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Health Information Standards and Regulations

Competency 730.2.4: Health Information Standards and Regulations for Documentation – The graduate ensures compliance with health information
standards and regulations as outlined in professional practice guidelines, government regulations, and accreditation standards; and analyzes health
record documentation practices in healthcare organizations.
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.
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. If you use sources, include all in-text citations and references in APA format.
    Health Data Management

Health Information Standards and Regulations ensures that the responsible health care information management employee maintains compliance with
set health information regulations and standards as outlined in government regulations, professional practice guidelines as well as accreditation standards by
conducting frequent analysis of the practices for health record documentation in their respective healthcare organizations (Uselton, Kienle & Murdaugh, 2010).
Thus, in any healthcare organization health informatics professionals are obliged to manage policies and processes in order to make sure that their organizations
are ready for the processes of accreditation, licensing, as well as certification. However, the health informatics professionals also need to have the knowledge
where to locate information concerning accreditation processes when it is needed. According to Joint Commission Resources, Inc. (2008) health informatics
professionals are required to be well-versed with all policies and processes regulating handling of health information, and they are supposed to always ensure
that there respective health organizations strictly adhere to the Joint Commission Information Standards for their readiness to the unannounced accreditation
visits by the Joint Commission.
Deficiencies in Willow Bend Hospital’s compliance with the Joint Commission Information Standards
According to Lima, Johns & Liebler (1998) healthcare organizations should always ensure that they comply with the Joint Commission Information
Standards by making sure that their policies are current and up to date with the reviewed standards. This is crucial in preventing deficiencies in compliance with
the health information standards outlined by the Joint Commission which may make the hospital fail to be accredited, licensed or certified. However, Diane’s
findings illustrate that there are deficiencies in Willow Bend Hospital’s compliance with the Joint Commission Information Standards.
For example, Diane could not locate the person responsible for updating the terminology and abbreviations list and ensuring it is posted within the
electronic record system, disseminated to all clinical areas, and performed within specific time frames. This deviates from section 3 of Standard IM.02.02.03
concerned with receival and transmission of health information which requires that someone be assigned to the dissemination of data and information in useful
formats to all clinical areas and within timeframes. The absence of staffs to address health records auditing process deviates from section 4 of Standard
IM.01.01.01 concerned with information management planning which requires the hospital to select a staff or licensed independent practitioners to be
participating in the assessment, integration, selection, as well as the use of the hospital’s information management systems (Joint Commission Resources, Inc.,
Diane also could not locate a policy addressing electronic information systems backup in her department. This is a deficiency from section 4 of Standard
IM.01.01.03 involved with continuity of information which requires the hospital to have a readily available plan for managing information processes
interruptions such as addressing the electronic information systems backup. Moreover, her finding that the release of information (ROI) policies for her
department are not updated is a deficiency from the Joint Commission Information Standards that requires them to be updated in order to accommodate release
of those documents only stored electronically because through her led project, the hospital has managed to convert all documents into electronic formats except
at the vision center (Uselton, Kienle & Murdaugh, 2010).
However, despite Diane’s knowledge that the hospital implements privacy policies, the fact that she can not locate evidence and proof of compliance,
specifically to show any cases of breeches, and how such incidences were handled is a deficiency from the Joint Commission Information Standards. In
particular, this deviates from section 5 of Standard IM.02.01.01 concerned with protecting privacy of health information, which specifically requires the hospital

