. The hospital administrator
has asked the Vice President of Risk Management to attend a meeting with the senior staff next week in
the Board Room. The hospital administrator has asked Vice President of Risk Management to present
areas of opportunity for increasing the hospital’s risk management strategies to ensure a litigation-free
environment for the facility, its patients, and its employees.

During the meeting, the Vice President of Risk Management reports that all the continuous quality
improvement (CQI) minutes for the past 3 months of meetings have been reviewed. Although most areas
are being adequately resolved, there are some that need more attention, especially from the senior staff.
Before specifically addressing those points, the Vice President of Risk Management briefs the staff on the
major areas of risk for the hospital. They are:

1. Employee-driven adverse actions against the facility
2. Medication errors
3. Surgery/Treatment errors
4. Patient falls
5. Patient elopements
6. Security breaches in secured areas
7. Inaccurate coding and billing for government/insurer reimbursements

Now that the senior staff is aware of the major areas of risk concern, you, as the administrator in charge
of all hospital business operations, assign each of these areas of concern to the respective director,
such as the Directors of Human Resources, Nursing, Medical, Social Services, and Facility Security.
Their reports of assessment, along with recommendations for achieving full compliance and reducing the
hospital’s litigation exposure, are due at the end of the month.

Questions:

1. While this situation has many areas of risk that are considered a top priority, focus on patient privacy
and information disclosure (HIPAA violations). Which department is responsible for leading the
initiative? As the administrator, describe your approach for managing this directive. Do you create a
special projects team? How do you gather pertinent data for a category? What tools would you use?
2. How do you determine if you are meeting the industry standards for this area of risk?
3. Would you change any current policies or procedures? How and why?
4. How would you train the affected staff with regard to this area of risk?
5. What are the sanctions, penalties, or government investigations that could present a worst-case
scenario if not addressed?

**## HealthCarePolicyMemoTemplate.docx**


**Health Care Policy and Procedure Memo**

Grand Canyon Transitional Care Organization

**MEMORANDUM**

| | |
| — | — |
| **TO:** | INSTRUCTOR A. NAME, MHA |
| **FROM:** | STUDENT A. SAMPLE |
| **SUBJECT:** | ENTER SUBJECT |
| **DATE:** | 3/29/2020 |
| CC<br>**:** | BOSS A. SUPERVISOR, MHA |

Through my experience as the Director of Human Resources, many issues that are occurring within our organization have been brought to my attention. One of the main issues brought to my attention through complaints from employees is that our organization has many policies that are out of date. These outdated policies are not effective within the current health care industry, causing further issues within our organization. I have created a new policy and procedure pertaining specifically to the steps of creating and regularly reviewing our current policies and procedures. This is a policy that we have lacked entirely in the past, creating the need for the development of one now. The new policy will promote compliance with relevant legislation, industry and other standards, and community expectations; promote our organization to achieve strides toward the mission, vision, and values; “promote operational efficiency;” and reduce potential risks within the health care environment (Example, 2019). The policy will benefit the employees of our health care organization immensely, along with the community members to which we are providing service.

The policy that I have developed is titled “Creation, Review, and Revision of Policies and Procedures Policy.” The policy and procedure will lay out specific guidelines, templates, and requirements for creating and regularly reviewing policies and procedures within our health care facility. The general steps involved in the procedure include needs analysis, development, approval, distribution, implementation, regular review, and revision (More, 2020). The health care industry is consistently transforming due to technology and other factors, creating the need for our organization to stay on top of policies creating a current, accurate, and effective environment for all of those who are involved. Overall, the policy will promote consistency, predictability, compatibility, risk mitigation, and high-quality care throughout our organization.

I believe that this new policy will not only help with eliminating the problem of out-of-date policies, but also the many other issues that have been brought to my attention by various staff members. These other issues include complaints about management, employee-related adverse actions, unfair treatment for corrective actions and progressive discipline, unfair administering of policies, a high number of medication errors, and harmful patient treatment. Although our organization has maintained a superb reputation for the last 40 years in service, our reputation and ability to perform is going to decline if we do not make the necessary changes in a timely manner. All of the issues pertain to specific policies and procedures that we have, but there is a clear need for revision to correct the actions of management and other employees. If implementation of this policy is successful, there will be a requirement for policies and procedures to be reviewed on an annual basis. This is strongly needed, as some of our policies have not been revised in years. Please consider administering this policy and procedure so that we are able to maintain ourselves as a reputable health care organization, willing and able to provide the highest quality of care for all of our patients.

I have attached the proposed policy and procedure. Please do not hesitate to contact me with any further questions, comments, or concerns.

Sincerely,

Student A. Sample

**ATTACHMENT:**

**\_\_\____________________________________________________________________________**

_Creation, Review, and Revision of Policies and Procedures Policy_

**Policy:** The purpose of this policy is to create guidelines and requirements for policies and procedures that promote consistency, predictability, and compatibility throughout Grand Canyon Transitional Care Organization. The policies for the organization will be generated according to a standard template. The requirement will be that policies are reviewed annually to ensure that they are still effective and up to date.

**Procedure:**

A. Needs Analysis

a. Identify the need for the creation of a new policy.

b. Identify the need for the review or revision of a current policy.

