Quality ethical and it controls course integration and reflection



In order for any foundation to build and grow starts with a variety of different factors besides the physical infrastructure. The integration of the Golden Age Hospital within the Mission Viejo community impacts the systems and structures within the hospital. The Golden Age Hospital requires quality, ethical. and information technology controls throughout the integration because an increase of the facility will lead to an increase in private patient information that will be flowing in and out. Systems will be based on implementing different policies, enforcing rules and regulations; therefore, the integration of the Golden Age Hospital will adhere to the standards and function synonymously with other healthcare facilities when patient and private information is involved.

It is vital to implement rules, regulations, and adhere to the set standards of the policies implemented; such as, HIPAA and the JCAHO because private information must be safeguarded at all times in respect towards the patient, the physicians, the Golden Age Hospital, the system, and what the hospital stands for. (Richmond, L.M., 2018) Everything relates back to the foundation when different systems is involved; such as, the mission statement of the Golden Age Hospital. The HIPAA Privacy guidance will be implemented within the Golden Age Hospital whereas, JCAHO implements other factors; such as, infection control, patient safety, credentials, staff communication. and medical management. (JCAHO accreditation issues to watch for, 2005). For any medical facility to be operational and maintain standards quality, ethics, and information technology controls are always involved.


JCAHO accreditation issues to watch for. (2005). AANA Journal, 59(2), 1. Retrieved from https://search-proquest-com.ezproxy.trident.edu/docview/222160051?accountid=28844

Richmond, L. M., (26 January, 2018). HIPAA Privacy Guidance Clarifies Patient Disclosures. Psychiatric News, 53(3). Retrieved from




Core Organizational Competencies

The five areas of core competency for GAH and CC include Patient Satisfaction, Interdisciplinary Communication, Quality Improvement & Education, Effective Care and Preventative Care. Patient Satisfaction, related to critical aspects of hospital experiences, will be scored and tracked by HCAHPS administered by CMS (CMS.gov. 2018). Interdisciplinary Rounding on patients will support the communication competency. The quality improvement competency will be met and measured through a structured, interdisciplinary quality improvement council which meets regularly to review all of the core competency measures, to perform root cause analysis and to review potential risk areas. Effective care will be measured by items such as effective sepsis care, surgical site infection rates, and urinary tract infection rates. Preventative care will be measured by items such as influenza vaccination rates and readmission rates.

Joint Commission & HIPAA

Seeking Joint Commission accreditation will require meeting patient safety goals, leadership expectations, medication management, and infection control expectations set forth by the Joint Commission (JointCommission.org. 2018). Adherence to the HIPAA Privacy Rule of how to properly use and disclose patient information will also be a federal requirement.

IT Systems

The major components needed include files and protection of patient records consisting of medical history, numerical lab results, and numerical vital signs, images of diagnostic testing, radiographic studies, laboratory graphs and pathology images (Szolovits. 2003).

Centers for Medicare & Medicaid Services (CMS.gov) (2018). HCAPS: Patients’ Perspectives of Care Survey. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-P…

Joint Commission.org. (2018). National Patient Safety Goals. Retrieved from:https://www.jointcommission.org/facts_about_the_na…

Szolovits, P. (2002). Nature of Medical Data. MIT/ Intro to Medical Informatics. Retrieved from:https://tlc.trident.edu/content/enforced/90241-MHM…


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Discussion Module 4

Statement of Problem

For Mission Hospital, Golden Age Hospital and Community Clinic, organizational competencies and functions should be clearly defined and each goal/objective should be clearly indicated for each one. Quality, Ethical and IT Controls have an effect on the hospital infrastructure. Goals and objectives help to set an aim for the health facility to meet. JCAHO Accreditation requires a series of steps to acquire strict regulations help to set high expectations. HIPPA Laws require personal patient data be kept confidential. Ethical Issues motivate creation of policies to prevent unethical practices. IT Systems have technological advances available that correlate with changing times.

The new hospital will require JCAHO accreditation. “Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance. The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care” (“Facts,” 2018).

Background Information

Mission Hospital is located in California. New annex Golden Age Hospital and Community Clinic is being created. Proposed plans are available for the new hospital. New patients can receive treatment once new annex is built. Proposed plans set a guideline to be followed, and give a structure to be enhanced. Federal regulations help to keep facilities up to date. Modern Innovations can be implemented to keep up with the technological advances including computerized modifications.

Description of any Alternatives

Alternatives are available to the organizational competence and functions for Mission Hospital, Golden Age Hospital and Community Clinic. Alternatives include other in-patient facilities such as Emergency Rooms, Hospices, Nursing homes and Rehab Centers. These health facilities have the capacity to provide specialized individual care, tailored to meet the unique needs of the patients. Facilities have professionals with years of education and training to provide expert care and treatment to patients. Alternatives are an additional option that can be utilized by patients.

Major Conclusions

There are major conclusions and recommendations that can be made based on the organizational competencies and functions for Mission Hospital Golden Age Hospital and Community Clinic. Conclusion is that Quality, Ethical and IT Control measures, help to enhance mechanisms within the health facility. Mechanisms such as modifications and adaptations help to renovate the health care agenda within health settings. There are a series of mechanisms within health facilities that have been implemented by the federal government such as HIPPA laws, that require that patient data be kept confidential.


Retrieved on June 23, 2018 from www.jointcommission.org/facts_about_joint_commission_accreditation_standards/