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GAH Organization Quality Control and Accreditation Coursework

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Updated: Jul 1st, 2020

Executive Summary

This section has covered core organizational competencies and functions for GAH. They include professionalism, evidence-based practices, effective communication, patient safety, patient-centered approaches and quality improvement. GAH shall ensure that it meets its core objective of providing safe and beneficial healthcare to the elderly. The facility will review its performances regularly to ensure that it meets its core objective. GAH management and staff shall demonstrate core competencies in leadership, teamwork and collaboration, communication and professionalism.

GAH will operate under HIPAA ethical guidelines. In this regard, the organization shall strive to promote patients’ confidentiality, privacy and rights by protecting data. It will seek legal guidance on controversial issues about HIPAA guidelines. GAH will adopt IT system components to facilitate information sharing within and between different units. The facility recognizes that data transmitted through IT components require protection from potential unauthorized access.

Overall, GAH will strive to meet all its core competencies, ethical standards and deploy IT systems to facilitate communication among various stakeholders.

Quality Control and Accreditation

Core organizational competencies and functions


GAH shall show high standards of accountability in evidence-based nursing practice. The facility will assess its internal practices to ensure that they are consistent with the legal and regulatory requirements, ethical and moral obligations, altruistic and humanistic principles.

Evidence-Based Practice (EBP)

GAH will identify, assess and integrate best practices and current research findings in care provisions for the elderly in Mission Viejo (Hughes, 2008). This will take into account patients’ preferences and values to ensure quality services and patient quality outcomes.


GAH will strive to facilitate effective communication between stakeholders. This would enhance mutual respect, shared decision-making processes, reduce risks to patients and facilitate care provision (Kavaler, 2012).


The facility will rely on clinically beneficial reasoning and thinking to develop a culture of safety for seniors. This will reduce risks associated with long-term care services (Kalra, 2011).

Patient-Centered Care

GAH will foster patient-centered care through communication and collaboration with the patient and families. This approach will facilitate discussions, decision-making, respect for values, patients’ preferences and needs. It will account for patients’ age and cultural orientations to meet their unique needs and ensure effective care.

Quality Improvement

GAH is aware of the impacts of evidence-based nursing practices on patients’ outcomes. Consequently, the facility will use evidence-based outcomes to improve care provision to the senior citizens (Healy, 2011). It will also conduct regular studies and use outcomes to improve safety and quality of care to patients.

Goal/objective for the core organizational competencies

The main objective of all these core competencies and functions is to improve geriatrics care. Consequently, they will account for unique physical, cultural, psychosocial and social characteristics of all senior patients. GAH will aim to promote healthy aging and offer safe and beneficial care to seniors.

A control method/scoreboard to be implemented at GAH to ensure that said core competencies and functions meet their goals and objectives

GAH will develop a Competency Assessment Tool to evaluate achievements of the core competencies and objectives. The following standards will determine the Competency Levels at the facility.

  • Excel level would show that the organization has met its competencies and functions in a given area. This performance will serve as the benchmark and model for the department.
  • Meet standard requirements

Achievements for the rating would be above the ‘Acceptable’ rating. These ratings shall indicate strong contribution to GAH’s competencies and functions in care provision for the elderly.

  • Require improvement

Organizational achievements in core competencies and functions do not meet the set standards. GAH must formulate strategies for improving performance in identified areas.

  • Not acceptable

This will indicate the worst achievement in the core competencies and functions. The rating will indicate a lack of attachment or relationships to any given core competencies and functions.

GAH shall evaluate achievement of core competencies and functions at the levels of care providers, managers and organizational.

The evaluation procedure shall involve the following steps.

  • Evaluation of job performance against the set objectives as a part of performance management process
  • The organizational shall review all core competencies and functions to determine if they are relevant to the overall objective and goal. While there are a number of core competencies and functions, GAH will concentrate on the major ones with maximum impacts. All stakeholders will identify the most relevant core competencies and functions.
  • GAH will assess indicators to identify core competencies and functions, which it has achieved and have contributed to the overall objective.
  • All care providers and managers will indicate how they have contributed to core competencies and functions on a consistent basis under different conditions.
  • Managers must review performances against the objectives and core competencies and functions. Performance assessment will be critical in this process.
  • GAH shall review performances against short-term goals. The organization will identify critical areas of improvement for immediate improvement.
  • Care providers and managers must agree on these specific short-term goals and identified improvement goals.
  • For any identified areas for improvement, GAH will define core competency and function requirements, training and learning needs, expected outcomes, potential benefits and date of implementation.

GAH will conduct assessments to review outcomes. For instance, the organization will focus on performance improvement to achieve it core competencies and functions. In this context, GAH will encourage staff to participate in self-assessment so that they can identify areas of strengths and weakness relative to core competencies and functions. AH shall use the outcomes to inform the improvement of performance objectives and show how personnel can improve their performance against objectives. In addition, GAH’s employees will use outcomes to identify areas in which they need personal improvement. For instance, GAH may decide to review the communication competency among all stakeholders and identify areas, which require immediate attention.

