Nightingale Community Hospital Jcaho Audit Preparation: Information Management

Running heading development management analyze 1 Executive Summary nightingale fellowship hospital is preparing for a correlative mission on Accreditation of Health cope Organizations, or JCAHO, audit. In preparation of the coming audit, Nightingale has released JCAHOs precedency Focus Areas for the infirmary. The precedence digest on demesnes outlined are Information nidus, Medication Management, Communication, and Infection Control. The realm of focus for this quantifyment depart be Information Management. Information management is one of the most important systems in health care.Maintaining a complete and accurate record of the patient of roles health care data. The patients health record let ins whole information about the patient, the health care the patient has received, and all practitioners notes pertaining to the patients care. Compliance in Information Management see to its that the infirmary maintains a high tonus of patient care. Information manag ement, as outlined by JCAHO, takes three joystick Commission Standards in the audit. The ? rst standard, IM. 02. 02. 01, which encompasses whether the infirmary manages the collection of information effectively.The standard includes three Elements of Performance, or EPs. The three EPs include whether the hospital uses standardized and uniform entropy sets to collect information, whether the hospital uses standard, consistent terminology, abbreviations, symbols and whether the hospital follows a form _or_ system of government of forbidden abbreviations, symbols, and dose designations among other performance measures (The roast Commission, 2012). Upon review article of the ? rst EP as well as the reports and financial backing contributed by Nightingale Community Hospital, the Admission Orders form allows for consistent, pertinent patient information to be gathered to check off optimal ontinuum of care for patients. The form should be reviewed on a regular basis to ensure th at vital entropy points are include in the data Running Head INFORMATION heed study 2 collection process and to include updated adoptments. One piece of critical information that should be included on all Admission Orders is the admitting diagnosis. The forms also include pre-checked consultations and orders which may not apply to all patient who is admitted this check marks in the boxes go forth impoverishment to be removed. In accordance with the atomic number 42 EP, the hospital uses standard terminology, de? itions, abbreviations, acronyms, symbols, and dose designations on the forms that have been provided (The reciprocal Commission, 2012). The third EP, which addresses whether Nightingale Community Hospital follows a list of prohibit abbreviations, is not in entry with the give voice Commissions standards. The graphical record on page three of the National Patient Safety Goal Data Information Management report, shows the relative incidence of using prohibited abb reviations was not within acceptable brinks for January or December the goal for respect is 99. 6%.To achieve submission with the critical point Commission, the organisation must not have more than 2 occurrences of non- accordance. The system of rules improved by eliminating the use of three abbreviations qd, x3d, and sc. The organizations graph shows that in January the abbreviation, u, was use 17% of the time and in December was used 63% which is an increase of 46%. To be in compliance with the hospitals benchmark, the occurrences must be at or below the error threshold of . 04%. To get to the task, the organization testament need to implement a corrective action plan.To begin, the organization provide need to appoint an Information Management compliance team up. The compliance teams primary responsibilities should be extra to auditing the non-compliant records to determine trends in economic consumption of prohibited abbreviations. When the audit is complete, the resu lts will determine the source of the usage of prohibited abbreviations. The possibility of a speci? c surgical incision or an individual within a department qualification the error will be reviewed. After identifying the cause of the increase in abbreviation errors, the team will make aRunning Head INFORMATION MANAGEMENT AUDIT 3 recommendation for departmental compliance cultivation or organization-wide compliance cultivation. 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. special audits will be performed at three month intervals post-training to ensure Nightingale Community Hospitals and The Joint Commissions standards are met on a consistent basis. The next priority focus sphere is RC. 1. 01. 01 which ensures that the hospital maintains a separate, complete checkup record for each patient. The EPs for this priority focus area inclu de 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 Commissions standards in this priority focus area. The ? nal priority focus area, RC. 01. 04. 01, which ensures that the hospital audits their medical records, has three signi? cantly 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(prenominal) than every three months. 3. The medical record delinquency rate averaged from the last four quarterly measurements is 50% or less of the average monthly discharge (AMD) rate. Each individual quarterly measurement is no greater than 50% of the AMD rate (Th e Joint Commission, 2012).The organization appears to be compliant with all three of the EPs. However, the organization fails to provide keep to reflect the interval in which audits are performed Running Head INFORMATION MANAGEMENT AUDIT 4 on the medical records. The medical record delinquency rate also inevitably to be documented and graphed along with other measures of delinquency. The current graph outlining patient identification documentation errors shows data for cardinal different years. Audit data needs to be consistent in all quality avail graphs and reports.The lack of adequate documentation on policy and procedure for the various measures makes it difficult to accurately assess whether Nightingale Community Hospital is in complete compliance with the Joint Commissions standards. The tincture for the team members responsible for ensuring accurate data is collected for the Joint Commissions early audit, is to work a spreadsheet listing the Priority Focus Areas as wel l as the Elements of Performance. The spreadsheet should reflect which EPs require documentation and which require a Measure of Success as well as the Scoring family of each.The spreadsheet will help keep the data unionized and the team members can quickly see what information is missing. Staying organized and thoroughly researching