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5-1 Final Project Milestone Two: Process Improvement Plan
Southern New Hampshire University
HIM-440: Management of Health Information Services
July 31,2022
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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. 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
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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.
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 in the plan so that employee performance can be upgraded in the health
care setting (Tamba & Riyanto, 2020).
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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. An emergency management plan must be
introduced that can be adopted in case any contingency arises in the future. It is also extremely
critical to 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).
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 risk analysts, and compliance officers. The risk analysts will be responsible
for monitoring the established system to make sure that appropriate policies and protocols are
followed within Gateway Healthcare Systems. The compliance officials 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 to ensure that the
policies are being revised and updated as per the industry standards. d d
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
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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.
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. d d d
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.
Conclusion
A comprehensive improvement plan has been designed that can be applied in the context
of Gateway Healthcare Systems. By focusing on the identified areas, it will be possible to
improve staff productivity and establish a robust and well-functional HIM department. d
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References
Art of Communication in Project Management - PMI. PMI. (2021). Retrieved July 31, 2022,
from https://www.pmi.org/learning/library/effective-communication-better-project-
management-6480
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 July 31, 2022, from
https://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm
Joint Commission. (2018). Specifications manual for Joint Commission national quality
measures. Perinatal Care (PC)-06 version.
Henderson, J. (2017). Research in health information management: An expanding field of
enquiry. Health Information Management Journal, 46(3), 103-104.
Kalyani, C. V.(2021). The 360 Degree Appraisal: Quality Indicator For Health Care: A
Systematic Review of Quantitative Studies.
Patient Safety Systems (PS) - Joint Commission. Joint Commission. (2021). Retrieved July 31,
2022, from https://www.jointcommission.org/-/media/tjc/documents/standards/ps-
chapters/camh_04a_ps_all_current.pdf
Tamba, N., & Riyanto, S. (2020). How to Improve Performance through Training and
Development. IOSR Journal of Business and Management, 22(5), 09-15.
What is phi? HHS.gov. (2021, October 20). Retrieved July 31, 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.