B. Development

a. Determine who will be creating and writing the policy.

b. Determine who will make changes to the existing policy.

c. Create all policies in accordance with the universal format.

i. Purpose/Policy statement.

ii. Procedure that will support the enactment of the policy.

C. Approval

a. Determine who will have the power to approve the new policy or the edited policy.

b. Get approval for the policy.

D. Distribution

a. Distribute the new policy to staff members.

i. Allow time for questions, thoughts, concerns.

b. Distribute the revised policy to staff members.

i. Allow time for questions, thoughts, concerns.

E. Implementation

a. Implement the new policy within the organization.

b. Implement the revision of the policy within the organization.

F. Regular Review

a. All policies and procedures are to be reviewed on an annual basis.

G. Revision

a. If the review deems revision necessary, repeat steps A through E.

b. Step F will occur after a year.

EFFECTIVE DATE: April 1, 2020

References

Example, J. (2019). Do you need a policy on policies? Retrieved from https://www.effectivecompliance.com.au/do-you-need-a-policy-on-policies/

More, E. (2020). Do you want a procedure date? Retrieved from https://www.effectiveprocess.au/do-you-wantd-a-procedure-date/

© 2026. Grand Canyon University. All Rights Reserved.

2

## image1.jpeg

**## Rubric-HealthCarePolicyandProcedureDevelopment.pdf**

Benchmark – Health Care Policy and Procedure Development – Rubric Total 80 points

Criterion 1. 1: Unsatisfactory
2. 2: Less Than

Satisfactory
3. 3: Satisfactory 4. 4: Good 5. 5: Excellent

Issue

Issue

0 points

A description of the issue is

not present.

8.84 points

A description of the issue is

present, but it lacks detail or

is incomplete.

10.2 points

A description of the issue is

present.

11.56 points

A description of the issue is

well developed.

13.6 points

A description of the issue is

thoroughly developed with

supporting details.

New Policy and Procedure

(B)

New Policy and Procedure

(C2.2)

0 points

A description of how the new

policy and procedure will

resolve the issue is not

present.

8.84 points

A description of how the new

policy and procedure will

resolve the issue is present,

but it lacks detail or is

incomplete.

10.2 points

A description of how the new

policy and procedure will

resolve the issue is present.

11.56 points

A description how the new

policy and procedure will

resolve the issue is well

developed.

13.6 points

A description of how the new

policy and procedure will

resolve the issue is

thoroughly developed with

supporting details.

Draft of Policy and

Procedure

Draft of Policy and Procedure

0 points

The draft of the policy and

procedure is not present.

8.84 points

The draft of the policy and

procedure is present, but it

lacks detail or is incomplete.

10.2 points

The draft of the policy and

procedure is present.

11.56 points

The draft of the policy and

procedure is detailed.

13.6 points

The draft of the policy and

procedure is thorough.

Research

Research

0 points

A description of research on

industry standards that

helped formulate the policy

and procedure is not

included.

8.84 points

A description of research on

industry standards that

helped formulate the policy

and procedure is present,

but it lacks detail or is

incomplete.

10.2 points

A description of research on

industry standards that

helped formulate the policy

and procedure is present.

11.56 points

A description of research on

industry standards that

helped formulate the policy

and procedure is clearly

provided and well developed.

13.6 points

A description of research on

industry standards that

helped formulate the policy

and procedure is thoroughly

developed with supporting

details.

Concepts

Concepts

0 points

Main concept is not clearly

identified, and subconcepts

do not consistently branch

from the main idea.

3.64 points

Main concept is not clearly

identified, and few

subconcepts branch

appropriately. Limited

understanding of assignment

is apparent.

4.2 points

Main concept is easily

identified, and few

subconcepts branch from the

main idea. Only a basic

understanding of assignment

is present.

4.76 points

Main concept is easily

identified and most

subconcepts branch from the

main idea. An original and

creative concept fulfills the

parameters of assignment.

5.6 points

Main concept is easily

identified, and subconcepts

branch appropriately from

the main idea. Projects

exhibit the process of

creative thinking and the

development of an individual

style.

Synthesis

Synthesis

0 points

Synthesis does not

successfully integrate ideas,

images, or objects to form a

cohesive whole. The

combination of elements is

not logical or verifiable.

5.2 points

Synthesis integrates ideas,

images, or objects

inadequately. The

combination of elements is

not logical.

6 points

Synthesis integrates ideas,

images, or objects but does

not fully form a cohesive

whole. Combination of

elements at times is

confusing.

6.8 points

Synthesis integrates ideas,

images, or objects to form a

cohesive whole. Combination

of elements is logical and

justified.

8 points

Synthesis is distinctive.

Synthesis shows careful

planning and attention to

how disparate elements fit

together. The combination of

elements is verified.

Mechanics of Writing

(includes spelling,

punctuation, grammar, and

language use)

Mechanics of Writing

(includes spelling,

punctuation, grammar, and

language use)

0 points

Surface errors are pervasive

enough that they impede

communication of meaning.

Inappropriate word choice or

sentence construction is

employed.

5.2 points

Frequent and repetitive

mechanical errors distract

the reader. Inconsistencies in

language choice (register) or

word choice are present.

Sentence structure is correct

but not varied.

