Question

Because performance improvement activities are information intensive, organizations must provide the proper resources and systems to support improvements. It’s important to recognize that PI programs need to meet accreditation standards such as The Joint Commission and Medicare and Medicaid Conditions of Participation, which require access to national comparative data collections. This assignment, based on a textbook case study, will help students to understand Joint Commission information management standards by analyzing how a scenario relates those standards.

Instructions

• Your assignment will focus on the Case study on pages 444-447 (added below). Please complete the tasks at the end of the case study (added below):
• Review the collected data
• Assign the appropriate quality code using the key provided in figure 17.5 (added below)
• Analyze the data:
  • Which code is most common?
  • Is there one service that seems to be a problem?
  • What can you conclude from the data?
• Establish a plan. How you are going to fix the problem?
• Your submission should be a minimum of two pages but does not require APA style or outside research.
• Be sure to fully address each of the questions in the assignment. If you do use outside research, list your references in proper APA style.

Pages 444-447 Joint Commission Information Management Standards

Effective information management for PI entails an understanding of the Joint Commission’s (2015c) information management standards. The information management chapter of the accreditation standards was developed during the mid-1990s to focus healthcare organizations on the importance of information systems issues in the provision of high-quality patient care. Any healthcare organization that uses accreditation as a component of its PI program must ensure that it meets these standards. Even healthcare organizations that do not seek Joint Commission accreditation as a component of their PI programs would be wise to consider the standards in developing PI systems and procedures.

The Joint Commission information management standards focus on information systems issues, not on information systems. The systems implemented may be computer based or paper based. Either way, solutions to these issues must be developed and consciously implemented in healthcare organizations so that information systems can contribute properly to high-quality patient care.

Information management standards address areas in which information resources management contributes to high-quality and improved patient care. These standards require the Joint Commission accredited healthcare organization to plan for, and organize their information resources, and ensure the confidentiality, privacy, security, and integrity of the information is maintained. The record of care standards state that the patient record should be detailed enough so the patient can be identified, as well as support the care provided to include diagnosis, treatments, care results, and staff communication. In addition, care providers should document patient progress in the patient record and use this information to make care decisions. There are also specific standards regarding the use of data and information in the PI function. These standards instruct the healthcare organization to collect and analyze appropriate data to monitor and improve processes within their organization. See table 17.1 for lists of the Joint Commission information management standards.

Table 17.1. Joint Commission Information Resource Standards Information Management Standards IM.01.01.01 The hospital plans for managing Record of Care, Treatment, and Services Standards Performance Improvement Standards RC.01.01.01 The hospital maintains complete and accurate medical records for each individual patient Pl.01.01.01 The hospital collects data to monitor its performance P1.02.01.01 The hospital compiles and analyzes data. Pl.02.01.03 The hospital improves its performance on ORYX accountability measures. P1.03.01.01 The hospital improves performance on an ongoing basis Pl.04.01.01 The hospital uses data from clinical/service screening indicators and human information IM.01.01.03 The hospital plans for continuity of its RC.01.02.01 Entries in the medical record are authenticated information management processes IM.02.01.01 The hospital protects the privacy of health RC.01.03.01 Documentation in the medical record is entered in a timely manner IM.02.01.03 The hospital maintains the security and RC.01.04.01 The hospital audits its medical records integrity of health information IM.02.02.01 The hospital effectively manages the RC.01.05.01 The hospital retains its medical records collection of health information resource screening indicators to assess and continuously improve staffing effectiveness IM.02.02.03 The hospital retrieves, disseminates, and RC.02.01.01 The medical record contains information that reflects the patient's care, treatment, and services transmit health information in useful formats. IM·03.01.01 Knowledge-based information resources RC·02.01.03 The patient's medical record documents operative or other high- risk procedures and the use of moderate or deep sedation or anesthesia are available, current, and authoritative IM.04.01.01 The hospital maintains accurate health RC.02.01.05 The medical record contains documentation of the use of restraint and/or seclusion. RC.02.01.07 The medical record contains a summary list for each patient who receives continuing ambulatory care services RC.02.03.07 Qualified staff receive and record verbal orders RC.02.04.01 The hospital documents the patient's discharge information

Case Study

During the last accreditation survey, the hospital had findings related to quality and timeliness of documentation. The facility is due for another survey very soon. To ensure that your organization is in compliance with the Joint Commission documentation standards, you need to conduct a quality audit. You have assigned one of your staff to collect data from patient records to accomplish this task. The staff member collected data for the month of December for quality and timeliness of documentation. The data collected are presented in figure 17.5.
CASE STUDY TASkS

1. Review the collected data.

2. Assign the appropriate quality code using the key provided in figure 17.5.

3. Analyze the data:

a. Which code is most common?

b. Is there one service that seems to be a problem?

c. What can you conclude from the data?

4. Establish a plan. How are you going to fix the problem?
Review Questions

1. Name the three categories into which healthcare organizations’ data collection falls.

2. A large database that stores every data element collected within a healthcare organization and is used for PI activities is called a/an _____.

a. Data repository

b. Information warehouse

c. Comparative performance data

d. PI database

3. This technology allows organizations to store reports, presentations, profiles, and graphics interpreted and developed from stores of data for reuse in subsequent organizations activities.

a. Data repository

b. Information warehouse

c. Comparative performance data

d. PI database
448

4. When healthcare organizations evaluate their core measure data with those of a similar organization, they are using what?

a. Data repository

b. Information warehouse

c. Comparative performance data

d. PI database

5. Which of the following is a healthcare IT initiative that is designed to improve quality of patient care through the use of electronic health records?

a. Hill-Burton Act

b. Managed care

c. Meaningful use

d. National Patient Safety Goals

Answer 1

Review Questions answers :

Q. No. 1. Answer :

Health care organizations data collection falls in to three categories those are

1. Patient specific data collection,

2. Aggregated data collection,

3. Comparative data collection.

Q. No. 2. Answer : is " d "

A large data base that source every data element that collected with in health organization and is used for PI activities is called as " PI data base "

Q. No. 3. Answer : is " a "

Datarepository means data were house, usually it aggregated the data from different sources of business, with out the data being necessarily related.

This data can be tagged and raised.

So answer is " a "

Q. No. 4. Answer : is " c "

Because they are evaluating the core data with similar health care organizations.

So the answer is " c ".