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Final Project
Dannie Goodmiller
Southern New Hampshire University
HIM-440: Management of Health Information Services
Shawna Sweeney
February 23, 2025
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Gateway Healthcare Systems is in the process of merging three hospitals St. Catherine’s
Medical Center, St. Luke’s Hospital, and Hickman Community Hospital creating the new
Gateway Healthcare System.
Summary
With the merger of the three hospitals there are a number of issues that need to be
addressed as these should have been addressed prior to the merger. Unfortunately these issues
has allowed for the facilities to be non-complaint with the HIPAA rules and regulations as well
as the principles that are set by the Joint commission. With each hospital mission and vision
statement will be combined into one new mission and one new vision statement under Gateway
Healthcare Systems.
Compliance
The first thing that needs to be addressed for this merger is that the department needs to
be in compliance. Having set standards of policies and procedures in place to ensure that all
compliance is being met and should be placed into action within the first few months of the
merger. These standards will consist of having the ICD-10 coding standards in place, all
employees within the organization follow the regulations and laws that are put into place not just
by the organization but also by state and federal government. Gateway Healthcare System will
ensure that the EHR system has in place timestamps for all systems. All staff are to adhere to the
laws of protecting patient confidential health information, abiding to protect patient health
information by following the laws of HIPAA regulations.
Cultural Diversity
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With the merger and the new organization Gateway Healthcare Systems must maintain
the consciousness as well as the understanding of the importance of cultural diversity. To do this
it is important that there is encouragement to the staff by providing them with training on cultural
diversity, being able to bridge the gaps of any understanding about cultural practices and
language opening employees minds to that there is more to the world. This will also allow for
staff to be able to develop a connection or a better understanding when they provide care for
patients that come from a diverse background. The cultural diversity that Gateway Healthcare
Systems will see is not just within the employees, but also within the patients as well.
Mission and Vision
Given prior to the merger, all three hospitals had separate mission and vision statements.
St. Catherine’s Medical Center mission statement is “Grounded in the Catholic mission of
service, we strive to provide accurate patient health information services to all patients with care,
concern, and dignity.” St. Catherine’s Medical Center vision statement is “Provide patients with
their health information with sensitivity and respect to their privacy.” St. Luke’s hospital mission
statement is “To provide providers, residents, and staff with timely access to patient health
information for purposes of treatment, research, and reimbursement.” St. Luke’s hospital vision
statement is “Promoting research through state of the art health information management and
technology.”
Hickman community hospital mission statement is “To assure protection of patient health
information at all times.” The vision statement for Hickman Community hospital is “Committed
to serving the local community health information needs and ensuring patient information is
secure.”
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With the new Gateway Healthcare Systems merger there needs to be one mission
statement. That statement will be “With the new Gateway Healthcare System, we will continue
to be dedicated to not only to protect patient privacy, but to serve the community as well and
provide the best healthcare experience that they all deserve. Giving the best care and treatment to
patients, and dedicate to the research for better outcomes for all.”
The vision statement for Gateway Healthcare Systems is “ Our vision is to continue to be
dedicated and committed to our patients to help promote Health Information Management with
the advanced technology, keep patient information protected and secure, and to always put our
patient’s care and health first.”
SWOT Analysis
With the SWOT analysis metrics it does show that there are significant issues between all
three hospitals before they can successfully merge into Gateway Healthcare Systems. Having the
new implementation of policies and procedures that are in place, this will allow for a more safe
guard with security to protecting patient health information with a better productive coding
standard.
St. Catherine’s
Strengths
Affiliation with Catholic religion
Variety of ethnic backgrounds, being diverse with
the staff and patients in linguistically, consistent
coding quality that exceeds 95%, having a
reputation with patients, and a good employee
retention.
Weaknesses
Budget issues, productivity level critically low,
average salary is lower, citation of no time stamp
on orders, complaints from coders standards
unreasonable.
Opportunities
Increasing training and education, creating new
policies and procedures, increase productivity,
increase staff salary levels, increase return
revenue for coding quality
Threats
Having citations from the TJC, potential loss of
staff by not addressing their complaints, not
having any training as well as education and
credentials.
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St. Luke’s
Strengths
First generation EHR, provides critical care to
patients who have no insurance, inner city
teaching hospital, provides services to a diverse
patient population with all backgrounds.
Weaknesses
No HIM manager or direct on staff, EHR
difficulty communication with other systems,
productivity low, low revenue, high volume of
staff turnover, low diversity in staff.
Opportunities
Have higher expectations, can increase revenue
with medical reimbursements, increase the
serving of patients with medical insurance,
increase productivity, improve the EHR system to
be able to communicate with other systems
Threats
Higher turnover rate with staff, not having either
a HIM manager or director of staff, not having
the proper training for staff.