6 points

Some mechanical errors or

typos are present, but they

are not overly distracting to

the reader. Correct and

varied sentence structure

and audience-appropriate

language are employed.

6.8 points

Prose is largely free of

mechanical errors, although

a few may be present. The

writer uses a variety of

effective sentence structures

and figures of speech.

8 points

The writer is clearly in

command of standard,

written, academic English.

Documentation of Sources

Documentation of Sources

(citations, footnotes,

references, bibliography, etc.,

as appropriate to assignment

and style)

0 points

Sources are not documented.

2.6 points

Documentation of sources is

inconsistent or incorrect, as

appropriate to assignment

and style, with numerous

formatting errors.

3 points

Sources are documented, as

appropriate to assignment

and style, although some

formatting errors may be

present.

3.4 points

Sources are documented, as

appropriate to assignment

and style, and format is

mostly correct.

4 points

Sources are completely and

correctly documented, as

appropriate to assignment

and style, and format is free

of error.

© 2026. Grand Canyon University. All Rights Reserved.

[https://www.gce.com/](https://www.gce.com/)

[https://www.gce.com/](https://www.gce.com/)

© 2026. Grand Canyon University. All Rights Reserved.

[https://www.gce.com/](https://www.gce.com/)

[https://www.gce.com/](https://www.gce.com/)

**## Rubric-HealthCarePolicyandProcedureDevelopment.pdf**

Benchmark – Health Care Policy and Procedure Development – Rubric Total 80 points

Criterion 1. 1: Unsatisfactory
2. 2: Less Than

Satisfactory
3. 3: Satisfactory 4. 4: Good 5. 5: Excellent

Issue

Issue

0 points

A description of the issue is

not present.

8.84 points

A description of the issue is

present, but it lacks detail or

is incomplete.

10.2 points

A description of the issue is

present.

11.56 points

A description of the issue is

well developed.

13.6 points

A description of the issue is

thoroughly developed with

supporting details.

New Policy and Procedure

(B)

New Policy and Procedure

(C2.2)

0 points

A description of how the new

policy and procedure will

resolve the issue is not

present.

8.84 points

A description of how the new

policy and procedure will

resolve the issue is present,

but it lacks detail or is

incomplete.

10.2 points

A description of how the new

policy and procedure will

resolve the issue is present.

11.56 points

A description how the new

policy and procedure will

resolve the issue is well

developed.

13.6 points

A description of how the new

policy and procedure will

resolve the issue is

thoroughly developed with

supporting details.

Draft of Policy and

Procedure

Draft of Policy and Procedure

0 points

The draft of the policy and

procedure is not present.

8.84 points

The draft of the policy and

procedure is present, but it

lacks detail or is incomplete.

10.2 points

The draft of the policy and

procedure is present.

11.56 points

The draft of the policy and

procedure is detailed.

13.6 points

The draft of the policy and

procedure is thorough.

Research

Research

0 points

A description of research on

industry standards that

helped formulate the policy

and procedure is not

included.

8.84 points

A description of research on

industry standards that

helped formulate the policy

and procedure is present,

but it lacks detail or is

incomplete.

10.2 points

A description of research on

industry standards that

helped formulate the policy

and procedure is present.

11.56 points

A description of research on

industry standards that

helped formulate the policy

and procedure is clearly

provided and well developed.

13.6 points

A description of research on

industry standards that

helped formulate the policy

and procedure is thoroughly

developed with supporting

details.

Concepts

Concepts

0 points

Main concept is not clearly

identified, and subconcepts

do not consistently branch

from the main idea.

3.64 points

Main concept is not clearly

identified, and few

subconcepts branch

appropriately. Limited

understanding of assignment

is apparent.

4.2 points

Main concept is easily

identified, and few

subconcepts branch from the

main idea. Only a basic

understanding of assignment

is present.

4.76 points

Main concept is easily

identified and most

subconcepts branch from the

main idea. An original and

creative concept fulfills the

parameters of assignment.

5.6 points

Main concept is easily

identified, and subconcepts

branch appropriately from

the main idea. Projects

exhibit the process of

creative thinking and the

development of an individual

style.

Synthesis

Synthesis

0 points

Synthesis does not

successfully integrate ideas,

images, or objects to form a

cohesive whole. The

combination of elements is

not logical or verifiable.

5.2 points

Synthesis integrates ideas,

images, or objects

inadequately. The

combination of elements is

not logical.

6 points

Synthesis integrates ideas,

images, or objects but does

not fully form a cohesive

whole. Combination of

elements at times is

confusing.

6.8 points

Synthesis integrates ideas,

images, or objects to form a

cohesive whole. Combination

of elements is logical and

justified.

8 points

Synthesis is distinctive.

Synthesis shows careful

planning and attention to

how disparate elements fit

together. The combination of

elements is verified.

Mechanics of Writing

(includes spelling,

punctuation, grammar, and

language use)

Mechanics of Writing

(includes spelling,

punctuation, grammar, and

language use)

0 points

Surface errors are pervasive

enough that they impede

communication of meaning.

Inappropriate word choice or

sentence construction is

employed.

5.2 points

Frequent and repetitive

mechanical errors distract

the reader. Inconsistencies in

language choice (register) or

word choice are present.

Sentence structure is correct

but not varied.

