Complete Phase III of semester project.

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Group3PhaseIIResidenctProjectInfoGovernanceMain.docx

RUNNING HEAD: Phase II Group 3 Project City General Hospital

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Phase II Group 3 Project City General Hospital

ITS 833- Information Governance

Fall 2018 – MAIN Term

Phase II Group 3 project Fall 2018 ITS 833

Yaswanth Kumar Asam

Dinesh Reddy Teegala

Bharath Kumar lagishetti

Pradeep Kumar Chilukury

Goutham Mohanarangan

Chaitanya P Gullapalli

University of the Cumberlands

Contents Introduction 3 1.0 Hospital Records 3 1.1 Identify Departments 4 1.2 Descriptive Names for Each Record Type 5 1.3 Develop Record Inventory 7 1.4 SECURITY DEPARTMENT 10 1.4.1 FOOD SERVICE DEPARTMENT 11 1.4.2 PURCHASING DEPARTMENT 13 1.5 Rationale for the Questions 13 1.6 INTERVIEW QUESTIONS 14 1.7 Retention Policy and Compliance 15 2.0 CONCLUSION 16 REFERENCES 17

Introduction

The City General Hospital has in many ways employed a number of strategies in various departments all to ensure a success in the better handling of patients and other clients in the process of operations. City general hospital just like any other relevant firm has had a number of challenges, but that cannot pin down the successes more so in line with skills advancements and employing of the most relevant methods for handling patients. Whatever the case, doctor's facility security is being evaluated with more noteworthy concern and in more detail than any time in recent memory. A principle assessor must be recognized, will's identity in charge of giving responses to every one of the inquiries in the overview. The fundamental assessor ought to have an essential comprehension of the office's general administration and its framework

1.0 Hospital Records

a)

As a team we decided to choose the below three functional areas for the research city general hospital record inventory phase.

1. Security

2. Food services

3. Purchasing for non-surgical equipment and supplies

b)

1.1 Identify Departments

We decided to choose the below sub departments for our research surveys and the interview process.

1. Hospital security department: Security is one of the key functional areas in a clinical setting and as a scope of this research paper we will discuss about the Record Management, Security Framework and how a standardized approach can identify physical and e-security risks. Additionally, we will talk about prevention and mitigation for internal and external threats.

2. Food services: Department main focus is to access the Patients Characteristics Record to Manage the Patient nutrition, dietary, disease and health records. Characteristics of Patients records will have primary information of the patient as Gender, Age, Ethnicity, Length of Stay and Living Arrangement.

3. Buying for non-surgical equipment and supplies department: Purchasing for non-surgical equipment’s. The purchasing department has a record of all the finances. The cost for the list of non-surgical equipment’s and supplies to be purchased, estimate received from suppliers and order reports.

c)

1.2 Descriptive Names for Each Record Type

We decided to choose the below assumptions for our research on records inventory for City General Hospital. The below table illustrates the record type, responsible department and the events which triggers to the below events are explained based on our assumptions towards the project.

RECORD TYPE

RESPONSIBLE DEPARTMENT

EVENTS

Information that can be kept under the security departments includes Information about physical security, information about mobile device policy, information about staff members, information about the network

Security department

Patience safety, the privacy of hospital data, the staff members working in a hospital.

Information that can be kept about the catering department information about staff schedule, information about a public health inspection report, equipment records, month-end data charge report (2013, International Survey).

Catering Department

Allocation of staff, Patience health of food given, inspection of the kitchen, hygiene, purchase of catering tools and equipment’s, maintenances of the materials.

Information that can be kept about the maintenance, Purchase department purchase order report, information about purchase requisition reports, receiving reports, request for proposal documents.

Purchasing and supplies department

Orders to be made, equipment’s to be purchased, financed to be used for purchasing, the material’s received from suppliers, the proposal received from defending departments

Record Type

Responsible Department

Event

Retention Period

Security Records

Includes: Patient record

Visitor Record

Employee Schedule

Physical Access Management Device Access Management

Security Department

Patient Admission/Discharge

Hiring/Termination

E+30

Food Records Includes:

Diet Manual Record

Patient Diet History Record

Dietary Restriction Record

Patient Menu Record

Patient Allergy Record

Budget Record

Staff Schedule Record

Health Inspection Report Record

Food Services

Patient Admission/Discharge

Dietary food

7 Years

Non-surgical equipment’s

Record Includes:

Purchase Records

Equipment records

Supplies records

Marketing records

Administration

Department

d)

1.3 Develop Record Inventory

Based on our assumptions for our scenarios we created the below Inventory survey form for which it contains all the crucial data which needs to be addressed for the survey to be conducted. It has in-depth options and detailed list for users to list all the necessary fields required for each associated functionality.