each performance measurement will help ensure a undefeated Joint Commission compliance audit. Running Head INFORMATION MANAGEMENT AUDIT 5 References The Joint Commission. (2012). The Joint Commission Comprehensive Accreditation and Certification Manual. Retrieved from https//e-dition. jcrinc. com/MainContent. aspx. Running Head INFORMATION MANAGEMENT AUDIT 6Hospitalaccreditation,Hospital,JointCommission,Healthcarequality,Internationalhealthcareaccreditation,TheComplianceTeam,Healthcare,MedicalrecordRunning Head INFORMATION MANAGEMENT AUDIT 1 Executive Summary Nightingale Community Hospital is preparing for a Joint Commission on Accreditation of Healthc are Organizations, or JCAHO, audit. In preparation of the coming audit, Nightingale has released JCAHOs 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 patients health care information. The patients health record includes all information about the patient, the health care the patient has received, and all practitioners notes pertaining to the patients care. Compliance in Information Management ensures that the hospital maintains a high quality of patient care. Information management, as outlined by JCAHO, includes three Joint Commission Standards in the audit. The ? rst standard, IM. 02. 02. 01, which encompasses whether the hospital manages the collection of information effectiv ely.The standard includes three Elements of Performance, or EPs. The three EPs include whether the hospital uses standardized and uniform data sets to collect information, whether the hospital uses standard, consistent terminology, abbreviations, symbols and whether the hospital follows a policy of prohibited abbreviations, symbols, and dose designations among other performance measures (The Joint Commission, 2012). Upon review of the ? rst EP as well as the reports and documentation provided by Nightingale Community Hospital, the Admission Orders form allows for consistent, pertinent patient information to be collected to ensure optimal ontinuum of care for patients. The form should be reviewed on a regular basis to ensure that critical data points are included in the data Running Head INFORMATION MANAGEMENT AUDIT 2 collection process and to include updated requirements. One piece of critical information that should be included on all Admission Orders is the admitting diagnosis. Th e forms also include pre-checked consultations and orders which may not apply to every patient who is admitted this check marks in the boxes will need to be removed. In accordance with the second EP, the hospital uses standard terminology, de? itions, abbreviations, acronyms, symbols, and dose designations on the forms that have been provided (The Joint Commission, 2012). The third EP, which addresses whether Nightingale Community Hospital follows a list of prohibited abbreviations, is not in compliance with the Joint Commissions standards. The graph on page three of the National Patient Safety Goal Data Information Management report, shows the incidence of using prohibited abbreviations was not within acceptable thresholds for January or December the goal for compliance is 99. 6%.To achieve compliance with the Joint Commission, the organization must not have more than 2 occurrences of non-compliance. The organization improved by eliminating the use of three abbreviations qd, x3d, a nd sc. The organizations graph shows that in January the abbreviation, u, was used 17% of the time and in December was used 63% which is an increase of 46%. To be in compliance with the hospitals benchmark, the occurrences must be at or below the error threshold of . 04%. To accomplish the task, the organization will need to implement a corrective action plan.To begin, the organization will need to appoint an Information Management compliance team. The compliance teams primary responsibilities should be limited to auditing the non-compliant records to determine trends in usage of prohibited abbreviations. When the audit is complete, the results will determine the source of the usage of prohibited abbreviations. The possibility of a speci? c department or an individual within a department making the error will be reviewed. After identifying the cause of the increase in abbreviation errors, the team will make aRunning Head INFORMATION MANAGEMENT AUDIT 3 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 Hospitals and The Joint Commissions standards are met on a consistent basis. The next priority focus area is RC. 1. 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 Commissions standards in this priority focus area. The ? nal priority focus area, RC. 01. 04. 01, which ensures that the hospital audits their medical records, has three signi? cantly more det ailed 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 than every three months. 3. The medical record delinquency rate averaged from the last four quarterly measurements is 50% or less of the average monthly discharge (AMD) rate. Each individual quarterly measurement is no greater than 50% of the AMD rate (The Joint Commission, 2012).The organization appears to be compliant with all three of the EPs. However, the organization fails to provide documentation to reflect the interval in which audits are performed Running Head INFORMATION MANAGEMENT AUDIT 4 on the medical records. The medical record delinquency rate also needs to be documented and graphed along with other measures of delinqu ency. The current graph outlining patient identification documentation errors shows data for two different years. Audit data needs to be consistent in all quality improvement graphs and reports.The lack of adequate documentation on policy and procedure for the various measures makes it difficult to accurately assess whether Nightingale Community Hospital is in complete compliance with the Joint Commissions standards. The suggestion for the team members responsible for ensuring accurate data is collected for the Joint Commissions future audit, is to create a spreadsheet listing the Priority Focus Areas as well as the Elements of Performance. The spreadsheet should reflect which EPs require documentation and which require a Measure of Success as well as the Scoring Category of each.The spreadsheet will help keep the data organized and the team members can quickly see what information is missing. Staying organized and thoroughly researching each performance measurement will help ensure a successful Joint Commission compliance audit. Running Head INFORMATION MANAGEMENT AUDIT 5References The Joint Commission. (2012). The Joint Commission Comprehensive Accreditation and Certification Manual. Retrieved from https//e-dition. jcrinc. com/MainContent. aspx. Running Head INFORMATION MANAGEMENT AUDIT 6