6 points

Some mechanical errors or

typos are present, but they

are not overly distracting to

the reader. Correct and

varied sentence structure

and audience-appropriate

language are employed.

6.8 points

Prose is largely free of

mechanical errors, although

a few may be present. The

writer uses a variety of

effective sentence structures

and figures of speech.

8 points

The writer is clearly in

command of standard,

written, academic English.

Documentation of Sources

Documentation of Sources

(citations, footnotes,

references, bibliography, etc.,

as appropriate to assignment

and style)

0 points

Sources are not documented.

2.6 points

Documentation of sources is

inconsistent or incorrect, as

appropriate to assignment

and style, with numerous

formatting errors.

3 points

Sources are documented, as

appropriate to assignment

and style, although some

formatting errors may be

present.

3.4 points

Sources are documented, as

appropriate to assignment

and style, and format is

mostly correct.

4 points

Sources are completely and

correctly documented, as

appropriate to assignment

and style, and format is free

of error.

© 2026. Grand Canyon University. All Rights Reserved.

[https://www.gce.com/](https://www.gce.com/)

[https://www.gce.com/](https://www.gce.com/)

© 2026. Grand Canyon University. All Rights Reserved.

[https://www.gce.com/](https://www.gce.com/)

[https://www.gce.com/](https://www.gce.com/)

**## HosptialApplication.docx**

Within the Allied Health Community media, read the "Hospital: Risk Management Scenario."

In a total of 250-500 words, respond to the questions located in the scenario.

**## HealthCarePolicyAssignment.docx**

Complete the
**Transitional Care Application assignment prior** to beginning this assignment.

Select
one conflict issue from the Transitional Care scenario in the Allied Health Community and write a new policy and procedure related to the issue that identifies methods or practices of rationally and effectively discusses issues and resolving conflict.

**Write a 500-word memo** to your supervisor (you may choose to use the "Health Care Policy and Procedure Memo" sample) that describes this issue and an explanation of how the new policy and procedure will resolve the issue. In the memo, include a draft of the policy and procedure. Be sure to include the research on industry standards that helped you formulate the policy and procedure.

·
**Memo template is attached**

**## HospitalRiskManagement_Scenario460.pdf**

HOSPITAL: Risk Management Scenario

Scenario

A rural country hospital facility provides health care services to over 35,000 citizens, with a high
percentage being older Americans who have retired to this area of the country. The hospital administrator
has asked the Vice President of Risk Management to attend a meeting with the senior staff next week in
the Board Room. The hospital administrator has asked Vice President of Risk Management to present
areas of opportunity for increasing the hospital’s risk management strategies to ensure a litigation-free
environment for the facility, its patients, and its employees.

During the meeting, the Vice President of Risk Management reports that all the continuous quality
improvement (CQI) minutes for the past 3 months of meetings have been reviewed. Although most areas
are being adequately resolved, there are some that need more attention, especially from the senior staff.
Before specifically addressing those points, the Vice President of Risk Management briefs the staff on the
major areas of risk for the hospital. They are:

1. Employee-driven adverse actions against the facility
2. Medication errors
3. Surgery/Treatment errors
4. Patient falls
5. Patient elopements
6. Security breaches in secured areas
7. Inaccurate coding and billing for government/insurer reimbursements

Now that the senior staff is aware of the major areas of risk concern, you, as the administrator in charge
of all hospital business operations, assign each of these areas of concern to the respective director,
such as the Directors of Human Resources, Nursing, Medical, Social Services, and Facility Security.
Their reports of assessment, along with recommendations for achieving full compliance and reducing the
hospital’s litigation exposure, are due at the end of the month.

Questions:

1. While this situation has many areas of risk that are considered a top priority, focus on patient privacy
and information disclosure (HIPAA violations). Which department is responsible for leading the
initiative? As the administrator, describe your approach for managing this directive. Do you create a
special projects team? How do you gather pertinent data for a category? What tools would you use?
2. How do you determine if you are meeting the industry standards for this area of risk?
3. Would you change any current policies or procedures? How and why?
4. How would you train the affected staff with regard to this area of risk?
5. What are the sanctions, penalties, or government investigations that could present a worst-case
scenario if not addressed?

**## HealthCarePolicyMemoTemplate.docx**


**Health Care Policy and Procedure Memo**

Grand Canyon Transitional Care Organization

**MEMORANDUM**

| | |
| — | — |
| **TO:** | INSTRUCTOR A. NAME, MHA |
| **FROM:** | STUDENT A. SAMPLE |
| **SUBJECT:** | ENTER SUBJECT |
| **DATE:** | 3/29/2020 |
| CC<br>**:** | BOSS A. SUPERVISOR, MHA |

Through my experience as the Director of Human Resources, many issues that are occurring within our organization have been brought to my attention. One of the main issues brought to my attention through complaints from employees is that our organization has many policies that are out of date. These outdated policies are not effective within the current health care industry, causing further issues within our organization. I have created a new policy and procedure pertaining specifically to the steps of creating and regularly reviewing our current policies and procedures. This is a policy that we have lacked entirely in the past, creating the need for the development of one now. The new policy will promote compliance with relevant legislation, industry and other standards, and community expectations; promote our organization to achieve strides toward the mission, vision, and values; “promote operational efficiency;” and reduce potential risks within the health care environment (Example, 2019). The policy will benefit the employees of our health care organization immensely, along with the community members to which we are providing service.

