1. Environmental Services
1.1. Resource Request
1.1.1. Floor Buffers
1.1.1.1. Cost Benefit Analysis
1.1.1.1.1. Repair Current Floor Buffers
1.1.1.1.2. Replace Floor Buffers
1.1.1.1.3. Efficiencies Gained
1.1.1.2. Safety
1.1.1.2.1. Prevention of Slips & Falls
1.1.1.2.2. Maintenance & Use of Chemicals
1.1.1.2.3. Training
1.1.1.3. Product Requirements
1.1.1.3.1. Pads
1.1.1.3.2. Chemicals
1.1.1.3.3. Power
1.1.1.3.4. Maintenance
2. Information Technology
2.1. Potential Information Breach
2.1.1. Type of Breach
2.1.1.1. Electronic
2.1.1.1.1. Hacking
2.1.1.1.2. Ransomware Attack
2.1.1.1.3. Phishing
2.1.1.1.4. Social Media
2.1.1.2. Physical
2.1.1.2.1. Loss of Device
2.1.1.2.2. Office Break-in
2.1.2. Source of Breach
2.1.2.1. Parent Company
2.1.2.2. Business Associate (BA)
2.1.2.2.1. Information provided to BA
2.1.3. Types of Information Impacted
2.1.3.1. Protected Health Information
2.1.3.2. Financial Information
2.1.4. Number of Individuals Impacted
2.1.4.1. Less than 500
2.1.4.2. 500 or more
2.1.5. Notification
2.1.5.1. Individuals Impacted
2.1.5.1.1. First-Class Mail
2.1.5.1.2. Email
2.1.5.1.3. Establish Toll-Free Phone Number for Use
2.1.5.1.4. Timelines
2.1.5.2. Department of Health and Human Services
2.1.5.2.1. Notice Requirements
2.1.5.2.2. Timelines
2.1.5.3. State Requirements
2.1.5.3.1. Notice Requirements
2.1.5.3.2. Timelines
2.1.5.4. Media
2.1.5.4.1. Major Print
2.1.5.4.2. Broadcast
2.1.5.5. Website
2.1.6. Risk Management & Mitigation
2.1.6.1. Financial
2.1.6.1.1. Penalties
2.1.6.1.2. Sanctions
2.1.6.2. Community Impact
2.1.6.2.1. Loss of Trust
2.1.6.3. Root Cause Analysis
2.1.6.3.1. Policy & Procedure Changes
2.1.6.3.2. Non-Compliance
2.1.6.3.3. Training/Education Needs
2.1.6.4. Compliance
2.1.6.4.1. Audits
3. Radiology Department
3.1. Software Implementation
3.1.1. Cost Benefit Analysis
3.1.1.1. Staffing Requirements
3.1.1.2. Implementation Costs
3.1.1.3. Maintenance Costs
3.1.1.4. Alternatives
3.1.2. Change in Process
3.1.2.1. Improved Throughput
3.1.2.2. Variation Reduction
3.1.2.3. Efficiencies Gained
3.1.3. Technology
3.1.3.1. Interoperability
3.1.3.2. HITECH/HIPAA Compliance
3.1.4. Quality
3.1.4.1. Patient Outcomes
3.1.4.2. Patient Safety
3.1.4.3. Patient Satisfaction
4. Labor & Delivery
4.1. Patient Satisfaction
4.1.1. Poor Bedside Manner
4.1.1.1. Nursing
4.1.1.1.1. Workplace Environment
4.1.1.1.2. Effective Patient Communication Strategies
4.1.1.2. Impact on Patient Outcomes
4.1.1.2.1. Joint Commission
4.1.1.2.2. HCAHPS
4.1.2. Emergency Department
4.1.2.1. Staffing
4.1.2.1.1. Nurses