Running Head: INFORMATION MANAGEMENT AUDIT 1
Executive Summary
Nightingale Community Hospital is preparing for a Joint Commission on Accreditation of
Healthcare Organizations, or JCAHO, audit. In preparation of the coming audit, Nightingale has released JCAHO’s Priority Focus Areas for the hospital. The priority focus areas outlined are Information Management, Medication Management, Communication, and Infection Control. The area of focus for this assessment will be Information Management. Information management is one of the most important systems in health care. Maintaining a complete and accurate record of the patient’s health care information. The patient’s health record includes all information about the patient, the health
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recommendation for departmental compliance training or organization-wide compliance training. The departments leaders will be responsible for developing a compliance training plan, performing the designated training, then documenting who attended training as well as the training dates. Additional audits will be performed at three month intervals post-training to ensure Nightingale Community Hospital’s and The Joint Commission’s standards are met on a consistent basis.
The next priority focus area is RC.01.01.01 which ensures that the hospital maintains a
separate, complete medical record for each patient. The EPs for this priority focus area include the medical record retention policy and the release of medical records policy (The Joint Commission, 2012). Nightingale Community Hospital appears to be compliant with the Joint Commission’s standards in this priority focus area.
The final priority focus area, RC.01.04.01, which ensures that the hospital audits their
medical records, has three significantly more detailed EPs: 1. The hospital conducts an ongoing review of medical records at the point of care, based on the following indicators: presence, timeliness, legibility (whether handwritten or printed), accuracy, authentication, and completeness of data and information. 2. The hospital measures its medical record delinquency rate at regular intervals, but no less
Preparing for The Joint Commission, Nightingale Community Hospital reviews areas of compliance and non-compliance. A periodic performance review, which is a self-evaluation, is utilized by Nightingale Community Hospital, to prepare for The Joint Commission. The Joint Commission has eighteen accreditation requirements. (Commission, 2013) The periodic performance review found the hospital to be compliant and non- compliant in the following areas:
In accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value.
Nightingale Hospital complying with Joint Commission’s is not occurring. The Universal Protocols (UP) met on some months and not on others. The Time-Out Hospital Wide UP looks like hospital was increase in compliance over the year and reached the one hundred percent make until December. This protocol should be preform at every surgery or minor procedure (where necessary) according to hospital policy in which involves laterality. The National Patient Safety Goal Data (NPSG) for communication in Hospital Wide Compliance of Reporting Critical Results within sixty minutes met one hundred percent, zero
One of the central codes of practice in health and social care has been provided by the GSCC and it sets standards of practice and behaviour for staff working in that field, including standards
Willow Bend Hospital’s compliance does indeed have multiple deficiencies and is in need of review as many were updated in 2009 and 2010. All information on deficiencies would be found on the latest updated version of the Joint Commission Information Standards. This should be located within the Corporate Compliance/Risk Manager’s office. As this information is not currently available to this writer without a subscription and fee, I must use the information available to me. So expansion and explanation of policy details are limited.
The Joint Commission defines the Periodic Performance Review as an assessment tool created to assist health organizations improve and monitor their performance throughout the year. This tool focuses on the processes that influence patient care and safety while providing the structure for unremitting standards fulfillment. Nightingale Community Hospital is compliant with most standards as set forth by the Joint Commission. However, upon inspection and in an effort to stay focused on compliance, our standards committee has located a few discrepancies that must be resolved to maintain our accreditation with the Joint Commission.
A.Nightingale Community Hospital is attempting to be in complete compliance with Joint Commission’s “communications” standards. Prior to the Joint Commission survey, Nightingale Community Hospital wanted to focus on items UP.01.01.01 through UP.01.03.01 of the Joint Commission handbook. According to the handbook, these items focus on the universal protocols for preventing wrong site, wrong procedure, wrong person surgery (2015). In response to these universal protocols, the hospital implemented a pre-procedure hand-off tool, which is completed and signed off by both the nurse handing off the patient as well as the nurse accepting the patient. The hospital also began
The four main areas of focus for the Joint Commission for Nightingale Hospital include Communication, Information Management, Medication Management and Infection
The Joint Commission on Accreditation of Healthcare Organizations or JCAHO was founded in 1951 as a private nonprofit organization that established guidelines for the running and management of hospitals and health care facilities in the United States. According to its website (n.d.), JCAHO’s primary mission is, “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest
The Office of Inspector General (OIG) has established a set of guidelines (e.g., auditing, monitoring, internal controls, sampling, due diligence, and standards of organizational and employee behavior, etc. Page 508 of the textbook) that physician practices should follow when creating a compliance plan. State an opinion as to which OIG guideline would be the single most significant aspect of a compliance plan for a small practice. Provide a rationale for your response.
Mission: To implement a corrective action plan in the area of Communication for Nightingale Community Hospital as required for Joint Commission Compliance.
The CNO outlined professional standards for nurses to comply with. The seven that are outlined are accountability, continuing competence, ethics, knowledge, knowledge application, leadership, and relationships. “A standard is an authoritative statement that sets out the legal and professional basis of nursing practice” (College of Nurses of Ontario, 2009, p. 3). Although each standard has different meaning, they all work together in order to provide the best possible patient care.
AHIMA recognizes that superior quality health care and clinical data are critical resources needed for effective healthcare, and works to assure that the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely. This group is concerned about the effective management of health information from all sources and its application in all forms of healthcare and wellness preservation. Health issues, disease, and care quality also transcend across national borders. AHIMA’s professional interest is in the application of best health information management practices when and wherever they are needed. (The American Health Information Management Association, 2010).
Nightingale Community Hospital (NCH) has thirteen months until their next Joint Commission audit. This report will evaluate Nightingale Hospital’s compliance in The Priority Focus Area of Communication using the Universal Protocol Standards from the Joint Commission Handbook. “The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations” (Joint Commission, 2013).
In addition to the core elements, providers will have to choose any five of the ten additional tasks to implement in 2011-2012. Some examples of these might be clinical lab results, patient appointment reminders and drug-formulary checks. This gives the providers a chance to choose their own path toward full EHR implementation and meaningful use. Legislation ties payments to the achievement of advances in health care processes and outcomes. The regulations are specific as to when providers will have to use particular functions in order to be considered meaningful users. The meaningful use rule acknowledges the urgency of adopting the electronic health record and recognizes the challenges it will pose on all providers.