Final Project 1
HIM 440 Final Project
Southern New Hampshire University
HIM-440: Management of Health Information Services
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
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comply with 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
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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 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. bb
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
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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
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
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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
between departmental and
organizational staff members
• Existence of family culture that
contributes to staff longevity
Weaknesses
• 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
Threats
• Low level of productivity
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Hickman
• Rise in AHIMA-credentialed
employees in HIM department
• Better automation
• 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
• Better compliance
• Enhanced productivity by leveraging
innovation
Threats
• 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,
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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. 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
Final Project 9
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 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
Final Project 10
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. bb
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
Final Project 11
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
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
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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. bb
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. bb
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.
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
Final Project 13
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 replacedbb 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 complianceb needs can be ensured.
Final Project 14
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 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
3
get the opportunity to share their input and 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
4
process, an integrated training program has been designed that can help to address the
existing issues and gaps.
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