The policy that I have developed is titled “Creation, Review, and Revision of Policies and Procedures Policy.” The policy and procedure will lay out specific guidelines, templates, and requirements for creating and regularly reviewing policies and procedures within our health care facility. The general steps involved in the procedure include needs analysis, development, approval, distribution, implementation, regular review, and revision (More, 2020). The health care industry is consistently transforming due to technology and other factors, creating the need for our organization to stay on top of policies creating a current, accurate, and effective environment for all of those who are involved. Overall, the policy will promote consistency, predictability, compatibility, risk mitigation, and high-quality care throughout our organization.

I believe that this new policy will not only help with eliminating the problem of out-of-date policies, but also the many other issues that have been brought to my attention by various staff members. These other issues include complaints about management, employee-related adverse actions, unfair treatment for corrective actions and progressive discipline, unfair administering of policies, a high number of medication errors, and harmful patient treatment. Although our organization has maintained a superb reputation for the last 40 years in service, our reputation and ability to perform is going to decline if we do not make the necessary changes in a timely manner. All of the issues pertain to specific policies and procedures that we have, but there is a clear need for revision to correct the actions of management and other employees. If implementation of this policy is successful, there will be a requirement for policies and procedures to be reviewed on an annual basis. This is strongly needed, as some of our policies have not been revised in years. Please consider administering this policy and procedure so that we are able to maintain ourselves as a reputable health care organization, willing and able to provide the highest quality of care for all of our patients.

I have attached the proposed policy and procedure. Please do not hesitate to contact me with any further questions, comments, or concerns.

Sincerely,

Student A. Sample

**ATTACHMENT:**

**\_\_\____________________________________________________________________________**

_Creation, Review, and Revision of Policies and Procedures Policy_

**Policy:** The purpose of this policy is to create guidelines and requirements for policies and procedures that promote consistency, predictability, and compatibility throughout Grand Canyon Transitional Care Organization. The policies for the organization will be generated according to a standard template. The requirement will be that policies are reviewed annually to ensure that they are still effective and up to date.

**Procedure:**

A. Needs Analysis

a. Identify the need for the creation of a new policy.

b. Identify the need for the review or revision of a current policy.

B. Development

a. Determine who will be creating and writing the policy.

b. Determine who will make changes to the existing policy.

c. Create all policies in accordance with the universal format.

i. Purpose/Policy statement.

ii. Procedure that will support the enactment of the policy.

C. Approval

a. Determine who will have the power to approve the new policy or the edited policy.

b. Get approval for the policy.

D. Distribution

a. Distribute the new policy to staff members.

i. Allow time for questions, thoughts, concerns.

b. Distribute the revised policy to staff members.

i. Allow time for questions, thoughts, concerns.

E. Implementation

a. Implement the new policy within the organization.

b. Implement the revision of the policy within the organization.

F. Regular Review

a. All policies and procedures are to be reviewed on an annual basis.

G. Revision

a. If the review deems revision necessary, repeat steps A through E.

b. Step F will occur after a year.

EFFECTIVE DATE: April 1, 2020

References

Example, J. (2019). Do you need a policy on policies? Retrieved from https://www.effectivecompliance.com.au/do-you-need-a-policy-on-policies/

More, E. (2020). Do you want a procedure date? Retrieved from https://www.effectiveprocess.au/do-you-wantd-a-procedure-date/

© 2026. Grand Canyon University. All Rights Reserved.

2

## image1.jpeg

**## Rubric-HealthCarePolicyandProcedureDevelopment.pdf**

Benchmark – Health Care Policy and Procedure Development – Rubric Total 80 points

Criterion 1. 1: Unsatisfactory
2. 2: Less Than

Satisfactory
3. 3: Satisfactory 4. 4: Good 5. 5: Excellent

Issue

Issue

0 points

A description of the issue is

not present.

8.84 points

A description of the issue is

present, but it lacks detail or

is incomplete.

10.2 points

A description of the issue is

present.

11.56 points

A description of the issue is

well developed.

13.6 points

A description of the issue is

thoroughly developed with

supporting details.

New Policy and Procedure

(B)

New Policy and Procedure

(C2.2)

0 points

A description of how the new

policy and procedure will

resolve the issue is not

present.

8.84 points

A description of how the new

policy and procedure will

resolve the issue is present,

but it lacks detail or is

incomplete.

10.2 points

A description of how the new

policy and procedure will

resolve the issue is present.

11.56 points

A description how the new

policy and procedure will

resolve the issue is well

developed.

13.6 points

A description of how the new

policy and procedure will

resolve the issue is

thoroughly developed with

supporting details.

Draft of Policy and

Procedure

Draft of Policy and Procedure

0 points

The draft of the policy and

procedure is not present.

8.84 points

The draft of the policy and

procedure is present, but it

lacks detail or is incomplete.

10.2 points

The draft of the policy and

procedure is present.

11.56 points

The draft of the policy and

procedure is detailed.

13.6 points

The draft of the policy and

procedure is thorough.

Research

Research

0 points

A description of research on

industry standards that

helped formulate the policy

and procedure is not

included.

8.84 points

A description of research on

industry standards that

helped formulate the policy

and procedure is present,

but it lacks detail or is

incomplete.

