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ASSIGNMENT: Prepare for Joint Commission  CAHIIM Competency: Interpret health information standards

You are the Health Information Director of a hospital, and your hospital has hired a consultant to help determine major issues with the hospital’s information technology. The consultant submitted the following report:

City Hospital has a variety of hardware and software that is used in its departments. Computer workstations are widely used across the organization, but in many departments the computer workstations are too old to provide an adequate platform for the later versions of software that would most effectively support departmental reporting responsibilities.

There is no organization-wide network in place. Software applications and versions are not standardized across the organization, and so members of different departments cannot share data and information in electronic formats. This forces members of the organization to duplicate report generation efforts when reports contain the same or similar data.

An office suite application available to users on a local­ area network could help solve this problem. The absence of a local­ area network and an administrative database accessible to department managers means that reports must be prepared in the generating department, output on paper, and then input again in administrative departments to be utilized in administrative applications. An administrative database served by a network to all departments would require data to be gathered only once and then would be made available for subsequent users and purposes without reprocessing.

All of the logs that the organization currently generates, many of which are on an hourly or daily basis, could be more effectively administered and accessed if they were in electronic formats. In addition, interviews with data users state that even with the existing software, they had not been trained well enough to use it.

You are now preparing for a Joint Commission visit that will be in about 6 months. Here are the Joint Commission standards that you are concerned about:

  • IM. 01.01.01 The [healthcare organization] plans for managing information.
  • IM. 01.01.03 The [healthcare organization] plans for continuity of its information management processes.
  • IM. 02.01.01 The [healthcare organization] protects the privacy of health information.
  • IM. 02.02.01 The [healthcare organization] effectively manages the collection of health information and retrieves, disseminates, and transmits health information in usable formats.
  • IM. 04.01.01 The organization maintains accurate health information.

INSTRUCTIONS: You need to prepare a memo for the CEO to tell him what you recommend be done before the visit. Tell the CEO why you are concerned about the findings. At the end of your memorandum to the CEO (as an annex, or table), create a table to map each concern to the related standard to show your interpretation of each of the standards that are not being met. Match the appropriate Joint Commission standard listed above to the each of the consultant’s findings. 

Prepare you memo as if you were working at the hospital.  The format should look like you are the HIM Director, addressing the Hospital CEO.  It does not have to be in APA format, but you must list your references in APA format at the very end, as it is an academic assignment.

PLEASE NOTE:  You will have to do research to determine the intricacies of each standard listed above, in order to complete the third column.  Here is one sample site to get you started https://foh.psc.gov/tjc/im/standards.pdf

Here is a sample of a table to get you started:

ISSUE

JOINT COMMISSION STANDARD

IMPORTANCE/ JOINT COMMISSION CRITERIA

Computer workstations are too old to provide an adequate platform for the later versions of software

IM.01.01.01  The organization plans for managing information

 

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