Security department form:

HOSPITAL SECURITY DEPARTMENT FORM

1. DEPARTMENT / SECTION / UNIT

     

2. LOCATION OF RECORDS/DIRECTORY NAME

     

3. NAME AND TITLE OF PERSON RESPONSIBLE FOR MAINTAINING RECORDS

     

4. TELEPHONE

     

RECORDS IDENTIFICATION

5. KINDS OF RECORDS

|_|PHYSICAL SECURITY      

|_|MOBILE POLICY      

|_|STAFF REPORT      

|_|NETWORK REPORT      

|_|FINANCIL REPORT      

|_|PURCHASES REPORT      

|_|OTHER      

6. ARRANGEMENT

|_|ALPHABETICAL |_|ALPHA-NUMERIC

|_|SUBJECT |_|CHRONOLOGICAL

|_|NUMERIC |_|OTHER      

|_|GEOGRAPHICAL

7. STORAGE

|_|FILING CABINET |_|BOXED

|_|ROLLED/FLAT |_|SHELVING

|_|NETWORK |_|OUTLOOK

|_|FILENET |_|PST

|_|OTHER

8. APPLICATIONS USED TO CREATE RECORDS

|_|BOX |_|LIBRIS

|_|WORK FRONT |_|M-FILES

|_|WIDEN COLLECTIVE |_|DOCUFACE

|_|EFILE CABINET |_|HOT DOCS

|_|OTHER

9. WHICH OTHER DEPARTMENT ACCESS THE RECORDS

|_| FINANCE DEPARTMENT

|_| MARKETING DEPARTMENT

|_| PURCHASING DEPARTMENT

|_| STORE DEPARTMENT

|_|OTHER      

10. HOW OFTEN ARE RECORDS CREATED?

FREQUENCY      

(Monthly, yearly, other)

11. IS THE RECORD INFORMATION VITAL?

|_|YES |_|NO

12. WHEN WAS THE INFORMATION LAST CHANGED

DATE CHANGED      

13. IS THERE ANY OTHER FORMS OF RECORDS?

     

HOSPITAL CATERING DEPARTMENT FORM

1. DEPARTMENT / SECTION / UNIT

     

1. LOCATION OF RECORDS/DIRECTORY NAME

     

2. NAME AND TITLE OF PERSON RESPONSIBLE FOR MAINTAINING RECORDS

     

3. TELEPHONE

     

Catering department form

RECORDS IDENTIFICATION

4. KINDS OF RECORDS

|_| STAFF SCHEDULE      

|_| PUBLIC HEALTH INSPECTION      

|_| EQUIPMENTS RECORDS      

|_| MOTH END DATACHARGE      

|_| FINANCIL REPORT      

|_| PURCHASES REPORT      

|_|OTHER      

5. ARRANGEMENT

|_|ALPHABETICAL |_|ALPHA-NUMERIC

|_|SUBJECT |_|CHRONOLOGICAL

|_|NUMERIC |_|OTHER      

|_|GEOGRAPHICAL

6. STORAGE

|_|FILING CABINET |_|BOXED

|_|ROLLED/FLAT |_|SHELVING

|_|NETWORK |_|OUTLOOK

|_|FILENET |_|PST

|_|OTHER

7. APPLICATIONS USED TO CREATE RECORDS

|_|BOX |_|LIBRIS

|_|WORK FRONT |_|M-FILES

|_|WIDEN COLLECTIVE |_|DOCUFACE

|_|EFILE CABINET |_|HOT DOCS

|_|OTHER

8. WHICH OTHER DEPARTMENT ACCESS THE RECORDS

|_| FINANCE DEPARTMENT

|_| MARKETING DEPARTMENT

|_| ICT DEPARTMENT

|_| SECURITY DEPARTMENT

|_|OTHER      

9. HOW OFTEN ARE RECORDS BEING CREATED?

FREQUENCY      

(Monthly, yearly, other)

10. IS THE RECORD INFORMATION VITAL?

|_|YES |_|NO

11. When Was The Information Last Changed

DATE CHANGED      

12. Is There Any Other Forms of Records?

     

Purchasing and supply department form

HOSPITAL PURCHASING AND SUPPLY DEPARTMENT FORM

1. DEPARTMENT / SECTION / UNIT

     

