Nightingale Community Hospital Jcaho Audit Preparation: Information Management

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Running Head: INFORMATION MANAGEMENT AUDIT 1

Executive Summary

Nightingale Community Hospital is preparing for a Joint Commission on Accreditation of

Healthcare Organizations, or JCAHO, audit. In preparation of the coming audit, Nightingale has released JCAHO’s Priority Focus Areas for the hospital. The priority focus areas outlined are Information Management, Medication Management, Communication, and Infection Control. The area of focus for this assessment will be Information Management. Information management is one of the most important systems in health care. Maintaining a complete and accurate record of the patient’s health care information. The patient’s health record includes all information about the patient, the health care the patient has received, and all practitioner’s notes pertaining to the patient’s care. Compliance in Information Management ensures that the hospital maintains a high quality of patient care.

Information management, as outlined by JCAHO, includes three Joint Commission

Standards in the audit. The first standard, IM.02.02.01, which encompasses whether the hospital manages the collection of information effectively. The standard includes three Elements of Performance, or EPs. The three EPs include whether the hospital uses standardized and uniform data sets to collect information, whether the hospital uses standard, consistent terminology, abbreviations, symbols and whether the hospital follows a policy of prohibited abbreviations, symbols, and dose designations among other performance measures (The Joint Commission, 2012).

Upon review of the first EP as well as the reports and documentation provided by

Nightingale Community Hospital, the Admission Orders form allows for consistent, pertinent patient information to be collected to ensure optimal continuum of care for patients. The form should be reviewed on a regular basis to ensure that critical data points are included in the data

Running Head: INFORMATION MANAGEMENT AUDIT 2

collection process and to include updated requirements. One piece of critical information that should be included on all Admission Orders is the admitting diagnosis. The forms also include pre-checked consultations and orders which may not apply to every patient who is admitted; this check marks in the boxes will need to be removed. In accordance with the second EP, the hospital uses standard terminology, definitions, abbreviations, acronyms, symbols, and dose designations on the forms that have been provided (The Joint Commission, 2012).

The third EP, which addresses whether Nightingale Community Hospital follows a list of

prohibited abbreviations, is not in compliance with the Joint Commission’s standards. The graph on page three of the National Patient Safety Goal Data: Information Management report, shows the incidence of using prohibited abbreviations was not within acceptable thresholds for January or December; the goal for compliance is 99.6%. To achieve compliance with the Joint Commission, the organization must not have more than 2 occurrences of non-compliance. The organization improved by eliminating the use of three abbreviations; qd, x3d, and sc. The organization’s graph shows that in January the abbreviation, u, was used 17% of the time and in December was used 63% which is an increase of 46%. To be in compliance with the hospital’s benchmark, the occurrences must be at or below the error threshold of .04%.

To accomplish the task, the organization will need to implement a corrective action plan.

To begin, the organization will need to appoint an Information Management compliance team. The compliance team’s primary responsibilities should be limited to auditing the non-compliant records to determine trends in usage of prohibited abbreviations. When the audit is complete, the results will determine the source of the usage of prohibited abbreviations. The possibility of a specific department or an individual...
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