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5-1 Final Project Milestone Two: Process Improvement Plan
Southern New Hampshire University
HIM-440: Management of Health Information Services
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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
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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. 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
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manager will also play an instrumental role to ensure that the policies are being revised
and updated as per the industry standards. bb
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.
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. bb 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.
Conclusion
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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. bb
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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.