2. LOCATION OF RECORDS/DIRECTORY NAME

     

3. NAME AND TITLE OF PERSON RESPONSIBLE FOR MAINTAINING RECORDS

     

4. TELEPHONE

     

5. KINDS OF RECORDS

|_| PURCHASE ORDER      

|_| PURCHASE REQUISITION      

|_| EQUIPMENTS RECORDS      

|_| REQUEST FOR PROPOSAL      

|_| RECEIVING REPORT      

|_| PURCHASES REPORT      

|_|OTHER      

6. ARRANGEMENT

|_|ALPHABETICAL |_|ALPHA-NUMERIC

|_|SUBJECT |_|CHRONOLOGICAL

|_|NUMERIC |_|OTHER      

|_|GEOGRAPHICAL

7. STORAGE

|_|FILING CABINET |_|BOXED

|_|ROLLED/FLAT |_|SHELVING

|_|NETWORK |_|OUTLOOK

|_|FILENET |_|PST

|_|OTHER

8. APPLICATIONS USED TO CREATE RECORDS

|_|BOX |_|LIBRIS

|_|WORK FRONT |_|M-FILES

|_|WIDEN COLLECTIVE |_|DOCUFACE

|_|EFILE CABINET |_|HOT DOCS

|_|OTHER

9. WHICH OTHER DEPARTMENT ACCESS THE RECORDS

|_| FINANCE DEPARTMENT

|_| MARKETING DEPARTMENT

|_| PURCHASING DEPARTMENT

|_| SECURITY DEPARTMENT

|_|OTHER      

10. HOW OFTEN ARE RECORDS BEING CREATED?

FREQUENCY      

(Monthly, yearly, other)

11. IS THE RECORD INFORMATION VITAL

|_|YES |_|NO

12. WHEN WAS THE INFORMATION LAST CHANGED

DATE CHANGED      

13. IS THERE ANY OTHER FORMS OF RECORDS?

     

Records Identification

E)

1.4 Security Department

The person to receive the survey form in the security department is ICT security officer and security guard it security officer is in charged with their concern security of the hospital devices which includes computers information, data, mobile devices used, laptops tablets. Which are used in the hospital he or she is the one to determine the protocol that under which all the tools will be used ensuring the hospital network is secured from unauthorized access to the hospital facilities,developing a security policy, access levels, providing user manuals, implement the passwords policies, firewalls. This will assist to identify the records that can be obtained, such as network report and mobile policy while security guard on the other side ensures that the hospital is safe for the patients by also providing a welcoming environment to the visitors and even to the staff members. They are also responsible for the protection of valuable hospital equipment’s and buildings, and their primary duties include patrolling, controlling traffic within the hospital.respond to any incident, control time in and time out for the visitors in the hospital and also set up and monitor the CCTV equipment’s this will assist in the creation of physical security report.

1.4.1 Food Service Department

Food Service Department: The management is responsible for Managing the Diet Manual Record, Patient Diet History Record, Dietary Restriction Record, Patient Menu Record, Patient Allergy Record, Budget Record, Staff Schedule Record, Health Inspection Report Record and food service activities being carried out.

Chart: Hospital Food Service Quality Model

The manager is responsible in ensuring the all the services in the catering department meets the health’s and safety standards for consumption by patients, he prepares a menu for the standard nutrition and the medical requirements for the food such as free gluten low fat and vegetarians. Food service department manages the staff schedule and regular diet menu and also responsible to deal with the commercial records to ensure enough budget to maintain the department. Food Service dept will assist in various records such as budget, staff schedule, and health inspection report.

1.4.2 Purchasing Department

Purchasing manager –this is because of the duties performed by the purchasing manager which includes the maintenance of the records of good that are being received in the hospital and those which have been ordered. He or she is also able to locate the vendors who will be able to supply the equipment’s and the supplies and control the budget of the purchasing department. He even ready to policies procedures for a contract in the purchasing department this will be able to create records such as purchases orders, purchases requisition, request for proposal document from various departments.

f)

1.5 Rationale for The Questions

Kinds of record, this question will help us regarding identifying all the files that are available in that department. Arrangement this will assist in the identification of the type of agreement at which their records are being organised in their location this is important for the proper place of any files at any given time. Storage this is where they will be able to store all the data after completion it helps in determining how to ease a document can be retrieved or created in a hospital facility. What applications are being used this will helps regarding ease of operation, processes and the procedures needed for timely devil very of reports in a hospital. Another department access the records this will maintains regarding identifying the flow of information across different departments for the proper generation of reports. How often are is information being created this will determine the frequency at which reports, or recourse are generated such as weekly, monthly or yearly?

g)

1.6 Interview Questions

General Questions:

1. What your department?

A.

