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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).
Accreditation Standards
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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. f f
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
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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. f f 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.
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. f
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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.