Hickman
Strengths
Positive good cultural atmosphere, staff are like
family, staff retention
Weaknesses
Facility accessibility issues, lack of staff cultural
diversity training, non compliant with ADA
guidelines, high turnaround time in filing for
billing, non AHIMA credentialed staff
Opportunities
Increase in revenue, increase the population that
it services, create a more family friendly
atmosphere, expand employee retention to be
more diverse
Threats
Being non-complaint with ADA guidelines, lack
of leadership, using manual code books, not
having the credentialed staff, and difficulty with
accessibility.
Unified HIM Department SWOT Analysis
Strengths
Improved reputation, an increase in diversity in
both staff and patients that they serve, retention in
employees, improved in coding quality, and a
more broader family type atmosphere.
Weaknesses
Non-compliance, poor training, citations, patients
more diverse than the staff that provides care,
revenue, and budget.
Opportunities
Being able to hire more credentialed staff,
increase in salary, increase revenue, expand
productivity, expand employee retention, and
create a budget that would improve the EHR
system
Threats
Poor education and credentials, low diversity with
patients and staff, poor procedures and policies,
poor expectations on quality, daily performance
and records, citations with TJC and ADA
guidelines, no coder, poor response to addressing
employee complaints
Process Improvement Plan Phase
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Performance Measurement
To be able to development a performance benchmarks there needs to be a baseline that is
stablished to be able to measure the metrics of performance against. Gateway Healthcare
Systems benchmarks need to include the standards for coding quality, patient record
maintenance, levels of productivity, return on reimbursements for services provided, quality of
care to patients, patient safety, and of course staff security and satisfaction. The project
management tool that would be ideal to use in this improvement plan would be Gantt Chart.
Employment Laws
Two employment laws that need to be considered at all times with this merger is both
The Civil Rights Act of 1964 and the OSHA Act also known as Occupational Safety and Health
Act. These two employment laws need to be in place when evaluating staff performance as well
as to ensure that not only compliance is being adhere but also that legal compliance is also being
adhered. Under law that protects employees is the EEO Equal Employment Opportunity as this is
put in place to ensure that employers cannot meaning they are not allowed to discriminate
against an employee based on their age, race, gender (sex), religion, disabilities, and pregnancy.
This also allows for employees to be able to get promotions to move up, while not being treated
differently because of their race, gender, or age. (Labor Laws and Worker Protection | USAGov,
n.d.-b)
Feedback
Evaluations that are completed between manager/supervisor and employee help
determine where the employee stands on their position, and where does there need to be
improvement. This allows for prioritizing for raises, promotions, or possibly dismissal if they are
not meeting the standards of the organization that was agreed upon hire. Once the evaluations
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have been completed then discussing the results between supervisor and employee are a must so
that they can come up with a plan that helps improve in the areas that were identified in the
evaluation, or what the goals are for the next step if they are already exceeding the expectations.
(Performance Measurement, n.d.)
Accreditation Standards
When it comes to accreditation standards it is important that the organization follows the
standards set by TJC known as The Joint Commission that was established in 1952 and grants
accreditations to healthcare organizations. TJC ultimately helps organizations to aspire to not
only enhance the patient care, but to also help the organizations with a positive impact by
allowing them to understand what issues are found during audits and for the organization to
strategize ways to improve the issues that were found. The TJC helps healthcare organizations to
not only have the standards in a guideline, but to also to ensure patient safety, privacy are being
adhere at all times. It will be extremely important that Gateway Healthcare Systems will need to
make sure that all departments are in compliance with the TJC standards, as well as standards for
the leadership. (Standards for Joint Commission Accreditation and Certification, n.d.-b)
Stakeholders
For the stakeholders Gateway Healthcare Systems will need to ensure that there is a team
that is not only diverse, but can work together as a team, be able to manage ensure that all are
adhering to the compliance. This team will consist of the CEO (chief executive officer), CFO
(chief financial officer), CNO (chief nursing officer), HIM director, compliance manager are just
to name a few upper management that are stakeholders. Other stakeholders consist of providers,
nursing staff, and other employees that work within the organization as well. This team will help
determine the benefits and disadvantages of making any changes to the organization plan.
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Policy and Procedures
Policy and procedures are put in place for standards for the organization as well as
guidelines on how to help with clarification on what to do with certain scenarios that could arise
in the healthcare field. Policy and procedures can also help ensure that compliance remains at all
times when it comes to HIPAA. This could ensure that all staff are expected to be have computer
stations locked if they walk away from their desk, or logged off completely when they leave for
the day, expected to conceal and secure patient privacy and their information are kept private,
shredding any documentation after it has been scanned and saved into patients medical records,
and employees shall not converse to other staff members about patient health information unless
it is in regards of needing to work on the patient chart. Gateway Healthcare Systems will ensure
that all staff follow the policy and procedures that are going to be in place to protect patients and
their information.
Cultural Diversity
With the merger and the new organization Gateway Healthcare Systems must maintain
the consciousness as well as the understanding of the importance of cultural diversity. To do this
it is important that there is encouragement to the staff by providing them with training on cultural
diversity, being able to bridge the gaps of any understanding about cultural practices and
language opening employees minds to that there is more to the world. This will also allow for
staff to be able to develop a connection or a better understanding when they provide care for
patients that come from a diverse background.
