In Kenya, healthcare quality management is crucial given ongoing efforts to improve patient outcomes and achieve universal health coverage. The focus on patient safety, efficiency, and equitable access necessitates robust frameworks for monitoring and enhancing healthcare delivery. Initiatives often involve standardizing clinical practices, implementing quality assurance programs, and fostering a culture of continuous improvement within healthcare facilities. Addressing issues like infection control, medication safety, and patient satisfaction are central to these efforts, ensuring that care meets national and international standards.

The requested survey aims to assess healthcare providers’ awareness of PHI exposure risks in routine actions and ways to minimize this exposure, based on evidence-based practices (EBP). It will include an introduction, survey questions with justifications, and a conclusion.## Survey: Assessing PHI Exposure Awareness in Routine Healthcare Actions

Introduction

Protected Health Information (PHI) is the bedrock of patient trust and a cornerstone of healthcare ethics and legal compliance. In any healthcare setting, from a large hospital to a small clinic, the daily routines of healthcare providers inherently involve handling sensitive patient data. Unintentional exposure of PHI, even through seemingly innocuous actions, can lead to serious breaches, compromise patient privacy, erode trust, and incur significant legal and reputational consequences. This survey aims to assess the current level of awareness among healthcare providers regarding routine actions that could inadvertently lead to PHI exposure and their understanding of best practices to minimize such risks. The insights gained from this assessment will inform targeted training and policy refinements to bolster patient data security.

PHI Exposure Awareness Survey for Healthcare Providers

Instructions: Please answer the following questions honestly. Your responses are anonymous and will be used to improve our organization’s patient data security practices.

Demographics (Optional):

1. What is your primary role? (e.g., Nurse, Physician, Administrator, Allied Health, Support Staff)
2. How many years have you worked in healthcare?
   • Less than 1 year
   • 1-5 years
   • 6-10 years
   • More than 10 years

Section A: Awareness of PHI Exposure Scenarios

1. On a scale of 1 to 5 (1 = Not at all confident, 5 = Extremely confident), how confident are you in your ability to identify situations where PHI might be unintentionally exposed during your daily work?

   • 1 – Not at all confident
   • 2 – Slightly confident
   • 3 – Moderately confident
   • 4 – Very confident
   • 5 – Extremely confident
   • Justification (EBP): Self-efficacy in identifying risks is a key predictor of compliance with safety protocols. Assessing confidence levels can reveal areas where providers feel less competent, indicating a need for more focused training or clear guidelines (Bandura, 1997).

2. Have you ever witnessed or been involved in a situation where you suspect PHI was unintentionally exposed in a routine clinical or administrative action?

   • Yes
   • No
   • If yes, briefly describe the nature of the situation (no patient or staff names):
   • Justification (EBP): Direct experience or observation of incidents, even minor ones, can highlight common vulnerabilities that might be missed in theoretical training. Near-miss reporting is a crucial component of a robust safety culture, allowing for proactive identification and mitigation of risks before they lead to full breaches (Reason, 2000).

3. Please indicate if the following routine actions carry a risk of PHI exposure (Yes/No/Unsure):

   • a. Discussing patient information in a crowded hallway or elevator. (Yes/No/Unsure)
   • b. Leaving patient charts or computer screens open and unattended in a clinical area. (Yes/No/Unsure)
   • c. Disposing of paper documents containing PHI directly into a regular trash bin. (Yes/No/Unsure)
   • d. Using personal mobile devices to take clinical photos without secure, approved applications. (Yes/No/Unsure)
   • e. Verbally giving patient updates at the nurses’ station without ensuring others can’t overhear. (Yes/No/Unsure)
   • f. Using a shared printer or fax machine for PHI without immediate retrieval. (Yes/No/Unsure)
   • Justification (EBP): These questions target specific, common, and often overlooked daily scenarios known to be sources of PHI breaches (HIPAA Journal, n.d.). They assess practical knowledge rather than just theoretical understanding. Identifying “Unsure” responses will pinpoint specific areas where education is lacking.

Section B: Knowledge of Minimizing PHI Exposure

4. Which of the following methods are effective in minimizing PHI exposure during verbal communications? (Select all that apply)

   • a. Using a low voice when discussing patient information.
   • b. Moving to a private area away from public access.
   • c. Only discussing information with individuals directly involved in the patient’s care.
   • d. Using patient initials or room numbers instead of full names.
   • e. All of the above.
   • Justification (EBP): This question assesses knowledge of “minimum necessary” principle and the importance of secure verbal communication environments, which are foundational to HIPAA compliance and general privacy best practices (Centers for Medicare & Medicaid Services, n.d.).

5. What is the correct procedure for disposing of paper documents containing PHI?

   • a. Tear them up and put them in a regular trash bin.
   • b. Shred them using a cross-cut shredder.
   • c. Place them in a designated secure shredding bin.
   • d. Burn them.
   • Justification (EBP): Improper disposal of physical PHI is a common breach source. This question checks adherence to secure disposal protocols, a basic but critical aspect of data security (HIPAA Journal, n.d.).

6. When working with electronic health records (EHRs), what is the most secure practice when stepping away from your workstation? (Select one)

   • a. Minimize the EHR window.
   • b. Log out of the system.
   • c. Lock the computer screen.
   • d. Rely on screen savers to activate automatically.
   • Justification (EBP): Unauthorized access to unattended workstations is a significant vulnerability. Locking the screen or logging out immediately is a universal best practice for electronic data security (National Institute of Standards and Technology, 2013).

7. How often do you feel you receive adequate training or reminders about PHI security and privacy best practices?

   • a. Never
   • b. Rarely
   • c. Sometimes
   • d. Often
   • e. Always
   • Justification (EBP): Training frequency and perceived adequacy are crucial for maintaining awareness and compliance. Regular, relevant training is an evidence-based strategy for reducing human error and improving adherence to security protocols (Joint Commission, 2014).

8. What additional training or resources related to PHI security would be most helpful to you? (Open-ended)

   • Justification (EBP): Open-ended questions provide qualitative data, offering insights into specific needs and perceived gaps in current educational offerings. This allows for tailoring future interventions based on direct feedback from the target audience.

Conclusion

This survey serves as a vital tool in our continuous commitment to safeguarding patient privacy and enhancing healthcare quality management. By systematically assessing provider awareness of PHI exposure risks in routine actions and their knowledge of mitigation strategies, we can pinpoint specific areas where educational reinforcement, process adjustments, or technological solutions are most needed. The questions, carefully selected based on common breach scenarios and established evidence-based practices, aim to yield actionable insights. The results will not only highlight current strengths but also expose vulnerabilities, enabling us to implement targeted interventions that foster a stronger culture of data security, ultimately reinforcing patient trust and upholding the highest standards of care.

References

Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman.

Centers for Medicare & Medicaid Services. (n.d.). HIPAA Privacy Rule and the “Minimum Necessary” Standard. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/HIPAA-ACA/MinimumNecessary (Note: Please verify the most current official CMS link for this resource).

HIPAA Journal. (n.d.). Biggest HIPAA violations of 2024. Retrieved from https://www.hipaajournal.com/biggest-hipaa-violations/ (Note: Please verify the most current content on the HIPAA Journal site).