10.2 points

A description of research on

industry standards that

helped formulate the policy

and procedure is present.

11.56 points

A description of research on

industry standards that

helped formulate the policy

and procedure is clearly

provided and well developed.

13.6 points

A description of research on

industry standards that

helped formulate the policy

and procedure is thoroughly

developed with supporting

details.

Concepts

Concepts

0 points

Main concept is not clearly

identified, and subconcepts

do not consistently branch

from the main idea.

3.64 points

Main concept is not clearly

identified, and few

subconcepts branch

appropriately. Limited

understanding of assignment

is apparent.

4.2 points

Main concept is easily

identified, and few

subconcepts branch from the

main idea. Only a basic

understanding of assignment

is present.

4.76 points

Main concept is easily

identified and most

subconcepts branch from the

main idea. An original and

creative concept fulfills the

parameters of assignment.

5.6 points

Main concept is easily

identified, and subconcepts

branch appropriately from

the main idea. Projects

exhibit the process of

creative thinking and the

development of an individual

style.

Synthesis

Synthesis

0 points

Synthesis does not

successfully integrate ideas,

images, or objects to form a

cohesive whole. The

combination of elements is

not logical or verifiable.

5.2 points

Synthesis integrates ideas,

images, or objects

inadequately. The

combination of elements is

not logical.

6 points

Synthesis integrates ideas,

images, or objects but does

not fully form a cohesive

whole. Combination of

elements at times is

confusing.

6.8 points

Synthesis integrates ideas,

images, or objects to form a

cohesive whole. Combination

of elements is logical and

justified.

8 points

Synthesis is distinctive.

Synthesis shows careful

planning and attention to

how disparate elements fit

together. The combination of

elements is verified.

Mechanics of Writing

(includes spelling,

punctuation, grammar, and

language use)

Mechanics of Writing

(includes spelling,

punctuation, grammar, and

language use)

0 points

Surface errors are pervasive

enough that they impede

communication of meaning.

Inappropriate word choice or

sentence construction is

employed.

5.2 points

Frequent and repetitive

mechanical errors distract

the reader. Inconsistencies in

language choice (register) or

word choice are present.

Sentence structure is correct

but not varied.

6 points

Some mechanical errors or

typos are present, but they

are not overly distracting to

the reader. Correct and

varied sentence structure

and audience-appropriate

language are employed.

6.8 points

Prose is largely free of

mechanical errors, although

a few may be present. The

writer uses a variety of

effective sentence structures

and figures of speech.

8 points

The writer is clearly in

command of standard,

written, academic English.

Documentation of Sources

Documentation of Sources

(citations, footnotes,

references, bibliography, etc.,

as appropriate to assignment

and style)

0 points

Sources are not documented.

2.6 points

Documentation of sources is

inconsistent or incorrect, as

appropriate to assignment

and style, with numerous

formatting errors.

3 points

Sources are documented, as

appropriate to assignment

and style, although some

formatting errors may be

present.

3.4 points

Sources are documented, as

appropriate to assignment

and style, and format is

mostly correct.

4 points

Sources are completely and

correctly documented, as

appropriate to assignment

and style, and format is free

of error.

© 2026. Grand Canyon University. All Rights Reserved.

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**## HosptialApplication.docx**

Within the Allied Health Community media, read the "Hospital: Risk Management Scenario."

In a total of 250-500 words, respond to the questions located in the scenario.

**## HealthCarePolicyAssignment.docx**

Complete the
**Transitional Care Application assignment prior** to beginning this assignment.

Select
one conflict issue from the Transitional Care scenario in the Allied Health Community and write a new policy and procedure related to the issue that identifies methods or practices of rationally and effectively discusses issues and resolving conflict.

**Write a 500-word memo** to your supervisor (you may choose to use the "Health Care Policy and Procedure Memo" sample) that describes this issue and an explanation of how the new policy and procedure will resolve the issue. In the memo, include a draft of the policy and procedure. Be sure to include the research on industry standards that helped you formulate the policy and procedure.

·
**Memo template is attached**

**## HospitalRiskManagement_Scenario460.pdf**

HOSPITAL: Risk Management Scenario

Scenario

A rural country hospital facility provides health care services to over 35,000 citizens, with a high
percentage being older Americans who have retired to this area of the country. The hospital administrator
has asked the Vice President of Risk Management to attend a meeting with the senior staff next week in
the Board Room. The hospital administrator has asked Vice President of Risk Management to present
areas of opportunity for increasing the hospital’s risk management strategies to ensure a litigation-free
environment for the facility, its patients, and its employees.

During the meeting, the Vice President of Risk Management reports that all the continuous quality
improvement (CQI) minutes for the past 3 months of meetings have been reviewed. Although most areas
are being adequately resolved, there are some that need more attention, especially from the senior staff.
Before specifically addressing those points, the Vice President of Risk Management briefs the staff on the
major areas of risk for the hospital. They are:

1. Employee-driven adverse actions against the facility
2. Medication errors
3. Surgery/Treatment errors
4. Patient falls
5. Patient elopements
6. Security breaches in secured areas
7. Inaccurate coding and billing for government/insurer reimbursements

Now that the senior staff is aware of the major areas of risk concern, you, as the administrator in charge
of all hospital business operations, assign each of these areas of concern to the respective director,
such as the Directors of Human Resources, Nursing, Medical, Social Services, and Facility Security.
Their reports of assessment, along with recommendations for achieving full compliance and reducing the
hospital’s litigation exposure, are due at the end of the month.

