Part A: DIANE’S FINDINGS

Joint Commission information standards offer general guidelines on the requirements that a hospital must fulfill for accreditation and licensing. Health informatics professional have the mandate of ensuring that their organizations have put in place policies and processes that conversant with the provisions of the joint commission information standards. This is the role that Diane has held in the Willow Bend Hospital where she has been the director of health information for several years. However, the survey in readiness of accreditation has unearthed several deficiencies in compliance with the set information standards.

For instance, we understand that Diane for updating and the list and ensure it is sent to all clinical areas.  Failure to indicate the located policy is addressing terminology and abbreviations but could not determine the person accountable to transmit information to all clinical areas fails to comply with requirement of standard receival and transmission of health information. The integrity and security of health information are also not considered by failing to identify the responsible person to disseminate information (Uselton, Kienle, Murdaugh & Coe, 2010). This implies that any person has access to health information which is not compliant with the joint commission information systems.

Diane also failed to locate a policy that addressed the backup of electronic information systems.  This deficiency fails to comply with the provision of ‘’continuity of information’’. Willow Bend Hospital should have a plan for managing interruptions to information processes addresses the backup of electronic information systems.

It is also important to note that Diane has found the need to add staff positions to the policy that sent the auditing of health records. The addition of new personnel may compromise the provisions of protecting the privacy of health information. Willow Bend hospital must have a policy that is compliance with the privacy of health information.

It is also imperative to note that the there is need to update release of information systems in her department to ensure the release of electronically stored data. This implies that Willow Bend hospital was over dependent on paper information and less retrieval of electronically stored. The hospital is known to adopt a hybrid recording systems that involve paper and electronic format. From this analysis, we can conclude that the commissions’ requirements on receive and transmission of health information has not been met at the hospital (Uselton, Kienle, Murdaugh & Coe, 2010). The hospital is required to put in place policies that make storage and retrieval of health information accessible when needed for patient care, treatment, and services.  Both paper and electronically stored data are essential for enhancing and safe patient care.

Another notable deficiency as stated by Diane is the need to check the contract language for the vendor that destroys their electronic data. This means that the issue of security and integrity of the health information must be addressed adequately. Willow Bend hospital is required to have a written policy that addresses the intentional destruction of health information. Destruction of electronic data may require outsourcing, and the vendor designated with this obligation must be of language to ensure that health information does not fall into the wrong hands.

Part B

1. INFORMATION TO GATHER FOR DEFICIENCIES

After understanding the different deficiencies in the Willow Bend’s hospital information system, it is paramount that Diane must be pro-active in fixing these shortcomings. Fixing of these shortcomings will be critical to accreditation and licensing of the hospital. For Diane to fulfill this objective, she must gather a lot of information from the joint commission of information systems and the hospital’s policy and procedure document that gives an explanation on how to handle health information.

For instance, Diane must gather enough information on the acronyms and abbreviations used in the hospital. This information is mostly stored in the organization’s electronic format, and paper documents since the hospital adopt a hybrid recording system. Joint Commission for information systems requires a hospital to have policies that ensure prompt receival and transmission of health information (Uselton, Kienle, Murdaugh & Coe, 2010). Diane must make sure that there is a person with the obligation of transmitting the acronyms to all clinical areas. Addressing the deficiency of backup of electronic information systems is critical to the accreditation of the hospital. Health information department is expected to ensure continuity of information in the health center which can be hampered by a lack of backup for electronic systems. Diane must get essential information from the IT department on how to develop policies that manage interruptions to information processes addresses the backup electronic systems.  The IT department and the provisions of the joint commission will be essential in fixing the backup issue.

The need to add staff to help in auditing of the health information is another important area of consideration. Auditing staff will assist in ensuring retention and destruction of information in agreement with provisions of the hospital policy and procedures. Nevertheless, the commission’s provisions on integrity and security of health information must be guiding principle in the staffing process. Protecting privacy of health information is critical requirement for hospitals by the commission. It is important to have policies that ensure that health information is only used for purposes permitted by law and regulation or as limited by the privacy policy of the hospital. With this information, Diane will be able to make the right staffing decisions.

2. SOURCES ON NEEDED INFORMATION

Destruction of electronic data is another area of concern, according to Diane’s checklist. The destruction of such information must be per the hospital’s policy and procedure. Diane must ensure that she gets reliable information from the policy to understand whether or not the information should be destroyed and understand the reasons for destruction (Uselton, Kienle, Murdaugh & Coe, 2010). Destruction of electronic information is either through overwriting of the disc or physical destruction of the disc.

Besides to the hospital’s policy, Diane must also get essential information from the joint commission for information systems. The provision requires that the hospital must maintain security and integrity of health information. On this note, the hospital must have a written policy addressing the intentional destruction of health information and has control over the destruction of such information. Diane must ensure that the vendor fails to understand the language through which the information scheduled for destruction is written.  This will help in sustaining the policy of security and integrity of health information. The Commission requires that a hospital must have a written policy that defines when and by whom removal of information is permitted. Protecting the privacy of health information is also critical for accreditation of the hospital. The hospital should only disclose health information only as authorized by the patients or as otherwise consistent with laws and regulations.

References

Uselton, J., Kienle, P., Murdaugh, L., & Coe, C. (2010). Assuring continuous compliance with Joint Commission standards. Bethesda, Md.: American Society of Health-System Pharmacists.

 
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