Major competencies from management and staff when seeking JCAHO accreditation


JCAHO requires healthcare facilities to demonstrate competent leadership. Leadership shall foster accountability, change management and partnership with other stakeholders in the healthcare sector. Thus, the GAH management team must demonstrate leadership skills that are necessary for running a long-term care organization (Greiner and Knebel, 2003; Kutsch, 2007).

Teamwork and Collaboration

The GAH management team will build effective relationships and promote open communications with all stakeholders in the health sector. This will foster shared decision-making in the organization. The team will act with integrity and in a consistent manner as it seeks to accommodate diverse opinions.


Nurses should be able to communicate effectively by using different modes, such as written, verbal and electronic.


Nurses must demonstrate professionalism when handling patients and other stakeholders.

The ethical requirements under HIPAA

Healthcare provision has become complex and requires effective regulations. Patients’ data pass from physicians, service providers to patients too. The industry is complex because of various relationships. This practice exposes individuals’ privacy to others and raises issues of ethical concerns (Pozgar, 2012; Jonsen, Siegler & Winslade, 2010). Hence, there is a need to protect patients’ data, their privacy and rights through the ‘Privacy Rule’ or the HIPAA.

GAH shall observe the privacy notice and the written consent required of patients. While these requirements may present ethical dilemma, GAH shall seek legal interpretation in case of any difficulties (Stiller and Weinstock, 2006).

The facility will maintain patient autonomy during decision-making processes and interaction with other care providers.

The organization will also adhere to the principle of the ‘minimum necessary’ patients’ data when handling healthcare transactions. In this respect, GAH will develop and implement the ‘minimum necessary’ procedures and guidelines within its units (Schubert, 2011).

While some of the requirements under HIPAA may be difficult to discern, GAH will act with the best interest of the patient and promote ethical standards. This will be critical in emergency cases, when the patient is not available to make independent decisions or physicians are unable to provide a privacy notice.

Students and other professionals at the care facility will only gain access to data they would be allowed to use for education purposes. GAH shall define the extent to which students and other professionals can handle patients’ information. The organization shall not allow any usages of patients’ data beyond the recommended usages.

GAH has recognized efficiency that the information system has brought about in the health sector. At the same time, the facility also recognizes HIPAA requirements under the use of technology to pass patients’ information. GAH will ensure that all patients’ electronic data are safe and confidential, and it will uphold patients’ privacy and rights.

The major components of an IT system that can best provide for the communication needs within and between health facility units

GAH will focus on the three components of the healthcare information infrastructure. These will include components for managing healthcare data, critical clinical packages, and information communication platforms (Reid, Compton, Grossman and Fanjiang, 2005). These components may support decision-making, act as sources of medical knowledge and transfer information on a real-time basis (Coiera, 2006).

GAH shall foster the delivery of quality healthcare by using information systems, particularly when handling highly fragmented units. These units require physicians and their patients to gain complete access to information and decision-support systems (Reid et al., 2005). Therefore, communication among stakeholders in GAH will be highly effective.

The IT system will allow patients and nurses to communicate effectively and improve service provisions. GAH will consider five critical factors when planning and implementing its IT components. These shall include high-speed Internet connection and availability; safety and privacy of the transferred information; reliability of the network systems; data confidentiality; and constant access of the network at any given location.

Conclusion and Recommendations

GAH’s core competencies and functions shall include professionalism, evidence-based practices, effective communication, patient safety, patient-centered approaches and quality improvement. These core competencies and functions will aim to promote healthy aging and offer safe and beneficial care to seniors. GAH shall review its performance to ensure that it realizes its main objective of promoting healthy aging and beneficial healthcare to older patients. Therefore, GAH will adopt IT systems and ethical standards as defined by HIPAA and meet JCAHO accreditation requirements to provide effective care for seniors.


Coiera, E. (2006). Communication Systems in Healthcare. Clinical Biochemist Reviews, 27(2), 89–98.

Greiner, A. C., and Knebel, E. (Eds). (2003). Agency for Healthcare Research and Quality. Washington, DC: Institute of Medicine.

Healy, J. (2011). Improving health care safety and quality: Reluctant regulators. Burlington, VT: Ashgate Publishing, Ltd.

Hughes, R. G. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality.

Jonsen, A.R., Siegler, M., & Winslade, W.J. (2010). Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (7th ed.). New York: McGraw-Hill.

Kalra, J. (2011). Medical errors and patient safety: Strategies to reduce and disclose medical errors and improve patient safety. New York, NY: Walter de Gruyter.

Kavaler, F. (2012). Risk management in health care institutions. Burlington, MA: Jones & Bartlett Publishers.

Kutsch, V. (2007). Caries risk assessment: Becoming the standard of care? Inside Dent, 4, 32-36.

Pozgar, G. (2012). Legal and ethical issues in healthcare (3rd ed.). Burlington, MA: Jones & Bartlett Learning.

Reid, P., Compton, D., Grossman, J., and Fanjiang, G. (Eds.). (2005). Building a Better Delivery System. Washington, DC: National Academies Press.

Schubert, F. A. (2011). Introduction to law and the legal system. Boston, MA: Wadsworth Cengage Learning.

Stiller, J., and Weinstock, J. L. (2006). Introduction to Health Law. Web.

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