Final Project 1
HIM 440 Final Project
Southern New Hampshire University
HIM-440: Management of Health Information Services
August 8,2022
Final Project 2
Initiation and Preparation Phase
For forming Gateway Healthcare Systems, St. Catherine’s Medical Center will be
merging with Luke’s Hospital and Hickman Community Hospital. The ‘Initiation and
Preparation Phase’ phase will be highly critical so that the facilities can function in a cohesive
manner and deliver quality services to the general public. While working on the phase, some of
the key elements that have been taken into consideration include the issues that could arise for
the HIM department, compliance concerns, cultural issues that could impact quality as well as
productivity and the mission and vision of the facilities. A detailed SWOT analysis has also been
conducted to identify the key variables that may impact the Health Information Management
department of the merged entity.
Summary
The merger of the three health care facilities into a single entity could give rise to a broad
range of issues in the HIM department. After the review of the data of St. Catherine’s Medical
Center, Luke’s Hospital and Hickman Community Hospital, some of the main issues that have
been identified are the limited staff diversity and the lack of necessary credentials of the staff.
Similarly, the department associations in some of the facilities is weak, which could adversely
affect collaboration and teamwork. The other elements that are lack within the organizations
include proper communication, training and development opportunities for the staff members,
etc.
Compliance
While merging the health care facilities together to form a single entity, a number of
compliance issues could arise. At present, compliance to relevant standards and policies is a
major source of concern. For example, the Hickman Community Hospital does not comply with
Final Project 3
the requisite ADA guidelines as highlighted by the previous Joint Commission accreditation
survey. Similarly, it does not adhere to the TJC standards concerning leadership. While merging
the facilities together, it is essential to focus on the compliance aspects so that Gateway
Healthcare Systems could function in a systematic and professional manner. The PHI must be
handled in a cautious manner so that the privacy of the patients would not get compromised.
Proper compliance with HIPAA is necessary (Nosowsky & Giordano, 2006). The leaders must
play a proactive role to ensure safe and quality care is delivered to patients and proper coding
methods are in place (Wightman, 2008).
Cultural Diversity
The cultural diversity is a vital aspect that must be given due importance while merging
the health care facilities to form a cohesive unit. At present, the cultural diversity in some of the
health care facilities is lacking. It is vital to address this imbalance by having in place a
diversified workforce. the cultural issues impacting quality and productivity. The lack of proper
cultural competence is a serious issue that could arise in the case study and affect the employees
and the organization. It is vital to focus on increasing the cultural competence of the staff
members so that they would be able to cohesively function with others (Nair & Adetayo, 2019).
Mission and Vision
The mission and vision of each of the hospital varies to a certain degree. The mission of
St. Catherine’s Medical Center is to offer correct PHI services to all patients by focusing on
concern, dignity and care. Its vision involves offering PHI to patients by focusing on privacy and
sensitivity. Luke’s Hospital’s mission is to offer providers, staff and residents, timely access to
PHI for research, treatment as well as reimbursement. Its vision revolves around state-of-the-art
technology and HIM. The mission of Hickman Community Hospital is to continuously safeguard
Final Project 4
PHI. Its vision is to serve the health information requirements of the local community and make
sure that patient information is securely handled. Even though the mission and vision of the
facilities vary, they revolve around PHI and creating value for others. a
SWOT Analysis
The SWOT analysis of each of the health care facilities has been presented below.
Emphasis has been laid on the strengths, weaknesses, opportunities, and threats that arise before
their Health Information Management departments.
