Survey Readiness in Hospitals - Case Study Example

?Survey Readiness The health sector is one of the few areas where it is prudent to manage information in the most professional manner. As such, health information policies within a health facility must be in compliance with the Joint Commission Information standards to ensure efficient management. Diane's findings after carrying out a survey to determine Willow Bend Hospital’s current state of affairs revealed certain deficiencies. Despite the fact that Willow Bend Hospital had a policy addressing terminology and abbreviations for use in the hospital, there was no one assigned to ensure that the lists were updated and disseminated to all the areas within the clinic. According to the Joint Commission Information Standards , it is required that staff chosen by the health center learn how to and actively use information management systems. These members of staff should thus be the ones to ensure that these lists are updated and disseminated. The addition of the position of the clinical documentation specialist had not been formalized, being a fundamental position that addressed the auditing process of health records. This denoted the deficiency that existed in compliance with the standards on the integrity and security of data. The health center needed to monitor its compliance with its policies related to the integrity and security of data in its possession. Diane's inability to locate the policy in her department governing the backup of electronic data depicted that the health center fell short of the Joint Commission's standards that address the continuity of information. Back up of information is necessary to prevent loss of information and should be effectively addressed through an overall organizational policy that should not only be located in the information technology department. The release of information policies within her department were also not updated depicting a deficiency in relation to the security and integrity of information section of the standards. According to the standards, it is required that the hospital maintain a documented policy that defines who within the hospital set-up is allowed to access and remove information and when specifically this should be done. It is also clear that privacy policies are in place within the hospital but fall short of the joint commission's standards of monitoring compliance. This is seen when Diane fails to locate evidence and proof of compliance that could have been evidenced by reports of any breeches and how they were handled. An organization may have clear privacy policies that are only stored on paper necessitating the need for a compliance system that would ensure that privacy concerns are handled in a proper manner. The mere fact that Diane has to investigate the types of online resources that are available to their staff denotes that there are no clear policies that govern these resources. This is in contravention with the Joint Commission's standards that require information to be managed properly. The standard on information management planning requires the health facility to identify how information flows within and leaves the organization. It also stipulates that internal and external sources of information be identified to enable the provision of safe and quality care. It also goes against the commission's requirement of knowledge based sources requiring that the health facility make contractual or cooperative arrangements with other institutions to offer knowledge-based information resources that are not within its reach. Willow bend hospital does not have an efficient system for the management of continuity of information as depicted by the case of the Locum Tenens physicians employed by the hospital from time to time. Diane was unable to locate any procedural documents that would describe how these contract physicians would manage interruptions with their information work flow if there was an unexpected power outage. The commission's standards clearly stipulate that the health care facility must have a documented plan to manage interruptions that may affect its information system by employing various methods involving paper based systems, electronic systems of a mixture of both. There is a policy within the hospital that allows patients to access information in the electronic document management system within the hospital but lacks certain specifications that allow for clarity as relates to the extent of information that they can access. This goes against the integrity and security of data stipulations of the commission which requires that the health facility have a clearly documented policy related to the security of health data including disclosure, access, and use. This section also requires that the hospital have a written policy that specifies who is authorised to remove data and when this can be done. Further, Diane needed to evaluate the turnaround time in accessing data on the electronic document management system depicting the obscure nature of the time that it takes to access information on the system. Such information should be easy to locate and Diane's need to look for the information depicts the deficiencies in relation to the receival and transmission of information standards that are required by the commission. In order to correct the deficiencies that have been encountered in the hospital’s system, certain information is required. To address the deficiency in information management and planning, Diane should identify which member of staff has been assigned to the assessment, selection, integration and use of the information management system. This will ensure that all these roles are performed within the stipulated time frames. In the event that no one has been appointed to this post then she must put in place measures to ensure that there is someone appointed to that position. To address the issues with the security and integrity of information, Diane should ensure that the position of clinical documentation specialist is introduced to allow for processes that will enable the auditing of health records within the hospital. In order to ensure the continuity of information, Diane should ensure that a policy to this effect is developed within clear guidelines on how the hospital should address its information back up requirements. These policies should also be integrated into the policies of the information and communication technology department. She should also update the release of information policies that touch on the security and integrity of information to ensure that access to information within the system is done in a systematic manner. Diane must sensitize the other members of staff on the privacy policy and its compliance section to ensure that there is a clear understanding on the nature of evidence and proof that is required to denote compliance (Berg, 2004). It is in this way that the staff will learn of the policies that are required to show if there has been a breech in the privacy policies and the different ways in which they were handled. In order to handle the deficiencies in the information management and planning, Diane needs to research and find the various categories of online resources that are available to the members of staff including any contracts that may exist. In the absence of either, she must initiate steps that enable a firm to be contracted to offer information resource services to the hospital. There has to exists a procedural document that ensures that contract physicians are able to manage interruptions to the flow of information. And because Diane could not locate such a document within the hospital, she must ensure that the facility establishes one so as to avoid loss of data in the event that an unexpected power outage occurs. Data relating to the turn-around time for accessing data kept in the electronic data management system ought be openly stated in writing to ensure that the patients are able to know how long it will take to receive a service. The policy on how much information the patients can access should also be clarified to define the extent of information that the patients can access within the system. The information that patients receive should be carefully selected to ensure that they have access to only the most relevant information (Tan, 2005). Other levels of information may be too complex or detrimental for their consumption and as such should be regulated. Information for the policy relating to the extent of information that the patients can access may be sought from the health management team within the hospital with each department stipulating what each patient can access. This can then be compiled to give the overall information of what a patient can access. Discussions can also be held with the health management team to gather information on the privacy policy and its current implementation (Tan, 2005). This will also provide a forum whereby discussions can be held on how to effectively implement this policy in relation to compliance; a concept that is often overlooked by the health management team. Physical inspection of the available online resources can be done to determine the nature of online resources that are available for use within the hospital. This will also enable the user to ascertain the suitability of the resource for the desired function. Any problems encountered in the use of the resource can also be experienced first hand in order to clearly understand the operations and initiate modifications. Market research for firms that can provide online sources of information for members within the hospital can also be done to ensure that information management within the hospital is efficient (Haux, 2004). This will ensure that only the best and most efficient companies are contracted to provide online resource services for the hospital. Small oversight and management teams can also be initiated within the hospital to oversee the operations of various sections within the hospital (Berg, 2004). This will ensure that various policies within the hospital are implemented accordingly under the supervision of these teams. Any problems with implementation and operations can also be promptly handled to ensure that the hospital handles information within the joint commission's information standards. References Berg, M. (2004). Health Information Management: Intergrating Information Technology in Health Care Work, Routledge, London.. Haux, R. (2004). Strategic Information Management in Hospitals: An Introduction to Hospital Information Systems, Springer, New York. Tan, J. (2005). E-Health Care Information Systems: An Introduction for Students and Proffessionals. John Wiley & Sons, New York. Read More