Health Care across the Continuum-Survey Readiness Scenario

Health Care across the Continuum-Survey Readiness Scenario
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. STOP INFO HERE
Task:
A. Discuss how Diane’s findings in the attached ‘Survey Readiness Scenario’ illustrate
deficiencies in Willow Bend Hospitals 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. If 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.
    Note: When using sources to support ideas and elements in a paper or project, the
    submission MUST include APA formatted in-text citations with a corresponding reference
    list for any direct quotes or paraphrasing. It is not necessary to list sources that were
    consulted if they have not been quoted or paraphrased in the text of the paper or project.
    Note: No more than a combined total of 30% of a submission can be directly quoted or
    closely paraphrased from sources, even if cited correctly.A high degree of Articulation of
    Response must be present.
    File Attachments:
  3. Joint Commission Information Standards
  4. Survey Readiness Scenario

Health Care across the Continuum-Survey Readiness Scenario
Willow Bend Hospital presents various deficiencies in compliance with the “Joint
Commission Information Standards (JCIS).” Initially, although the hospital has a policy that
defines terminologies and abbreviations, its policies fail to describe the entity or individual who
is responsible for updating the list and ensuring that it is distributed to all hospital areas, linked
with the electronic record system, and executed within specified time. The hospital can correct
this deficiency by hiring licensed independent practitioners who would monitor implementation
of the information management procedures (Joint Commission, 2012). In order to correct the
deficiency, the hospital should collect information regarding the information management

HEALTH CARE ACROSS THE CONTINUUM-SURVEY READINESS SCENARIO 2

planning. The information management team can find this information from the JCIS’s standard
IM.01.01.03.
The second deficiency in the Willow Bend’s health information policy is that it lacks a
detailed formal procedure of including a new clinical documentation specialist on the committee.
The hospital should adjust its recruitment policies to provide clear procedure of hiring new
personnel. This should include the qualifications for such specialists, personality and the
recruitment steps. Furthermore, the procedure should describe the key evaluation components at
each step of recruitment and the criteria for disqualifying a candidate (Peden, 2011). Information
about essential skills that specialists need to have and their roles is essential in correcting this
deficiency. This information is available in the important documents that describe criteria for
hiring specialists who are responsible for managing health information.
Furthermore, the hospital’s plan does have a policy for installing backup of electronic
information systems. Consequently, health information officer assumes that the procedure is to
be guided by the IT policies. Corrective steps include establishing effective procedure for
managing interruptions to the information model by providing guidelines about the backup
activities for protecting electronic information scheme. This means that the hospital needs to
collect information about the continuity of information. This information is accessible in the
JCIS’s standard IM.01.01.03.
The hospital’s release of information (ROI) policies does not account for the documents
that are stored electronically only. The hospital should adjust its information release policies to
account entirely for the information that is stored electronically. This means that the hospital
should collect information about security and integrity of information in order to correct this

HEALTH CARE ACROSS THE CONTINUUM-SURVEY READINESS SCENARIO 3

deficiency. This information is available in the JCIS manual script in the category that provides
standards about the information system security (Peden, 2011).
Moreover, Willow Bend has formulated effective procedure for implementing its privacy
policy; however, the hospital does not keep a record for its implementation actions that would
provide a model for checking any breeches and strategies for handling them. Consequently, the
hospital does not have evidence and proof for the implementation of its privacy guidelines.
Corrective strategy includes storing all documents that are related with the implementation of the
privacy policies to create reliable statistics essential for crosschecking in future (Joint
Commission, 2012). This would ensure that the hospital has an effective strategy for monitoring
compliance of the security guidelines. In order to correct this deficiency, the hospital must
collect information regarding the security and integrity of information that is available in the
JCIS standards under IM.02.01.03 category.
The plan also fails to provide a clear highlight of all types of online resources that are
available to the hospital’s staff and locating essential contracts associated with the information
resources is challenging. The hospital should establish a clear guideline that describes all
information that is available in its records and the procedure of retrieving such information
(Skurka, 2003). The hospital should collect information about the collection and retrieval and
transmission of health information. This information is available in the JCIS manual in the
categories describing information collection and transmission.
Furthermore, the hospital lacks a reliable project team for ensuring constant adoption of
the electronic health record plan. The hospital should establish a permanent team for monitoring
the information system procedures. This team should be equipped with effective evaluation tools
that are capable of providing clear highlight of the implementation procedure (Joint Commission,