St. Catherine’s
Strengths
• High emphasis is given to delivering
accurate patient health information
services to all patients
• High diversity of staff and patients
• Reputation
• Strong record of employee retention
Weaknesses
• Low level of productivity
• Limited formal health information
credentials or qualification of the long-
term employees
• Non-compliance of staff
• Application of manual coding books
Opportunities
• Upgrading staff productivity
• Enhancing the existing coding standards
as well as dictation system
• Offering new opportunities to employees
with disability or special physical needs
Threats
• Poor ability to attract talented staff as a
result of low salary level as compared to
industry standards
• Unable to capitalize on technologies since
obsolete practices are in place
Final Project 5
St. Luke’s
Strengths
• Emphasis on research, treatment, and
reimbursement areas
• Existence of credentialed HIM staff
• High patient diversity
Weaknesses
• High staff attrition
• Poor diversity of staff
• Lack of the existence of an HIM manager
or director
• Existence of obsolete EHR system
• Poor communication between EHR and
other systems
• Lack of experience of the coding manager
and poor work relationships
• Low performance expectations relating to
coding
Opportunities
• Retention of credible HIM staff for over
2 years
• Strengthening interoperability of the
innovative systems
• Proper alignment of existing processes
Threats
• Unable to retain talented staff
• Chances of poor level of productivity as a
result of high dependence on manual
practices
Hickman
Strengths
Weaknesses
Final Project 6
Hickman
• Robust professional relationships
between departmental and
organizational staff members
• Existence of family culture that
contributes to staff longevity
• Accessibility concerns
• Non-compliance with the necessary ADA
guidelines as per the last Joint Commission
accreditation survey
• Poor diversity of patients and staff
• Non-adherence to TJC standards on leadership
• Lack of HIM staff with AHIMA credentials
• Poor coding quality or quantity expectations
• Use of manual coding methods
Opportunities
• Better cultural diversity
• Rise in AHIMA-credentialed
employees in HIM department
• Better automation
Threats
• Low level of productivity
• Non-compliance leading to complications
Unified HIM Department SWOT Analysis
Strengths
• Focus on PHI
• Presence of HIM department
• Credentials of some staff members
Weaknesses
• Poor management of PHI
• Lack of professionalism of staff members
• Obsolete technological practices
Opportunities
Threats
Final Project 7
Unified HIM Department SWOT Analysis
• Better policies on handling PHI
• Better compliance
• Enhanced productivity by leveraging
innovation
• Low productivity
• Lack of ability to use new technologies
Process Improvement Plan Phase
It is essential for the Health Information Management (HIM) department of a health care
entity to have a clear vision and purpose so that it can optimally meet its information
management needs. A well-structured and coordinated HIM system can help in generating
information that can aid in the decision-making process (Henderson, 2017). In the context of the
Gateway Healthcare Systems, a process improvement plan has been devised by taking into
consideration elements like the performance measurement benchmarks, employment laws,
feedback process, leadership standards, stakeholders, new policies and procedures, training for
cultural diversity and compliance aspects.
Performance Measurement
For addressing the productivity of the staff members, a number of performance-
measurement benchmarks can be introduced in the health care facility. At present, St. Catherine’s
coding productivity standard is low. It is evident from the fact that a coder can work on only two
inpatient charts and 10 outpatient charts in an hour. Revision of the existing coding standards is
required. Current performance is reflective of ICD-9. However, it must be replaced with ICD-10
so that the quality of data can be upgraded and the efficiency of the HIM professionals can be
improved (Centers for Disease Control and Prevention, 2015). St. Luke must move away from
Final Project 8
manual coding books to automated processes so that the productivity of staff can get enhanced.
The specific project management tool that might be used for facilitating the process is a project
communication plan. It can ensure the training needs of the employees are identified and met
(Art of Communication in Project Management - PMI. PMI, 2021).
Employment Laws
The implementation of appropriate employment laws can ensure that a proper work
setting is established and the employees do not face any kind of discrimination in the health care
facility. Anti-discrimination laws need to be applied so that the staff will not face discrimination
based on their color, age, religion, gender, etc. Title VII of the Civil Rights Act of 1964 must be
followed so that all the employees as well as job applicants can be safeguarded from employment
discrimination. The Americans with Disabilities Act (ADA) must be followed so that employees
suffering from any kind of disability would be treated fairly in Gateway Healthcare Systems, and
a welcoming work environment can be created that can positively impact work performance. The
other laws that must be complied with include the Fair Labors Standards Act, Family and
Medical Leave Act, and Occupational Safety and Health Act. These laws can ensure that
employees can work in a safe and nurturing environment (The Employment Law Review: USA.
