Golden Age Hospital: Quality Control and Accreditation Presentation

Executive Summary

• The section covered GAH’s core competencies and functions, IT controls, JCAHO accreditation and HIPAA ethical requirements;
• GAH’s core competencies include professionalism, evidence-based practices, effective communication, patient safety, patient-centered approaches and quality improvement;
• GAH’s core objective is to provide safe and beneficial healthcare to the elderly;
• The facility will review its performances regularly to ensure that it meets its core objective;
• Management and staff shall demonstrate core competencies in leadership, teamwork and collaboration, communication and professionalism;
• GAH will operate under HIPAA ethical guidelines;
• GAH will adopt IT system components to facilitate information sharing within and between different units.

Core organizational competencies and functions

• Professionalism – 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);
• Communication would enhance mutual respect, shared decision-making processes, reduce risks to patients and facilitate care provision (Kavaler, 2012);
• Safety 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;
• Quality improvement – the facility will use evidence-based outcomes to improve care provision to the senior citizens (Healy, 2011).

Goal/Objectives

The main objective of all these core competencies and functions is to improve geriatrics care.

A Control Method for Core Competencies and Functions

GAH will develop a Competency Assessment Tool to evaluate achievements.

Competency Levels will include:

• Excel level for excellent performances;
• Meet standard requirements;
• Require improvement;
• Not acceptable;
• GAH shall evaluate achievement of core competencies and functions at the levels of care providers, managers and at the organizational level.

The Evaluation Procedure

• Evaluation of job performance against the set objectives as a part of performance management process;
• Review all core competencies and functions to determine if they are relevant to the overall objective and goal;
• 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;
• Managers must review performances against the objectives and core competencies and functions;
• GAH shall review performances against short-term goals;
• Care providers and managers must agree on these specific short-term goals and identified improvement goals;
• GAH will define core competency and function requirements, training and learning needs, expected outcomes, potential benefits and date of implementation.

Major competencies from management and staff when seeking JCAHO accreditation

• Leadership: 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: GAH management team will build effective relationships and promote open communications with all stakeholders in the health sector;
• Communication: Nurses should be able to communicate effectively by using different modes, such as written, verbal and electronic;
• Professionalism: Nurses must demonstrate professionalism when handling patients and other stakeholders.

The ethical requirements under HIPAA

• The complex healthcare system exposes patients’ privacy to others and raises issues of ethical concerns (Pozgar, 2012; Jonsen, Siegler & Winslade, 2010);
• GAH recognizes the need to protect patients’ data, privacy and rights through the ‘Privacy Rule’ or the HIPAA;
• The facility shall seek legal interpretation in case of any difficulties (Stiller and Weinstock, 2006);
• The organization will adhere to the principle of the ‘minimum necessary’ patients’ data during transactions (Schubert, 2011);
• GAH shall define the extent to which students and other professionals can handle patients’ information.

The major components of an IT system

GAH will focus on the three components of the healthcare information infrastructure, such as 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 will consider 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 Recommendation

GAH’s core competencies and functions shall include professionalism, evidence-based practices, effective communication, patient safety, patient-centered approaches and quality improvement.

Core competencies and functions will aim to promote healthy aging and offer safe and beneficial care to seniors.

GAH will adopt IT systems and ethical standards as defined by HIPAA and meet JCAHO accreditation requirements to provide effective care for seniors.

References

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.