The goal of this assignment is to analyze applicable HR principles, which incorporate healthcare laws while considering ongoing personnel needs of a healthcare organization. Research the literature and write a document that speaks to the following elements to create leadership accountability for a chosen healthcare setting. Include the following components:
- Analyze laws that are important for effective healthcare leadership (such as ACA, HIPAA, EMTALA) and propose how you would monitor for and assure compliance with these laws.
- Consider the leadership plan to implement the new strategy as outlined in assignments u02a1 and u04a1. Discuss potential gaps (for example, compliance with existing or emerging regulations, available versus needed resources for implementation, external environmental/business risks, stated values versus actual culture, et cetera).
- Propose interventions to close gaps (education, team building, et cetera) in the leadership plan to implement the new initiative.
- Explain the relevance of succession planning and talent development. Provide resources for ongoing healthcare executive competency development.
Running head: ORGANIZATIONAL NEEDS AND LEGAL CONSIDERATIONS 1
DHA 8004 – Innovative Business Practices in Health Care
Unit 7 Assignment 1
ORGANIZATIONAL NEEDS AND LEGAL CONSIDERATIONS 2
Organizational Needs and Legal Considerations
Laws Important for Effective Health Care Leadership
Healthcare changes daily because the laws, policies and procedures that guide the
healthcare industry change daily. It seems appropriate that in a field like healthcare that rules and
policies need to change to keep current with new technologies, medications and other
innovations. Two of the rules that play a major part in critical access hospitals is a called the 96-
hour rule and the two-midnight rule. First, according to the U.S. Department of Health and
Human Services: Centers for Medicare and Medicaid Services (2019) on average inpatients
should not be admitted to a critical access hospital for longer than 96 hours. Facilities must track
their inpatient days and be sure at the end of the year, the average stay is less than 96 hours per
patient. Some patients may have longer stays, but the average of all patients must be 96-hours or
less. Second, the two-midnight rule requires that a patient must be admitted and stay across two
midnights to have a Medicare qualifying stay. For example, a patient is admitted at 10:00 PM on
Tuesday should stay until past midnight on the following Wednesday. These two rules are set by
Medicare to ensure that the patient is in the correct level of care and that patient’s condition
warrants a hospital admission.
These two rules can cause confusion for the patient, the admitting Provider and the
Facility. In most cases, hospitals will have a department that monitors these rules because if the
facility doesn’t follow these rules, Medicare and take back payments, as well as exclude the
facility from further Medicare payments. The difficult part is trying to get Providers to do their
pre-admission certification that states the Provider is anticipating the patient stay to be less than
96 hours and that the patient will be admitted across two midnights unless the patient’s condition
declines that prompts and interfacility transfer to a higher level of care.
ORGANIZATIONAL NEEDS AND LEGAL CONSIDERATIONS 3
Data mining within the electronic medical record, as well as staff and patient education
will be needed to ensure that the 96-hour rule and the two-midnight rule are followed. First, the
facility will have to be able to data mine the length of stay data out of their EMR and then have
the expertise to understand the data once it has been extracted. Most EMR systems can break up
length of stay by admission type, admitted Provider and diagnosis. Utilization review staff will
have to monitor the length of stay and provide data to the Chief Nursing Officer so that leader
can work with Provider to adjust future admissions and hold all staff accountable for length of
stay. Second, the facility must provide comprehensive education to the Providers and patients on
what is required during their admission to ensure that all parties have similar information. This
will ensure that Provider provides correct certification of admission and the patient understands
their length of stay. The CNO should provide oversight on the data mining and the education as
part of her leadership and accountability role for the Medical/Surgical floor of the facility.
The CNO should use a balance scorecard approach to track these two important statistics. In the
balance scorecard, a few important sections need to be identified including the indicator, the time
period that is going to be examined, year-to-date-averages and a relevant benchmark. Then each
time period should be color coded to ensure easy readability. A sample my include:
Indicator Jan-19 Feb-19
Length of Stay – Average 88 99 91 92.7 < 96
followed 100 100 96 98.7 100
ORGANIZATIONAL NEEDS AND LEGAL CONSIDERATIONS 4
After collection the information for the balanced scorecard, the CNO should be disseminating the
information to all parties involved including nursing staff, Providers, Utilization Review staff
and the Board of Directors.
Potential Gaps in the Leadership Plan
In the leadership plan, growing the swing bed census and length of stay was addressed.
The 96-hour rule and the two-midnight rule do not apply to a swing bed patient. A swing bed
patient is a patient that needs long term care that will be in the facility longer than 96 hours but
isn’t critical enough to send to a higher level of care or is a patient coming back from a higher
level of care. These patients typically cannot care for themselves on their own, often have
medications and need some sort of therapy services. The issue arises when the Provider doesn’t
know how to properly admit the patient into a swing bed status or doesn’t follow the certification
guidelines to have the admission be considered a qualifying stay. The Utilization Review
department will often find issues associated with a swing bed admission in areas such as poor
documentation, no services ordered that are needed to qualify the patient or lack of meeting
admitting criteria. Also, many times the patient or patient family doesn’t understand the
difference between the admission types, and this could cause trouble with their insurance.
