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 the
requisite ADA guidelines as highlighted by the previous Joint Commission accreditation survey.
Final Project 3
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
PHI. Its vision is to serve the health information requirements of the local community and make
Final Project 4
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. f
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
St. Luke’s
Final Project 5
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
• Robust professional relationships
Weaknesses
• Accessibility concerns
Final Project 6
Hickman
between departmental and
organizational staff members
• Existence of family culture that
contributes to staff longevity
• 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
• Better policies on handling PHI
Threats
• Low productivity
Final Project 7
Unified HIM Department SWOT Analysis
• Better compliance
• Enhanced productivity by leveraging
innovation
• 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
manual coding books to automated processes so that the productivity of staff can get enhanced.
Final Project 8
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. 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
would ensure that the views ad opinions of every person are taken into account who interacts with
Final Project 9
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 care can be maintained (Joint Commission,
2018). Adequate training opportunities must be offered to maintain quality in the entity. f
Final Project 10
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 introduced.
Another policy that must be included is the mandatary use of latest coding procedures within the
facility.
Cultural Diversity
Final Project 11
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. f
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. f
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 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.
Final Project 12
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
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. Thesef steps must be introduced in
the new workflow of the health care facility so that proper compliance needs can be ensured.
Final Project 13
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
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 14
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 15
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 feedback on the training
3
(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.
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