September 22, 2024

Massachusetts General Hospital (MGH) is a teaching-related general hospital in Boston, Massachusetts. Being the third-oldest general hospital in the country, this facility has one of the largest capacities, boasting over 1,000 beds (MGH, 2021). Primarily, MGH is among the providers of the best patient care, thanks to its constant innovation and a culture of inclusion. The organization provides primary, secondary, and tertiary care, including sophisticated diagnostic services, treatment for minor illnesses, and innovative interventions for cancer, cardiovascular complications, neurological diseases, urological diseases, diabetes, and others (MGH, 2024).

Besides occupying the role of a provider, MGH is also the producer of evidence-based knowledge through which it aims to sustain quality patient care. The hospital invests over $1 billion in research to drive discoveries to enhance treatments within the US and globally (MGH, 2024). The hospital’s inclusive culture, innovation, and research have enabled it to fulfill the critical tenets of quality care, including safety, patient-centeredness, effectiveness, efficiency, and timeliness.

My roles will be acting as the coordinator of daily operations, resource and inventory manager, performance promoter, and relationship officer. Hence, I will lead the human resources department, procurement personnel, finance employees, and public relations employees.

Specifically, in this position, I will develop and implement policies and mechanisms to monitor daily operations to ensure that operations align with healthcare regulations and standards and the facility’s core values. Thus, the responsibility of the employees from different departments, including human resources, will be to actualize those policies. Some of the aspects I will focus on are implementing strategies to reduce patient wait times, prevent medical errors, and maintain high patient satisfaction levels.

I will also manage the facility’s inventory and resources like personnel, equipment, and tools to maximize performance and avoid wastage. In this case, procurement and support employees will be responsible for acquiring appropriate inventory quantities or proper storage of supplies and equipment. More importantly, I will liaise with the hospital’s human resource department, the president, and the board to maintain the staffing and competency levels necessary for quality patient care. The responsibilities of human resource managers in this case will be hiring adequate physicians and nurses, implementing flexible scheduling, and staff training. Besides, this administrator passes crucial communication across departments to ensure every employee understands procedures, expectations, and their roles in maintaining quality (Tacconelli et al., 2020). Thus, the responsibility of departmental managers is to enforce the procedures and quality standards. I must promote positive relationships with external stakeholders, such as regulators, partners, suppliers, and patients. In this case, I will develop strategies and directives and allow departmental managers, including leaders of personnel handling patients and other external stakeholders, to implement them. For instance, I may need to develop a mechanism for collecting daily patient feedback. Physicians, nurses, and front desk personnel will actualize these directives.

The key stakeholders for the operations department can be categorized as internal or external. Internal stakeholders are MGH’s healthcare professionals (HCPs) and other employees and senior executives. External stakeholders are patients, regulators, and vendors. MGH’s employees, including HCPs, enable the department to achieve its objectives of maintaining quality care, efficiency, and positive relationships with external stakeholders by actualizing its plans. Doctors and nurses are particularly crucial to this department. Doctors provide direct

medical care to patients and thus help enforce the department’s guidelines regarding patient care (Panda & Mohapatra, 2021). Nurses build quality and productive care environments by ensuring effective communication, offering direct care, and advocating for patients (Panda & Mohapatra, 2021). Therefore, without these employees, the department may not achieve these objectives.

Senior executives support the normal operation of the department by providing the resources it needs to operate effectively, such as giving it legitimate authority to lead other departments, technologies, and adequate personnel.

Regarding external stakeholders, patients give the operations department a reason to exist. This department’s responsibilities primarily revolve around promoting patient care, safety, and satisfaction. Therefore, like other hospital departments, this department exists to fulfill patient needs. Regulators provide insights into the department’s operations by setting healthcare standards (Shi & Singh, 2022). The operations manager relies on these standards and policies to formulate operational policies, strategies, and processes. The vendors enable the department to acquire medical equipment, devices, and technologies.

The operations department must comply with the Health Insurance Portability and Accountability Act (HIPAA), which requires covered entities to establish mechanisms to protect patient health information (PHI) (Limmroth, 2020). This legislation also prohibits these entities from disclosing PHI to unauthorized parties (Limmroth, 2020). The operations department usually utilizes patient data in some of its duties, especially when reviewing patient safety protocols, performance, or other operational processes. Therefore, it must comply with HIPAA to avoid legal consequences. In addition, most of the department’s activities, including patient safety strategies, involve working with patient data. For instance, when the operations manager

recommends the need to improve patient treatment, he or she might need to share recent patient safety issues with senior executives to justify that position. However, sharing information increases the risk of breaching HIPAA unless the manager puts mechanisms to avoid it.

Moreover, the operations department must comply with the False Claims Act (FCA), which prohibits entities from defrauding the government through false claims (Adashi & Cohen, 2022). For example, the operations department should not influence HCPs to fill false claims on Medicaid forms. Instead, the departmental leaders, including the manager, should encourage compliance and implement mechanisms to verify the authenticity of the hospital’s claims to the government.

In addition, the operations department must adhere to the principle of beneficence, which requires providers to act in the best interest of patients (Shi & Singh, 2022). Although the operations department usually aims to foster quality patient care, it also focuses on increasing profitability. In this goal, it can easily forgo patient welfare despite being key stakeholders.