Insurance companies do not handle the different types of admissions the same and their
payments are different leading to different financial obligations by the patient. Many times, the
patient doesn’t know how much they will be spending out of their own pocket until the patient is
discharged from the hospital.
Best Practices and Proposed Intervention
To overcome the gaps, hospitals need to find ways to educate the admitting staff,
educating the patients and providing quality studies on the admitting process. Educating
ORGANIZATIONAL NEEDS AND LEGAL CONSIDERATIONS 5
Providers will help ensure that they follow all the guidelines for different types of admissions.
This will make a more streamline process and ensure that the admission get certified for payment
by the payer. Next, the facility must educate patients on their admission status to ensure that
patient is included in their own care. This would ensure that the patient has a basic
understanding of their health, any financial obligation for their admission and information
needed to properly communicate with their insurance provider. Finally, the hospital needs to
audit their admissions for proper documentation, the admission meets admitting criteria and the
patient bills properly reflect the treatment provided. The audits should be shared with all parties
involved in the admission process, as well as administration.
A well-designed leadership plan should be effectively communicated to all parties that
are involved in the plan. When completing the leadership plan, there should be open and honest
dialogue about the tactics, measurement, benchmarks, frequency and results. If these areas
haven’t been thoughtfully identified and communicated, then it will be just words on paper. In
this case, the leader has to identify the gaps in the overall admission process to ensure that each
patient meets qualifications for admission, the Provider has completed their required work and
the patient is educated on their admission status. If all those items are not completed, then the
leadership plan will not be successful.
Succession Planning and Talent Development
Succession planning is crucial for the success of any organization, but in healthcare
finding talent can be the difference between staying viable and having to close the facility. In
some organizations, succession planning is simply placing an ad in the newspaper or on some
internet hiring site and hoping that a great candidate will see the ad and they will be the right fit
for the job. According to Olivio (2014) there is a need for qualified leaders who can lead a
continually complex healthcare organization. Over the past several years, many experienced
ORGANIZATIONAL NEEDS AND LEGAL CONSIDERATIONS 6
healthcare leaders have been leaving their positions for retirement, academia or consulting.
Many of these leaders have three or even four decades of healthcare experience and they are
being replaced with highly educated but inexperienced leaders. These new leaders have to be
given an opportunity to show they can fill the shoes of their predecessors, but the learning curve
is often sharp and very time bound. This can put stress on the organization, and it doesn’t take
long for the organization to start to show negative repercussions. On the other hand,
organizations that have foresight have prepared for the moment in which their leaders are leaving
the organization and they have detailed strategies to ensure that the organization will continue to
be successful or even stronger. Every organization may approach succession planning
differently, but in the end the organization needs a step by step process for how they are looking
for in a leader, what characteristics and personality do they want the leader to possess, how that
leader will drive the strategic direction of the organization and what they are going to do until
they find that specific person. The strategy must fit the culture of the organizations and the
resources available to find a successful candidate.
Succession planning isn’t always bringing in people from the outside, but also learning
when and who to promote. Well-designed succession plans look for the best candidate and fit
for the organization. At times, the best fit can be a person in the organization that has proven
he/she has the ability, educations, experience and behaviors the organization is search for in their
new leaders. A high functioning talent development process can help current employees
blossom into successful leaders for the organization.
Executive Competency Development
Executive competency development is going to be a crucial element in the evolution of
leaders in an organization. The type of program that each organization will use to develop
ORGANIZATIONAL NEEDS AND LEGAL CONSIDERATIONS 7
executive leaders are going to be much different depending on size of the facility, location,
resources available and culture. According to the American College of Healthcare Executives
(2017) has a leadership certification for healthcare leaders. This program is designed to provide
leaders with a comprehensive education program that will help them develop into a well-rounded
healthcare executive. The certification program is designed to educate and broaden the horizons
of its certified members. This program, as detailed below, not only helps train new leaders, but
requires these leaders to stay current by obtaining annual continuing education credits. Also, the
ACHE offers state, regional and national meetings and educational offerings. Not only do
Members and Fellows get current education, they also have an opportunity to increase their
Along with certification, networking is another very important element in executive
competency development. Networking can help a young leader learn from other’s mistakes and
success, as well as provide someone to help reduce the stress associated with being a executive
ORGANIZATIONAL NEEDS AND LEGAL CONSIDERATIONS 8
leader in a complex environment. No matter how much education a new leader has, experience
has value. As an executive leader, learning and growing is a lifetime activity.
ORGANIZATIONAL NEEDS AND LEGAL CONSIDERATIONS 9
American College of Healthcare Executives (2017). Board Certification in Healthcare
Management. Retrieved from https://www.ache.org/about-ache/our-story/our-
Fowler, J. (2016). From staff nurse to nurse consultant: Clinical leadership part 9:
Succession planning. British Journal of Nursing, 25(22), 1272-1272.
Olivio, T. (2014). Is Your Leadership Vulnerable? 5 Trends for Succession Planning.
Becker’s Healthcare. Retrieved from https://www.beckershospitalreview.com/hospital-
U.S. Department of Health and Human Services: Centers for Medicare and Medicaid Services.
(2019). State Operations Manual Chapter 2 – The Certification Process. Retrieved from