Questions:

1. While this situation has many areas of risk that are considered a top priority, focus on patient privacy
and information disclosure (HIPAA violations). Which department is responsible for leading the
initiative? As the administrator, describe your approach for managing this directive. Do you create a
special projects team? How do you gather pertinent data for a category? What tools would you use?
2. How do you determine if you are meeting the industry standards for this area of risk?
3. Would you change any current policies or procedures? How and why?
4. How would you train the affected staff with regard to this area of risk?
5. What are the sanctions, penalties, or government investigations that could present a worst-case
scenario if not addressed?

**## HealthCarePolicyMemoTemplate.docx**


**Health Care Policy and Procedure Memo**

Grand Canyon Transitional Care Organization

**MEMORANDUM**

| | |
| — | — |
| **TO:** | INSTRUCTOR A. NAME, MHA |
| **FROM:** | STUDENT A. SAMPLE |
| **SUBJECT:** | ENTER SUBJECT |
| **DATE:** | 3/29/2020 |
| CC<br>**:** | BOSS A. SUPERVISOR, MHA |

Through my experience as the Director of Human Resources, many issues that are occurring within our organization have been brought to my attention. One of the main issues brought to my attention through complaints from employees is that our organization has many policies that are out of date. These outdated policies are not effective within the current health care industry, causing further issues within our organization. I have created a new policy and procedure pertaining specifically to the steps of creating and regularly reviewing our current policies and procedures. This is a policy that we have lacked entirely in the past, creating the need for the development of one now. The new policy will promote compliance with relevant legislation, industry and other standards, and community expectations; promote our organization to achieve strides toward the mission, vision, and values; “promote operational efficiency;” and reduce potential risks within the health care environment (Example, 2019). The policy will benefit the employees of our health care organization immensely, along with the community members to which we are providing service.

The policy that I have developed is titled “Creation, Review, and Revision of Policies and Procedures Policy.” The policy and procedure will lay out specific guidelines, templates, and requirements for creating and regularly reviewing policies and procedures within our health care facility. The general steps involved in the procedure include needs analysis, development, approval, distribution, implementation, regular review, and revision (More, 2020). The health care industry is consistently transforming due to technology and other factors, creating the need for our organization to stay on top of policies creating a current, accurate, and effective environment for all of those who are involved. Overall, the policy will promote consistency, predictability, compatibility, risk mitigation, and high-quality care throughout our organization.

I believe that this new policy will not only help with eliminating the problem of out-of-date policies, but also the many other issues that have been brought to my attention by various staff members. These other issues include complaints about management, employee-related adverse actions, unfair treatment for corrective actions and progressive discipline, unfair administering of policies, a high number of medication errors, and harmful patient treatment. Although our organization has maintained a superb reputation for the last 40 years in service, our reputation and ability to perform is going to decline if we do not make the necessary changes in a timely manner. All of the issues pertain to specific policies and procedures that we have, but there is a clear need for revision to correct the actions of management and other employees. If implementation of this policy is successful, there will be a requirement for policies and procedures to be reviewed on an annual basis. This is strongly needed, as some of our policies have not been revised in years. Please consider administering this policy and procedure so that we are able to maintain ourselves as a reputable health care organization, willing and able to provide the highest quality of care for all of our patients.

I have attached the proposed policy and procedure. Please do not hesitate to contact me with any further questions, comments, or concerns.

Sincerely,

Student A. Sample

**ATTACHMENT:**

**\_\_\____________________________________________________________________________**

_Creation, Review, and Revision of Policies and Procedures Policy_

**Policy:** The purpose of this policy is to create guidelines and requirements for policies and procedures that promote consistency, predictability, and compatibility throughout Grand Canyon Transitional Care Organization. The policies for the organization will be generated according to a standard template. The requirement will be that policies are reviewed annually to ensure that they are still effective and up to date.

**Procedure:**

A. Needs Analysis

a. Identify the need for the creation of a new policy.

b. Identify the need for the review or revision of a current policy.

B. Development

a. Determine who will be creating and writing the policy.

b. Determine who will make changes to the existing policy.

c. Create all policies in accordance with the universal format.

i. Purpose/Policy statement.

ii. Procedure that will support the enactment of the policy.

C. Approval

a. Determine who will have the power to approve the new policy or the edited policy.

b. Get approval for the policy.

D. Distribution

a. Distribute the new policy to staff members.

i. Allow time for questions, thoughts, concerns.

b. Distribute the revised policy to staff members.

i. Allow time for questions, thoughts, concerns.

E. Implementation

a. Implement the new policy within the organization.

b. Implement the revision of the policy within the organization.

F. Regular Review

a. All policies and procedures are to be reviewed on an annual basis.

G. Revision

a. If the review deems revision necessary, repeat steps A through E.

b. Step F will occur after a year.