The Employment Law Review - The Law Reviews, 2021). Some of the employment laws that
must be considered while evaluating the staff performance to ensure compliance with legal
standards are the Civil Rights Act and Title VII of Equal Employment Opportunity Commission. a
These laws can ensure there is no discrimination while evaluating staff performance.
Feedback
For delivering feedback to the staff members on the basis of their performance appraisal,
the 360-degree feedback system can be introduced in the facility. Such a feedback mechanism
Final Project 9
would ensure that the views ad opinions of every person are taken into account who interacts
with an employee. Kalyani has identified a 360-degree feedback system as one of the most
powerful methods that can be used in the performance appraisal context (Kalyani, 2021). The
supervisor or manager must play a proactive role while offering feedback so that appropriate
goals could be set for employees and a robust performance improvement plan can be followed
that can help in accomplishing the individual goals and objectives. The plan must encompass
diverse elements such as the specific performance element that needs to be improved, the
availability of resources to help employees improve their performance and the alternative courses
of action in case performance goals remain unmet. Training and development details must also
be captured in the plan so that employee performance can be upgraded in the health care setting
(Tamba & Riyanto, 2020).
Accreditation Standards
The Joint Commission has introduced a number of standards that the healthcare system
needs to adhere to so that it can retain accreditation and the work staff can effectively function
and ensure safety and quality. One of the fundamental standards that must be followed is
Standard LD.04.01.10 which revolves around hospital leaders (Patient Safety Systems (PS) -
Joint Commission. Joint Commission, 2021, p . 32). It is the responsibility of the leaders to offer
insight into emergency management activities. For ensuring compliance with the leadership
standards that have been set by the Joint Commission for evaluating the effectiveness of staff for
ensuring safety and quality in the organization, an emergency management plan must be
introduced. This plan can be adopted in case any contingency arises in the future. It is also
extremely critical for leaders make sure that proper communication is in place for diverse
stakeholders such as health care staff, patients and their family members so that the quality of
Final Project 10
care can be maintained (Joint Commission, 2018). Adequate training opportunities must be
offered to maintain quality in the entity. a
Stakeholders
A diverse group of stakeholders can serve as an effective team and help in validating the
viability of strategic recommendations and addressing the identified compliance issues. These
stakeholders include the HIM manager, a compliance officer, and IT head of the healthcare
facility. The compliance official will be responsible for ensuring compliance and educating the
staff about the relevant policies and practices and the need to abide by them. The HIM manager
will also play an instrumental role as he will serve as the leader and ensure that the policies are
being revised and updated as per the industry standards. The identified stakeholders can work
cohesively to ensure they are responsible for validating the viability of strategic
recommendations for addressing the identified compliance concerns.
Policy and Procedures
In the health care setting, it is necessary to implement new policies and procedures that
can help in addressing the compliance issues that have been identified in the initiation and
preparation phase. One of the chief policies relates to the safe and secure discarding of protected
health information of the patients (What is phi? HHS.gov, 2021). Proper adherence to HIPAA
Privacy Rules is critical and the facility must be introduced suitable technical, administrative as
well as physical safeguard mechanisms so that the privacy of PHI would not get compromised
(What is phi? HHS.gov, 2021). Paper shredding machines must be introduced in every floor of
the office and the staff must be trained on how to use it so that they can discard sensitive patient
information in a secure way. Strict policies relating to maintaining PHI confidentiality must be
Final Project 11
introduced. Another policy that must be included is the mandatary use of latest coding
procedures within the facility.
