You have been hired to serve as the new Chief Compliance and Quality Officer at Community Hospital, a small 75-bed acute care facility in a suburban location. During your first week in this position, you decide to review of the hospital's Complaint Hotline Log to determine potential risk areas and gaps in compliance and quality program functioning.

Your review of the disclosure log reveals the following complaints that have been received within the last 30 days:

• Several nurses reported widespread infection control lapses by staff.
• Emergency room staff reported on four occasions that patients left the hospital prior to being medically assessed due to staffing shortages in that department.
• Patients routinely reported that they did not receive discharge instructions upon leaving the hospital.
• High rates of medication errors by nursing staff were reported by on-call and attending physicians.
• Nurses expressed frustration that the hospital has no clear system to report adverse events in patient care.
• Several employees reported that they felt they were being retaliated against by their supervisors for raising concerns.

Based upon this review, you research whether the organization has comprehensive policies, procedures, and dashboards to define the organization's performance across key compliance and quality indicators, only to learn that such documents are limited and infrequently referenced by the organization or its staff. It is clear to you that the senior leadership must be informed of your findings.

Question:

Prepare a memorandum to the organization's senior leadership team. Your memorandum should:

1. Present your assessment of the need for policies and procedures.
2. Explain why they are important from a quality and safety perspective.
3. Outline your plan for developing all necessary operating procedures.
4. You may assume additional facts to support your memorandum and you may rely on the supplemental reading materials that have been recommended under this assignment.