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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 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. m m
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
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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. m m m
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. m
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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.