to monitor compliance with its policy on the privacy of health information. If proper monitoring and evaluation of the hospital’s privacy policies were
implemented, it could have been easy for Diane to find evidence and proof of compliance by readily locating cases of previous incidences of breeches, and how
they were handled (Wager, Lee & Glaser, 2009).
Diane’s indication that there was a project team in place for the electronic health record adoption project that was temporary shows a deficiency from the
Joint Commission Information Standards. This is mainly because, first, the project of converting all hospital’s information into electronic format is not yet
complete, and second, the role of maintaining, monitoring and evaluating the converted information should have been delegated to this team meaning it was not
supposed to be temporary (Joint Commission Resources, Inc., 2008). Moreover, the finding that Diane needs to review the department of information
technology policies on security is evidently another deficiency in Joint Commission Information Standards. This is due to the fact that according to section 1 of
Standard IM.02.01.03 which is concerned with the security and integrity of information, the hospital needs to always maintain up to date written policy
addressing the security of health information, including access, use, and disclosure. Hence the finding that she needs to review the policies on health
information security is an indication that they have not been updated for a while considering she has been the department’s director for several years.
In addition, considering that in the summer months the hospital employs a considerable number of Locum Tenens physicians, the fact that Diane could
not locate a procedural document that describes how these contract physicians should manage interruptions with their information workflow, in case of a power
outage that is unexpected is another deficiency from the Joint Commission Information Standards. This is mainly because according to section 3 of Standard
IM.01.01.03 dealing with continuity of information; the hospital needs to have a plan for managing information processes interruptions by addressing the
training for staff and licensed independent practitioners on alternative procedures that they should follow when electronic information systems are unavailable,
for example, in case of unexpected power outage (Joint Commission Resources, Inc., 2008). Finally, the finding that the policy stating patients could access
health information stored in the electronic document management system, but in need of further specifications for clarity is another deficiency. This is because
all policies concerning access to health information should be sufficiently detailed and succinctly clear on all involved aspects (Roach, H. et al. 2008).
Recommendations to address each deficiency and the information required
In order to appropriately address the identified deficiencies, Diane will be required to adopt various steps aimed at filling the identified gaps. For
instance, the hospital will need to add staff positions to the policy addressing health records auditing process in order to facilitate easy updating, dissemination,
posting, and ensuring this is performed within specific time frames (Wager, Lee & Glaser, 2009). The other step would be to devise a training program for all
staff and licensed independent practitioners about an alternative backup plan, including the Locum physicians in case of information interruptions such as those
caused by unexpected power outage. However, in order to ensure that the established training program for locum physicians regarding how to access
information during an unexpected downtime is adhered to, the hospitals will need to come up with an appropriate policy and a compliance program. Both of
these will ensure the set code of conduct is always followed. Moreover, for the purpose of minimizing these incidences that are sometimes caused by
unexpected power interruptions, a standby generator would also be necessary to address this problem.
However, in order to ensure the release of information (ROI) policies are up to date all the hospital’s information should be converted to electronic
format. Moreover, it would also be necessary to ensure that all policies are maintained current and up to date with the Joint Commission Information Standards
as well as ensuring that they are sufficiently detailed and succinctly clear on all aspects involved (Roach, H. et al. 2008). This would be solved by ensuring that
the project team given the task is reversed from temporary to permanent.
However, despite the presence of information security policies in order to ensure Diane will be able to locate evidence and proof of security policy
compliance, specifically to show any cases of breeches, and how such incidences were handled; the hospital will require to implement a proper monitoring and
evaluation system for precise and easy location of previous incidences of breeches, and how they were handled. Furthermore, the information technology
policies on security need to be always maintained updated in order to adequately address the security of health information, including access, use, and disclosure
(Roach, H. et al. 2008).
Moreover, Diane needs to ensure that online resources are available to their staff concerning all the necessary procedures, policies and alternative plans
available with the aim of making sure the required reference information is easily and conveniently available to hospital staff. Furthermore, all contracts related
to information resources need to be appropriately stored in both electronic and paper formats to allow easy location whenever needed. Moreover, the language
used in these contracts need to be reviewed in order to ensure that they are easily understandable as well as making sure that they are properly detailed.
Information Diane needs to be gather and their sources
In order to correct each deficiency, Diane should gather sufficient information concerning why all departments are not using electronic systems and how
much it would cost to acquire the electronic systems as well as whether each department keeps its files secure in proper filing system for easy retrieval (Wager,

Lee & Glaser, 2009). Moreover, Diane will also need to gather information concerning the challenges faced by staffs when using information systems and
policies in their current state. This would provide insights into how they deviate from the Joint Commission Information Standards and the appropriate
corrective actions to be taken. Therefore, Diane will need to gather information on the number of staffs needed to be hired, the costs involved in implementing
the corrective actions for the identified deficiencies as well as information concerning the ways of maintaining the corrective measures implemented.
This information is obtainable from various departments within the hospital. This is mainly because the staffs that are specifically attached to various
departments within the hospital have first hand information concerning day to day operations of their respective departments. This includes the vision center
whose documents are not yet electronic. Therefore, conducting personal interviews with these staffs would be an appropriate source of information.
The other information should be about the necessary training and compliance programs as well as monitoring and evaluation systems required. This can
also be obtained from various departments, preferably the IT department. Moreover, it would also be appropriate to seek the assistance of a consultant for more
information about the most effective programs that can be implemented to ensure the hospital staffs are properly trained on how to comply with the monitoring
and evaluation systems to be put in place.
Furthermore, apart from the above mentioned primary sources of information, Diane would also obtain such information from secondary sources such as
internet, books, journal articles and magazines. Therefore, Diane would be required to conduct the information search herself or delegate that duty to junior
staffs. This would enable collection of the necessary information concerning the particular issues Diane wants to address. These sources of information would
apply for all the deficiencies identified.
It is undoubtedly evident that the hospital has had many deficiencies in its electronic information handling such as lack of proper backup plan,
inadequate staff and so on. However, it has been shown that these deficiencies can be addressed through proper backup plan; employment of more staff and
prioritization of information security policies. Finally, the required information to address the identified deficiencies and where the information can be collected
has also been discussed.

Joint Commission Resources, Inc. (2008). Managing performance measurement data in health care. Oakbrook Terrace, IL: Joint Commission on Accreditation
of Healthcare Organizations.

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