Assignment 1
Because performance improvement activities are information intensive, organizations must provide the
proper resources and systems to support improvements. It’s important to recognize that PI programs
need to meet accreditation standards such as The Joint Commission and Medicare and Medicaid
Conditions of Participation, which require access to national comparative data collections. This
assignment, based on a textbook case study, will help students to understand Joint Commission
information management standards by analyzing how a scenario relates to those standards.
Instructions
Your assignment will focus on the Case study at the end of Chapter 17, addressing quality and
timeliness of documentation. After reading Chapter 17 and the Case Study, please complete the
tasks at the end of the case study:
Review the collected data
Assign the appropriate quality code using the key provided in figure 17.6 “Data for timeliness of
documentation study.”
Analyze the data:
o
Which code is most common?
o
Is there one service that seems to be a problem?
o
What can you conclude from the data?
Establish a plan. Summarize how you propose to fix the problem.
Your submission should be a minimum of two pages of content.
Be sure to fully address each of the questions in the assignment. If you use outside research, list
your references in proper APA style.
During the last accreditation survey, a hospital had findings related to quality and timeliness of documentation. The facility is due for another survey very soon. To ensure that the hospital is in compliance with the Joint Commission documentation standards, you need to conduct a quality audit. This audit should carefully assess documentation compliance for history and physicals (H&Ps) and operative reports (Ops). A history and physical report must be available in the patient’s health record before any surgical procedure can begin. The H&P can be completed up to 30 days prior to the procedure as long as the surgeon updates any information prior to starting the procedure. The Op must be dictated by the surgeon within 24 hours of the procedure to be compliant. You have assigned one of your staff to collect data from patient records to accomplish this task. The staff member collected data for the month of December for quality and timeliness of documentation. The data collected are presented in figure 17.6.
Case Study Tasks
1. Review the collected data.
2. Assign the appropriate quality code using the key located at the bottom of figure 17.6.
3. Analyze the data:
a. Which code is most common?
b. Is there one service that seems to be a problem?
c. What can you conclude from the data about compliance with documentation standards?
4. What measures do you need to implement to correct any documentation compliance issues?
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