Cultural Diversity
Cultural diversity training must be introduced so that a welcoming workplace can be
established. The leader must ensure that new hires feel welcomed and the existing staff act in a
respectful manner towards them. Diverse attributes relating to color, religion, gender, sexual
orientation, etc. must be respected within Gateway Healthcare Systems. Introducing training
sessions on cultural awareness is vital to foster a healthy and nurturing work setting. Employees
must be made aware of diverse cultures and how it can contribute to new ideas and better
performance in the facility. a
Compliance Issues
HIPAA compliance training must be introduced so that all employees will understand the
need to adhere to necessary policies and practices. An integrated training must be introduced so
that diverse compliance issues can be addressed effectively. The key training needs that must be
addressed are sensitive handling of PHI, professional conduct, adoption of coding methods and
better cultural intelligence of the staff. a
Change Management and Training Implementation Phase
In Gateway Healthcare Systems, it is essential to introduce the changes that have been identified
in the implementation plan. For making the successful transition, emphasis has been laid on
training the staff members so that they will be better equipped to handle the compliance
requirements and understand the relevance of cultural diversity in the work setting. While
implementing health information systems in health care settings, it is essential to acknowledge
Final Project 12
the importance of staff training (Bygholm, 2018). The training has to be aligned with the current
practices and processes in the health care context so that the workforce can be empowered to
address the existing gaps and issues (Bygholm, 2018). The training phase mainly focuses on the
compliance aspects and cultural diversity aspects that require urgent attention in Gateway
Healthcare Systems.
New Workflow
The review of St. Luke’s workflow has revealed that several manual processes are carried out
when it comes to the handling of the sensitive and confidential personal health information (PHI)
of patients. For example, loose lab reports are processed by the staff, and the reports are
discarded in dust bins. Such workflow practices increase the risks pertaining to compliance
aspects in the health care domain. In order to effectively tackle these issues, it is essential to
introduce a new workflow system within Gateway Healthcare Systems so that the existing
compliance issues and concerns can be addressed. The fundamental element that must be given
high priority in the new workflow is the proper compliance with HIPAA rules and regulations.
Similarly, compliance with HIPAA Security Rule is also vital while developing the new
workflow in the health care organization (Official 2022 HIPAA Compliance Checklist. HIPAA
Journal, 2022).
One of the fundamental elements that must be taken care of in the new workflow is the safe
handling of loose lab reports. In Step 1 of the existing workflow, the lab clerk places the reports
face up in the HIM foyer. Such a practice needs to be deterred immediately. Since the reports
contain sensitive personal health information, they must be kept in a secure shelf or folder so that
others cannot see the information contained in them. Step 2 involves the processing of the loose
lab reports by scanning them and placing them in the EHR of each patient. The clerks need to
Final Project 13
maintain a timestamp while maintaining the patient records and scanning them. A code could
also be assigned to the patient documents for simpler and systematic identification purposes. Step
3 involves the discarding of the loose lab reports of patents in a regular trash receptacle. Tin the
new workflow system, the conventional and outdated discarding approach must be replaced with
the shredding of the records so that the information cannot be used. These steps must be
introduced in the new workflow of the health care facility so that proper compliance needs can be
ensured.
New Workflow
Step 1
Placing picked lab
reports in a secure folder
or shelf
Step 2
Scanning of lab reports
and using a code to
identify the records of
each patient and placing
them in the respective
EHR
Step 3
Shredding of reports for
disposal purposes
Project management tool
Final Project 14
A professional development plan (PDP) has been developed using the Gantt chart, a useful
project management tool. The objective of choosing the specific tool is to identify the specific
activities that need to be carried out and the estimated time that would be required for attaining
the intended objective. In the context of Gateway Healthcare Systems, the use of the Gantt chart
is highly relevant since it can ensure that training is offered in a timely manner to the staff on
diverse areas, including cultural diversity as well as compliance aspects.
