Reference no: EM13778986

Introduction:

Health informatics professionals may be responsible for managing policies and processes in order to ensure organizational readiness for accreditation, licensing, and certification processes. Knowledge of accreditation processes, and where to locate information when it is needed, is a necessary skill.

Task:
A. Discuss how Diane's findings in the attached "Survey Readiness Scenario" illustrate deficiencies in Willow Bend Hospital's compliance with each standard in the attached "Joint Commission Information Standards."

B. Recommend the steps Diane could take to address each deficiency.

1. Discuss what information Diane should gather to correct each deficiency.

2. Discuss where the needed information for each correction could be found.

C. When you use sources, include all in-text citations and references in APA format.

Note: When bulleted points are present in the task prompt, the level of detail or support called for in the rubric refers to those bulleted points.

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Joint Commission Information Standards

The hospital plans for managing information.

1. The hospital identifies the internal and external information needed to provide safe, quality care.

2. The hospital identifies how data and information enter, flow within, and leave the organization.

3. The hospital uses the identified information to guide development of processes to manage information.

4. Staff and licensed independent practitioners selected by the hospital participate in the assessment, selection, integration, and use of

information management systems for the delivery of care, treatment, and services.

The hospital plans for continuity of its information management processes.

1. The hospital has a written plan for managing interruptions to its information processes (paper-based, electronic, or a mix of paper-based and electronic).

2. The hospital's plan for managing interruptions to information processes addresses the scheduled and unscheduled interruptions of electronic information systems.

3. The hospital's plan for managing interruptions to information processes addresses the training for staff and licensed independent practitioners on alternative procedures to follow when electronic information systems are unavailable.

4. The hospital's plan for managing interruptions to information processes addresses the backup of electronic information systems.

5. The hospital's plan for managing interruptions to electronic information processes is tested for effectiveness according to timeframes defined by the organization.

6. The hospital implements its plan for managing interruptions to information processes to maintain access to information needed for patient care, treatment, and services.

The hospital protects the privacy of health information.
1. The hospital has a written policy addressing the privacy of health information.

2. The hospital implements its policy on the privacy of health information.

3. The hospital uses health information only for purposes permitted by law and regulation or as further limited by its policy on privacy.

4. The hospital discloses health information only as authorized by the patient or as otherwise consistent with law and regulation.

5. The hospital monitors compliance with its policy on the privacy of health

survey Readiness Scenario

Diane has been the director of the Health Information Management Department at Willow Bend Hospital for several years. She is project manager for the team which led the organization in the lengthy process of adopting an electronic system for all health records and clinical documentation. Currently, the hospital's vision center is still using paper records, but should be fully integrated within the next six months. Certain departments such as Pediatrics and Oncology are using a hybrid record, and scanning most of their paper documents into the electronic document management system. All other departments are fully electronic.

Because most of the project is behind her, Diane is turning her focus to hospital policies for information management in preparation for a Joint Commission visit. Because accreditation visits are unannounced, Diane knows all health information policies and procedures must be current and in alignment with Joint Commission standards. It has been several years since Willow Bend Hospital received a visit from the Joint Commission; in fact, it occurred when she was a new manager. At that time, she was grateful her predecessor left her with policies and processes in alignment with the standards.

However, with new information systems in place, new policies need to be reviewed or revised. She had been working on them with the policy committee for the past several years as the electronic health record adoption project was ongoing, and now that she has the time to direct her focus to ensuring organizational readiness in information management, in anticipation of the next unannounced visit by the Joint Commission.

Diane's immediate supervisor, the chief information officer (CIO), has requested a summarized plan from Diane describing the intent of each Joint Commission standard for information management. The CIO will be presenting this to the hospital Board of Directors in order to assure them Willow Bend is well-prepared for an accreditation visit.