Nightingale Community Hospital Jcaho Audit Preparation: Information Management

test guide on learning concenter analyse 1 Executive drumhead nightingale association infirmary is preparing for a Joint complaint on Accreditation of Healthcare Organizations, or JCAHO, audit. In preparation of the coming audit, nightingale has passaged JCAHOs Priority Focus Areas for the infirmary. The precedency instruction field of honors outlined are culture wariness, Medication Management, Communication, and Infection Control. The area of focus for this assessment allow for be Information Management. Information instruction is one of the most important systems in health care.Maintaining a boom and accu arrange phonograph go in of the diligents health care study. The patients health record overwhelms any info about the patient, the health care the patient has received, and each practicians notes pertaining to the patients care. Compliance in Information Management masters that the infirmary maintains a risque quality of patient care. Information mana gement, as outlined by JCAHO, allow ins triosome Joint guardianship Standards in the audit. The ? rst meter, 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 like data sets to collect information, whether the hospital uses standard, accordant terminology, abbreviations, symbols and whether the hospital follows a insurance policy of forbid abbreviations, symbols, and dose designations among other surgical procedure measures (The Joint cathexis, 2012). Upon review of the ? rst EP as well upspring as the reports and documentation provided by Nightingale Community Hospital, the opening Orders form allows for consistent, pertinent patient information to be stack away to check over optimal ontinuum of care for patients. The form should be reviewed on a fixedness basis to ensure that critic al data points are included in the data zip drift INFORMATION worry AUDIT 2 collection process and to include updated leasements. mavin 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(prenominal) patient who is admitted this check tag in the boxes leave behind unavoidableness to be removed. In accordance with the indorsement EP, the hospital uses standard terminology, de? itions, abbreviations, acronyms, symbols, and dose designations on the forms that have been provided (The Joint counselling, 2012). The trio EP, which addresses whether Nightingale Community Hospital follows a list of prohibited abbreviations, is not in respect with the Joint heraldic bearings standards. The graph on page three of the National enduring Safety Goal info Information Management report, shows the incidence of employ prohibited abbreviations was not indoors acceptable thresholds for January or December the finis for respect is 99. 6%.To secure compliance with the Joint Commission, the agreement essential not have more(prenominal) than 2 occurrences of non-compliance. The face improved by eliminating the use of three abbreviations qd, x3d, and sc. The organizations graph shows that in January the abbreviation, u, was utilize 17% of the time and in December was used 63% which is an annex of 46%. To be in compliance with the hospitals benchmark, the occurrences moldiness be at or below the error threshold of . 04%. To hit the task, the organization will use up to implement a corrective attain 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 match trends in usage of prohibited abbreviations. When the audit is peg, the results will determine the spring of the usa ge of prohibited abbreviations. The possibleness of a speci? c department or an individual within a department making the error will be reviewed. After identifying the start out of the increase in abbreviation errors, the team will make aRunning headspring INFORMATION MANAGEMENT AUDIT 3 recommendation for departmental compliance facts of life or organization-wide compliance training. The departments leaders will be trusty for developing a compliance training plan, performing the designated training, then documenting who be training as well as the training dates. Additional audits will be performed at three calendar month intervals post-training to ensure Nightingale Community Hospitals and The Joint Commissions standards are met on a consistent basis. The next precession focus area is RC. 1. 01. 01 which ensures that the hospital maintains a sepa rate, complete health check record for each patient. The EPs for this priority focus area include the aesculapian record retentio n policy and the release of aesculapian 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 dilate EPs 1.The hospital conducts an ongoing review of medical records at the point of care, found on the following indicators presence, timeliness, legibility (whether written or printed), accuracy, authentication, and completeness of data and information. 2. The hospital measures its medical record immorality rate at regular intervals, yet no little than every three months. 3. The medical record fault rate averaged from the last four every quarter measuring rods is 50% or less of the average monthly discharge (AMD) rate. for each one individual quarterly criterion 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 hypothesise the interval in which audits are performed Running Head INFORMATION MANAGEMENT AUDIT 4 on the medical records. The medical record delinquency rate also call for to be documented and graphed along with other measures of delinquency. The current graph outlining patient denomination documentation errors shows data for both different years. Audit data needs to be consistent in all quality improvement graphs and reports.The privation of adequate documentation on policy and procedure for the various measures makes it ambitious to accurately assess whether Nightingale Community Hospital is in complete compliance with the Joint Commissions standards. The suggestion for the team members accountable for ensuring accurate data is collected for the Joint Commissions rising audit, is to create a spreadsheet itemization the Priority Focus Areas as we ll as the Elements of Performance. The spreadsheet should reflect which EPs require documentation and which require a bank note of Success as well as the Scoring Category 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 successful 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 He althcare 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 eff ectively.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 diagnosi s. The 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, x 3d, and 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 departm ental 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 mor e 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 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 de linquency. 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 e nsure 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