Final Project 15
Gantt Chart for training at Gateway Healthcare Systems
Period
Highlight:
1
Plan Duration
Actual Start
%
Complete
Activity
Project Lead
Plan
Start
Plan
Duration
Actual
Start
Actual
Duration
% Complete
Periods
Actual (beyond plan)
% Complete (beyond
plan)
1
2
3
4
5
6
7
8
9
1
0
1
1
1
2
1
3
1
4
1
5
1
6
1
7
1
8
St Catherine’s Medical Center
Assessment of cultural diversity
and compliance needs
HIM
Manager
1
1
1
2
100%
Training on cultural diversity
HIM
Manager
2
10
3
6
100%
Training on compliance aspects
HIM
Manager
9
10
7
8
100%
St Luke’s Hospital
Assessment of cultural diversity
and compliance needs
HIM
Manager
1
1
1
1
100%
Training on cultural diversity
HIM
Manager
2
10
2
7
100%
Training on compliance aspects
HIM
Manager
9
10
7
9
100%
Final Project 16
Hickman Community Hospital
Assessment of cultural diversity
and compliance needs
HIM
Manager
1
2
1
3
100%
Training on cultural diversity
HIM
Manager
2
10
4
10
100%
Training on compliance aspects
HIM
Manager
9
10
12
0
100%
1
In the Gantt Chart, the three main tasks that have been identified that need to be carried out in
each of the health care facilities include the assessment of cultural diversity and compliance
needs, training on cultural diversity and training on compliance requirements. For making a
successful transition, it is essential to complete the identified activities within the estimated
timeframe. For completing the entire project, it should take approximately 13 to 14 weeks,
provided no emergency or contingency would arise. Within this period, in each of the facilities,
the tasks should have been accomplished. For the project to be successful, the role of the HIM
manager would be instrumental.
Cultural diversity educational program
Currently, cultural diversity in the health care setting is lacking. So, it is imperative to introduce a
new hire cultural diversity education program in Gateway Healthcare Systems that is based on
the identified training needs of the staff members. A culturally competent health care facility can
enhance the quality of care that is delivered to the patients by understanding the relevance of
culture (Handtke et al., 2019). According to the Joint Commission, cultural competence is a
critical requirement that health care facilities must focus upon (Health equity. The Joint
Commission, 2021). For ensuring that Gateway Healthcare Systems demonstrates cultural
competence, a robust cultural diversity educational program has been designed and presented
below.
Cultural diversity educational program components
• Compulsory quarterly cultural diversity training for all the staff members, including new
and existing personnel.
2
• A uniformity will be maintained in terms of training standards relating to cultural diversity
in the three facilities, i.e., St. Luke’s Hospital, St Catherine’s Medical Center and Hickman
Community Hospital.
• New hires will get three months’ time to complete their cultural training
• The education program will be held using online as well as offline modes such as webinars
and on-the-job training.
• The fundamental objective of the training is to create an inclusive culture where diversity is
respected and appreciated.
• Some of the key topics that will be covered in the education program include cultural
awareness, communication across diverse cultural backgrounds, diversity, inclusion and
equity and cultural intelligence.
• Online resources and e-learning materials will be made available to the staff of the health
care facility so that cultural competence can be improved at the individual and
organizational levels.
Evaluation of the success of the training
After the training initiatives have been taken within the health care organization, it is vital to
evaluate the same to check for its effectiveness as well as success. Devi has pointed out that an
effective training initiative is one that is able to optimally address the training needs of
individuals and deliver training in accordance with the training goals and objectives (Rama &
Shaik, 2012). In the particular health care context, the fundamental objective of the training
activities is to meet the cultural diversity needs and tackle the compliance issues that exist within
the facilities. One of the main tools that will be used for the training evaluation purpose is a
survey. The staff who have received training will get the opportunity to share their input and
3
feedback on the training (Grohmann & Kauffeld, 2013). Another vital evaluation tool that will
also be used in the context of Gateway Healthcare Systems is Kirkpatrick’s Four Levels Training
Evaluation Model. It will help to capture the effectiveness of the training in an in-depth manner
by focusing on four key elements, including reaction, learning, behavior as well as results
(Alsalamah & Callinan, 2021). By using both the methods it will be possible to get a holistic
insight into the impact and overall effectiveness of the training initiatives. On the basis of the
evaluation results, it will be possible to determine whether the training activities have helped to
address the existing needs relating to cultural diversity and compliance or not.
Conclusion
For the formation of Gateway Healthcare Systems, the successful integration of St Catherine’s
Medical Center, St. Luke’s Hospital, and Hickman Community Hospital is a basic necessity. The
merger of the health care facilities into a single unit could give rise to diverse issues and
challenges relating to compliance, cultural problems, and the misalignment of mission and
visions. Such issues could adversely affect the ability of the new HIM unction to optimally
function. It is essential for the merged entity to leverage the common strengths and capitalize the
existing opportunities so that it could optimally functions and deliver value in the community
setting. By focusing on the identified areas, it will be possible to improve staff productivity and
establish a robust and well-functional HIM department. Some of the key issues that exist in each
of the health care organizations have been identified, and a suitable implementation plan has
been designed to address the same. The key issues that need to be dealt with on an urgent basis
include cultural diversity and compliance issues. For ensuring an effective change management
process, an integrated training program has been designed that can help to address the existing
issues and gaps.
