HIMA250 Healthcare Delivery Systems and Documentation
Assignment: Prepare for Joint Commission
You are the Health Information Director of a hospital, and your hospital has hired a consultant to help determine major issues with the hospital’s information technology. The consultant submitted the following report:
City Hospital has a variety of hardware and software that is used in its departments. Computer workstations are widely used across the organization, but in many departments the computer workstations are too old to provide an adequate platform for the later versions of software that would most effectively support departmental reporting responsibilities.
There is no organization-wide network in place. Software applications and versions are not standardized across the organization, and so members of different departments cannot share data and information in electronic formats. This forces members of the organization to duplicate report generation efforts when reports contain the same or similar data.
An office suite application available to users on a local area network could help solve this problem. The absence of a local area network and an administrative database accessible to department managers means that reports must be prepared in the generating department, output on paper, and then input again in administrative departments to be utilized in administrative applications. An administrative database served by a network to all departments would require data to be gathered only once and then would be made available for subsequent users and purposes without reprocessing.
All of the logs that the organization currently generates, many of which are on an hourly or daily basis, could be more effectively administered and accessed if they were in electronic formats. In addition, interviews with data users state that even with the existing software, they had not been trained well enough to use it.
You are now preparing for a Joint Commission visit that will be in about 6 months. Here are the Joint Commission standards that you are concerned about:
IM. 01.01.01 The [healthcare organization] plans for managing information.
IM. 01.01.03 The [healthcare organization] plans for continuity of its information management processes.
IM. 02.01.01 The [healthcare organization] protects the privacy of health information.
IM. 02.02.01 The [healthcare organization] effectively manages the collection of health information and retrieves, disseminates, and transmits health information in usable formats.
IM. 04.01.01 The organization maintains accurate health information.
PLEASE NOTE: You will have to do research to determine the intricacies of each standard listed above, in order to complete the third column. The third column is an explanation as to why the standards are necessary. Here are two sample sites to get you started
EP_Review_Prepub_Disposition_HAP_IM_PI_RC_20180108pdf new.pdf
Create a table to map each concern to the related Joint Commission standards. Match the appropriate Joint Commission standard listed above to the each of the findings (see sample table).
Hospital Issue
Joint Commission Standard
Explanation: Why is this necessary?
Computer workstations are too old to provide an adequate platform for the later versions of software
IM.01.01.01 The organization plans for managing information
“appropriate individuals ensure that required data and information are provided efficiently for patient care, research, education and management at every level”
2. Prepare a 3-page report to the CEO of the hospital. Your report should include:
- A memo addressed to the Hospital CEO (memo format):
- An introduction of the review and Joint Commission.
- Summarize findings (include a copy of the table).
3. Comparative analysis of the findings with Joint Commission standards and requirements.
Interpret the standards and case information. The interpretation should be an informed conclusion based on all the information you’ve gathered – a meaning to the information and its significance.
Explain why you are concerned about the findings.
Discuss at least two in detail.
Justify your concerns, with supportive information, examples, or references.
3. Recommend a plan for the hospital to address and correct the findings, based on your analysis and interpretation of the standards. The plan should outline actions needed to correct the deficient standards –a sequence of steps that must be taken, or activities that must be performed well, to meet the standard.
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2018 AHIMA Entry-Level Competencies Health Information Management Baccalaureate Degree
Domain I. Data Structure, Content, and Information Governance
I.1. Compare diverse stakeholder perspectives through the delivery of health care services.
I.4. Recommend compliance of health record content across the health system.