However, to operate effectively, the department must comply with beneficence. For example, when cutting down operational costs, such as by retrenching some HCPs or reducing purchases, the quality of care should not be sacrificed.

The first step I would take to address HIPAA privacy requirements is to educate departmental employees, physicians, and nurses. Indeed, HCPs should deeply understand HIPAA’s disclosure requirements regarding PHI. First, I will inform HCPs that PHI encompasses health status, treatment procedures, and payments for those treatments. This awareness creation will prevent professionals from sharing PHI unknowingly. After this, I will educate physicians, nurses, and other professionals who participate in treatments that although HIPAA allows them

to share PHI, such disclosure should only occur to facilitate treatment or treatment payments. In other instances, PHI disclosure should only happen after acquiring a patient’s written consent (Moore & Frye, 2019). Moreover, I will develop a system for verifying PHI requests, such as requiring such requests to be handled by a team rather than individuals to ensure full compliance. Lastly, I will formulate a policy to direct HCPs to provide patients with their health information whenever they request it because the Privacy Rule gives patients the right to their information.

Besides complying with the privacy rule, the facility must fulfill the security requirements. Notably, HIPAA requires hospital leaders to ensure the security of patient information from administrative, physical, and technical perspectives. The administrative part of compliance includes policies and procedures that promote a facility’s compliance with HIPAA (Moore & Frye, 2019). Thus, I will lead teams to develop policies illustrating those who can or cannot access certain information, including respect for privacy as a core value of the facility, purchasing data storage technologies that do not involve hosting data outside the hospital, maintaining data storage systems occasionally to address loopholes that can expose patient information, and staff training. The physical safeguards encompass mechanisms to control who can access patient data (Moore & Frye, 2019). In this category of safeguards, I will liaise with team leaders to assign specific people responsible for monitoring access to systems with patient information and placing computers and other relevant systems away from public view to avoid exposing sensitive data to unauthorized persons. I will direct the information technology (IT) department to monitor every disposal process to avoid disposing of equipment storing patient data. In technical safeguards, I will liaise with the IT unit to implement cybersecurity

mechanisms like encryption, intrusion detection systems, firewalls, anti-malware software, and reliable authentication and access control mechanisms, such as strong passwords.

Certainly, even after installing the necessary safeguards, the facility may experience data breaches. In this case, I will follow the breach notification guidelines required under HIPAA. First, I shall guide the staff to keep a database of our patients’ contacts, especially email or physical address, so that I can notify the victims of a breach via formal notice through email or first-class mail. If employees could not access these contacts before the breach, I would notify those affected via the hospital’s website. However, I will use local media channels if the breach affects many people. In such a case, I will notify the Secretary of Health as HIPAA requires.

More importantly, I will do these notifications immediately after the incident because HIPAA directs hospital leaders to notify victims and relevant authorities within at least sixty days.

However, I will also investigate the case further, and if it occurred due to deviation from the facility rules, subject culprits via a disciplinary process, including suspension or financial penalties.

Conclusion

The discussion reveals that a hospital operations manager oversees every aspect of operations, from patient care to inventory management. Therefore, this role is crucial in driving patient safety and satisfaction. A person occupying the role must also understand the interests of internal and external stakeholders and put mechanisms in place to maintain positive relationships with them. More importantly, he or she must establish mechanisms to comply with ethical and legal policies, such as HIPAA and the FCA, as well as ethical principles like beneficence.

Personal Thoughts

After completing the case study, I have learned that the operations management role is broader than I thought. Previously, I thought this role only dealt with patient care, but now I know it covers every aspect of a hospital’s operations. I also learned that an operations manager must have deep knowledge of legal requirements to prevent the hospital from being exposed to legal risks, such as HIPAA-related lawsuits.

References

Adashi, E. Y., & Cohen, I. G. (2022). Health care fraud: The leading violation of the False Claims Act. The American Journal of Medicine, 135(5), 558–559. https://doi.org/ 10.1016/j.amjmed.2021.12.014

Limmroth S. (2020). Policies and procedures: The foundation for a comprehensive HIPAA program. Journal of Health Care Compliance, 22(2), 41–46.

Massachusetts General Hospital. (2021). Massachusetts General Hospital overview. https:// www.massgeneral.org/assets/mgh/pdf/faculty-development/new-faculty-trainee/nfo2021- brown_mghoverview.pdf

Massachusetts General Hospital. (2024). The Mass General difference. Retrieved September 14, 2024, from https://www.massgeneral.org/ about#:~:text=Our%20many%20multidisciplinary%20care%20teams,

%2Dthe%2Dart%20medical%20care.

Moore, W., & Frye, S. (2019). Review of HIPAA, part 1: history, protected health information, and privacy and security rules. Journal of Nuclear Medicine Technology, 47(4), 269–272.

Panda, A., & Mohapatra, S. (2021). Online healthcare practices and associated stakeholders: Review of literature for future research agenda. Vikalpa: The Journal for Decision Makers, 46(2), 71-85. https://doi.org/10.1177/02560909211025361

Shi, L., & Singh, D. A. (2022). Essentials of the US health care system. Jones & Bartlett Learning.

Tacconelli, S., DeLellis, N., Ankomah, S., Nowak, A., & Zikos, D. (2020). Health administration graduates: Responsibilities expected by Michigan employers. Journal of Health Administration Education, 37(1), 335-348.