EFFECTIVE DATE: April 1, 2020

References

Example, J. (2019). Do you need a policy on policies? Retrieved from https://www.effectivecompliance.com.au/do-you-need-a-policy-on-policies/

More, E. (2020). Do you want a procedure date? Retrieved from https://www.effectiveprocess.au/do-you-wantd-a-procedure-date/

© 2026. Grand Canyon University. All Rights Reserved.

2

## image1.jpeg

**## Rubric-HealthCarePolicyandProcedureDevelopment.pdf**

Benchmark – Health Care Policy and Procedure Development – Rubric Total 80 points

Criterion 1. 1: Unsatisfactory
2. 2: Less Than

Satisfactory
3. 3: Satisfactory 4. 4: Good 5. 5: Excellent

Issue

Issue

0 points

A description of the issue is

not present.

8.84 points

A description of the issue is

present, but it lacks detail or

is incomplete.

10.2 points

A description of the issue is

present.

11.56 points

A description of the issue is

well developed.

13.6 points

A description of the issue is

thoroughly developed with

supporting details.

New Policy and Procedure

(B)

New Policy and Procedure

(C2.2)

0 points

A description of how the new

policy and procedure will

resolve the issue is not

present.

8.84 points

A description of how the new

policy and procedure will

resolve the issue is present,

but it lacks detail or is

incomplete.

10.2 points

A description of how the new

policy and procedure will

resolve the issue is present.

11.56 points

A description how the new

policy and procedure will

resolve the issue is well

developed.

13.6 points

A description of how the new

policy and procedure will

resolve the issue is

thoroughly developed with

supporting details.

Draft of Policy and

Procedure

Draft of Policy and Procedure

0 points

The draft of the policy and

procedure is not present.

8.84 points

The draft of the policy and

procedure is present, but it

lacks detail or is incomplete.

10.2 points

The draft of the policy and

procedure is present.

11.56 points

The draft of the policy and

procedure is detailed.

13.6 points

The draft of the policy and

procedure is thorough.

Research

Research

0 points

A description of research on

industry standards that

helped formulate the policy

and procedure is not

included.

8.84 points

A description of research on

industry standards that

helped formulate the policy

and procedure is present,

but it lacks detail or is

incomplete.

10.2 points

A description of research on

industry standards that

helped formulate the policy

and procedure is present.

11.56 points

A description of research on

industry standards that

helped formulate the policy

and procedure is clearly

provided and well developed.

13.6 points

A description of research on

industry standards that

helped formulate the policy

and procedure is thoroughly

developed with supporting

details.

Concepts

Concepts

0 points

Main concept is not clearly

identified, and subconcepts

do not consistently branch

from the main idea.

3.64 points

Main concept is not clearly

identified, and few

subconcepts branch

appropriately. Limited

understanding of assignment

is apparent.

4.2 points

Main concept is easily

identified, and few

subconcepts branch from the

main idea. Only a basic

understanding of assignment

is present.

4.76 points

Main concept is easily

identified and most

subconcepts branch from the

main idea. An original and

creative concept fulfills the

parameters of assignment.

5.6 points

Main concept is easily

identified, and subconcepts

branch appropriately from

the main idea. Projects

exhibit the process of

creative thinking and the

development of an individual

style.

Synthesis

Synthesis

0 points

Synthesis does not

successfully integrate ideas,

images, or objects to form a

cohesive whole. The

combination of elements is

not logical or verifiable.

5.2 points

Synthesis integrates ideas,

images, or objects

inadequately. The

combination of elements is

not logical.

6 points

Synthesis integrates ideas,

images, or objects but does

not fully form a cohesive

whole. Combination of

elements at times is

confusing.

6.8 points

Synthesis integrates ideas,

images, or objects to form a

cohesive whole. Combination

of elements is logical and

justified.

8 points

Synthesis is distinctive.

Synthesis shows careful

planning and attention to

how disparate elements fit

together. The combination of

elements is verified.

Mechanics of Writing

(includes spelling,

punctuation, grammar, and

language use)

Mechanics of Writing

(includes spelling,

punctuation, grammar, and

language use)

0 points

Surface errors are pervasive

enough that they impede

communication of meaning.

Inappropriate word choice or

sentence construction is

employed.

5.2 points

Frequent and repetitive

mechanical errors distract

the reader. Inconsistencies in

language choice (register) or

word choice are present.

Sentence structure is correct

but not varied.

6 points

Some mechanical errors or

typos are present, but they

are not overly distracting to

the reader. Correct and

varied sentence structure

and audience-appropriate

language are employed.

6.8 points

Prose is largely free of

mechanical errors, although

a few may be present. The

writer uses a variety of

effective sentence structures

and figures of speech.

8 points

The writer is clearly in

command of standard,

written, academic English.

Documentation of Sources

Documentation of Sources

(citations, footnotes,

references, bibliography, etc.,

as appropriate to assignment

and style)

0 points

Sources are not documented.

2.6 points

Documentation of sources is

inconsistent or incorrect, as

appropriate to assignment

and style, with numerous

formatting errors.

3 points

Sources are documented, as

appropriate to assignment

and style, although some

formatting errors may be

present.

3.4 points

Sources are documented, as

appropriate to assignment

and style, and format is

mostly correct.

4 points

Sources are completely and

correctly documented, as

appropriate to assignment

and style, and format is free

of error.

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© 2026. Grand Canyon University. All Rights Reserved.

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