4
References
Alsalamah, A., & Callinan, C. (2021). Adaptation of Kirkpatrick’s four-level model of training
criteria to evaluate training programmes for head teachers. Education Sciences, 11(3), 116.
Art of Communication in Project Management - PMI. PMI. (2021). Retrieved August 1, 2022,
from https://www.pmi.org/learning/library/effective-communication-better-project-
management-6480
Bygholm, A. (2018, January). Staff training on the use of health information systems: what do we
know?. In MIE (pp. 191-195).
Centers for Disease Control and Prevention. (2015, November 6). ICD - ICD-10-CM -
International Classification of diseases,(icd-10-CM/PCS transition. Centers for Disease
Control and Prevention. Retrieved August 1, 2022, from
https://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm
Grohmann, A., & Kauffeld, S. (2013). Evaluating training programs: development and correlates
of the Q uestionnaire for P rofessional T raining E valuation. International Journal of
Training and Development, 17(2), 135-155.
Joint Commission. (2018). Specifications manual for Joint Commission national quality
measures. Perinatal Care (PC)-06 version.
Kalyani, C. V.(2021). The 360 Degree Appraisal: Quality Indicator For Health Care: A
Systematic Review of Quantitative Studies.
5
Handtke, O., Schilgen, B., & Mösko, M. (2019, July 30). Culturally competent healthcare - A
scoping review of strategies implemented in healthcare organizations and a model of
culturally competent healthcare provision. PloS one. Retrieved August 13, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6667133/
Health equity. The Joint Commission. (2021). Retrieved August 13, 2022, from
https://www.jointcommission.org/resources/patient-safety-topics/health-
equity/#t=_Tab_StandardsFAQs&sort=relevancy
Henderson, J. (2017). Research in health information management: An expanding field of
enquiry. Health Information Management Journal, 46(3), 103-104.
Nosowsky, R., & Giordano, T. J. (2006). The Health Insurance Portability and Accountability
Act of 1996 (HIPAA) privacy rule: implications for clinical research. Annu. Rev. Med., 57,
575-590.
Nair, L., & Adetayo, O. A. (2019). Cultural competence and ethnic diversity in healthcare.
Plastic and Reconstructive Surgery Global Open, 7(5)
Official 2022 HIPAA Compliance Checklist. HIPAA Journal. (2022, June 24). Retrieved August
13, 2022, from https://www.hipaajournal.com/hipaa-compliance-checklist/
Patient Safety Systems (PS) - Joint Commission. Joint Commission. (2021). Retrieved August 1,
2022, from https://www.jointcommission.org/-/media/tjc/documents/standards/ps-
chapters/camh_04a_ps_all_current.pdf
6
Rama Devi, V., & Shaik, N. (2012). Evaluating training & development effectiveness-A
measurement model.
Tamba, N., & Riyanto, S. (2020). How to Improve Performance through Training and
Development. IOSR Journal of Business and Management, 22(5), 09-15.
The Employment Law Review: USA. The Employment Law Review - The Law Reviews. (2021).
Retrieved August 4, 2022, from https://thelawreviews.co.uk/title/the-employment-law-
review/usa#:~:text=The%20numerous%20federal%20employment%20laws,the%20Nation
al%20Labor%20Relations%20Act%20
Wightman, J. (2008). SSIS Security. Pro SQL Server 2005 Integration Services, 337-353.
What is phi? HHS.gov. (2021, October 20). Retrieved August 1, 2022, from
https://www.hhs.gov/answers/hipaa/what-is-
phi/index.html#:~:text=PHI%20stands%20for%20Protected%20Health,with%20respect%2
0to%20that%20information.