Compliance Issues
The compliance issues that need to be addressed is training on the importance of PHI
(protected health information), how to dispose of PHI, and HIPAA. It was found that there were
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compliance issues from the previous three facilities and with the merger it is important to make
sure that there is regular trainings of the importance of PHI. It is also important that there is
compliance of how to properly dispose of PHI, this would be putting the documents into a secure
bin that goes for shredding which is the proper way of destroying PHI. It is also important that
employees know that keeping patient information protected and secure at all times allows the
patients to feel that their information is being secured. With all staff knowing and understanding
the importance of HIPAA with continuous training and reminders will allow for them to be in
compliance and know with an understanding that if they violate HIPAA that there is
consequences. It is important to know that patient information remains confidential, private,
secure as it builds a trust with the patient and the healthcare organization.
Change Management and Training Implementation Phase
Project Management Tool
The project management tool that will be used to help ensure that things are working
smoothly and accurately would be to use benchmarks. The benchmarks will help establish what
the focuses needs to be on for improvements in both staff and the organization itself. The
benchmarks with Gateway Healthcare Systems need to be able to address the coding quality,
maintenance of medical records, return on reimbursements for services provided, productivity
level, the quality of care being provided, patient safety, and of course patient satisfaction and
employee satisfaction.
Cultural Diversity
With Gateway Health System there should be no discrimination against race, sex, age,
religion, language, etc for both new hires as well as retaining staff. All employees shall undergo
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training and education on cultural diversity. After this training and education has been completed
it will be required to have a signed acknowledgement into each employee file. With the merger
of the three hospitals this training ands education will be mandatory. This training can be done
on site, and/or remote depending on the instructor and or guest speaker. This training shall also
offer translators for employees that need it for language barriers, hearing/vision impairment. The
main purpose of this training/education will to be provide all staff/employees the complete
understanding that importance of cultural diversity and the compliance. All is welcome both
employees and patients, that no one shall turn their head based on diversity.
Training for HIPAA Security Laws
With the merger creating Gateway Healthcare Systems the first thing that needs to be enforced is
the proper and improper way of storing records, disposing of records. The importance of keeping
patient records can not be overlooked. Patient health information are to be protected, secure, as
the patient is trusting the healthcare organization with their private information. All employees
will adhere that they are to not talk to each other regarding patient information, speak loudly to
patients regarding their health information will be prohibited. It is important to be mindful when
speaking to patients when other people are around.
Training for Policy and Procedure Changes
With training in place for both policy and procedure changes needs to ensure that all
three hospitals involved in the merger understand what these are. The policy and procedures that
will be implemented are the proper disposal of patient information. Know when the correct
moment or time is for discussing patient information, and when is the incorrect time and
moment. This would be for employees to have a casual conversation regarding patient
information, this would violate HIPAA laws and regulations. During the training there will be
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questionnaires that will allow for employees to answer, the answers can be discussed after all
questions have been answered. This questionnaires will allow for scenarios to be presented
allowing the employees to really think about the actions and if they are ok or not. This will
provide feedback and allow for group discussions so that everyone is on the same page and know
to uphold the policy and procedures that are being implemented.
Evaluate Success
With the merger of the three hospitals the members of Gateway Healthcare Systems are
going to be a wonderful culturally diverse group. To be able to evaluate success after training it
would be ideal to have job simulators, instructor led trainings and follow ups, as well as proving
coaching for anyone who still struggles. It will help see where employees stand with the diversity
of not just with their coworkers, but also with the patients that they are treating. It would also be
ideal to send out surveys to both staff and patients, to see how they stand with satisfaction and
where improvements can be made.
Conclusion
With the new Gateway Healthcare Systems, it is important that HIM department remains
unified and committed to the cultural diversity and protecting patient information. The topics that
were discussed were summarizing the issues between the three hospitals, compliance that needs
to be maintained and addressed, the cultural diversity between staff and patients, the new mission
and vision statements. Gateway Healthcare System is taking the strengths, weaknesses, threats
and opportunities from St. Catherine’s Medical Center, St. Luke’s hospital and Hickman’s
Community hospital and combing them to create a better improved Gateway Healthcare System.
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References
1. Performance measurement. (n.d.). The Joint Commission.
https://www.jointcommission.org/measurement/
2. Labor laws and worker protection | USAGov. (n.d.-b). https://www.usa.gov/labor-
laws
3. Standards for joint Commission accreditation and certification. (n.d.-b). The Joint
Commission. https://www.jointcommission.org/standards/
4. Alu. (2024, May 22). How to improve cultural competence in health care. School of
Public Health. https://publichealth.tulane.edu/blog/cultural-competence-in-health-
care/#:~:text=Cultural%20competence%20in%20health%20care%20means
%20delivering%20effective%2C,health%20care%20according%20to%20cultural
%20and%20linguistic%20differences.