HEALTH CARE ACROSS THE CONTINUUM-SURVEY READINESS SCENARIO 4

2012). This team should also have authority of proposing procedural adjustments in situations
where the project is performing poorly. In order to correct this deficiency, the hospital should
collect information on information management planning and continuity of information that is
available in the JCIS’s standards under IM.01.01.03 & IM.02.01.01 categories.
Willow Bend’s contract language for the vendor responsible for destroying the hospital’s
electronic data is deficient. Corrective steps should entail developing a written policy that
describes the intentional destruction electronic data. This should provide an overview of
situations under which health information need to be destroyed, legal approvals that needs to be
obtained and how the information is to be destroyed (Peden, 2011). In order to correct this
deficiency, the hospital should collect information about security and integrity of information.
This information is available in the JCIS standards under category IM.02.01.03.
Additionally, the hospital’s policies on security are out dated. Corrective steps include
updating the hospital’s security policies frequently. Consequently, Willow Bend should conduct
frequent surveys to identify emerging concerns that are threatening their information system
(Skurka, 2003). Furthermore, the hospital should maintain close track on the JCIS’s security
standards in order to ensure that its policies are up to date. With the information obtained from
these studies, the hospital can formulate effective security procedures. Particularly, information
about security and integrity of information is essential in correcting this deficiency (Joint
Commission, 2012). The hospital can access such information from the JCIS manual script in the
category “standard IM.02.01.03”. Furthermore, vital information about the security of the
information system is accessible from agencies concern with IT management.
Willow Bend hires a group of Locum Tenens physicians in the summer months; however,
it information system plan is not accompanied with a procedural document that could describe

HEALTH CARE ACROSS THE CONTINUUM-SURVEY READINESS SCENARIO 5

how the contract physicians can manage interruptions with the information workflow especially
in case of an unexpected power breakdown. Effective steps for correcting this deficiency include
providing a clear guideline of individuals with the right of accessing the information system
database and the code of conduct essential when working with the hospital’s information system.
Furthermore, the hospital should extend its information interruption policies to account for the
unprecedented instances. This means that the hospital should train its permanent and contract-
based employees on ideal strategies for addressing disasters such as the ones including power
outage. In order to correct this deficiency, the hospital should collect information regarding
continuity of information and security and integration of information. This information is
accessible in the JCIS’s standards IM.01.01.03 & category IM.02.01.03.
Lastly, the hospital’s policies for accessing information stored in the electronic
management scheme are not clear. For example, the policy highlighting that a patient may access
the stored information fails to describe the procedure and conditions for accessing the
information. Corrective strategies include ensuring that the hospital’s procedures for disclosing
health information are within the law and regulations (The Joint Commission, 2012). Moreover,
the hospital should establish clear procedures for retrieving, distributing and transmitting its
health information. This should also include protection against unauthorized access of the stored
data. This means that the hospital should collect information about data security, and retrieval
and transmission of the health information (Skurka, 2003). This is information is available in the
JCIS standards IM.02.02.03 & IM.02.01.03. Moreover, the information is obtainable from
relevant knowledge based resources.

HEALTH CARE ACROSS THE CONTINUUM-SURVEY READINESS SCENARIO 6

References

Peden, A. H. (2011). Comparative health information management. Clifton Park, NY: Delmar
Cengage Learning.
Skurka, M. F. (2003). Health information management: Principles and organization for health
information services. San Francisco: Jossey-Bass.
The Joint Commission (2012).Standards.

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