Security department

B.

finance department

C.

Catering Department

Others      

2. What records do you have in your department?

A.

Security records

B.

finance records

C.

Staff scheduling records

D.

equipment’s records

E.

Finance Catering records

F.

Purchasing records

Others      

3. How do you arrange your department’s records?

A.

Alphabetical

B.

Subject

C.

Numerical

D.

alphanumeric

Others      

4. How do you store your department’s records?

A.

In a filing cabinet

B.

In a network

C.

In a shelve

D.

In an outlook

Others      

5. What application do you characteristically used in your department records?

specify them

     

6. How often do you create reports?

A.

Daily Basis

B.

Weekly basis

C.

Monthly basis

D.

Yearly basis

For Security Department:

· What are the Encryption standards followed?

· How backup we have onsite and off-site (Cloud)?

· What is the SLA for record availability on cloud?

· What is the disaster recover policy?

· What are the risk mitigation strategies we have in place right now?

For Food Services:

· What is the level of access for chefs and kitchen managers?

· Do suppliers send an electronic bill?

· How are paper and electronic bills managed in a single system?

· What is the training procedure for food services staff?

· Are there any individual tools and applications used by your department outside of organizational architecture?

Purchasing of non-surgical equipment:

· How much are the office supplies records are intertwined with lab equipment and room equipment?

· How are maintenance records managed?

· What events are triggered when a new equipment is bought?

h)

1.7 Retention Policy and Compliance

Type of Record

Legal and recommended retention periods

Patient Records

Though HIPAA says that Retention period of patient records should be at least 6 years from date of discharge it can vary from state to state. Kentucky rule says that “5 years from date of discharge or 3 years after the patient reaches the age of majority (i.e., until patient turns 21) whichever is longer.”

902 Ky. Admin. Regs. 20:016 (2007).

Employee records

Employee records such as hours of time they were paid should be in compliance with state laws. In kentucky the law requires the HR to keep the records for 1 year from the date of termination

Ky. Rev. Stat. Ann. § 337.320

Administration records

General hospital records retention compliance varies widely. But the usual recommended period is 6+ years. In case of false claims, malpractices the administration records will be subjected to other compliance laws which may require them to retain longer periods than usual.

Laboratory administration records

Laboratory records that include maintenance records, quality inspection records etc. are required to be retained for 1 year but the usual recommended is 21 years.

Laboratory clinical records

For the lab clinical records, the recommended retention policy is 25 years.

Purchase order records

For the purchase and supply orders it the recommended retention period is 15 years from the date of getting the order.

As for the record destruction, time-based destruction is suitable only for the non-vital records that does not have fall under legal compliance. As for the requested records deletions it can be done at a scheduled time of a day and clear the cache. For other vital records that are kept for a long period of time it can be moved to an archive where it is not necessary to retrieve them instantly and destroyed after certain period of time.

2.0 Conclusion

For the proper care requires an effective, efficient and sustainable flow of activities within the hospital premised different departments must ensure the useful recording of all the activities that are being done on each of the departments; these provide more secure and welcoming environment for the patient, visitors and the staff thus heath life.

References

Hayride, K., Saranto, K., & Nykänen, P. (2008). Definition, structure, content, use and impacts of electronic health records: a review of the research literature. International journal of medical informatics77(5), 291-304.

Fernández-Alemán, J. L., Señor, I. C., Lozoya, P. Á. O., & Toval, A. (2013). Security and privacy in electronic health records: A systematic literature review. Journal of biomedical informatics46(3), 541-562.

Wilson, M., Murray, A. E., Black, M. A., & McDowell, D. A. (1997). The implementation of hazard analysis and critical control points in hospital catering. Managing Service Quality: An International Journal7(3), 150-156.

Barnum, H., & Kutzin, J. (1993). Public hospitals in developing countries: resource use, cost, financing. Johns Hopkins University Press.

Suchman, L. A. (1983). Office procedure as practical action: models of work and system design. ACM Transactions on Information Systems (TOIS)1(4), 320-328.

(2007). Retrieved from https://www.healthit.gov/sites/default/files/appa7-1.pdf

Retrieved from http://www.lrc.ky.gov/statutes/statute.aspx?id=32071

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