Health Information Standards and Regulations for Documentation
Order Description
Health informatics professionals may be responsible for managing policies and processes in order to ensure organizational readiness for accreditation, licensing, and certification processes. Knowledge of accreditation processes, and where to locate information when it is needed, is a necessary skill.

Task:
A. Discuss how Diane’s findings in the attached “Survey Readiness Scenario” illustrate deficiencies in Willow Bend Hospital’s compliance with each standard in the attached ”Joint Commission Information Standards.”

B. Recommend the steps Diane could take to address each deficiency.
1. Discuss what information Diane should gather to correct each deficiency.
2. Discuss where the needed information for each correction could be found.

C. When you use sources, include all in-text citations and references in APA format.
Survey Readiness Scenario
Diane has been the director of the Health Information Management Department at Willow Bend Hospital for several years. Diane is focused on hospital policies for information management in preparation for a Joint Commission visit. Because accreditation visits are unannounced, Diane knows all health information policies and procedures must be current and in alignment with Joint Commission standards. It has been several years since Willow Bend Hospital received a visit from the Joint Commission; in fact, it occurred when she was a new manager. At that time, she was grateful her predecessor left her with policies and processes in alignment with the standards.
However, with new information systems in place, policies need to be reviewed or revised. She had been working on them with the policy committee for the past several years as the electronic health record adoption project was ongoing, and now that she has the time to direct her focus to ensuring organizational readiness in information management, in anticipation of the next unannounced visit by the Joint Commission.
Diane’s immediate supervisor, the chief information officer (CIO), has requested a summarized plan from Diane describing the intent of each Joint Commission standard for information management. The CIO will be presenting this to the hospital Board of Directors in order to assure them Willow Bend is well-prepared for an accreditation visit.
In addition, the CIO has requested a list of policies and processes in need of Diane’s attention, and her summary as to how she will address any problem areas. Diane is reviewing current policies against the Joint Commission standards. Her recent review found several deficiencies in need of attention.
Diane located the policy addressing terminology and abbreviations, but she could not locate who is responsible for updating the list and ensuring it is disseminated to all clinical areas, posted within the electronic record system, and performed within specific time frames.
Diane needed to add staff positions to the policy which addressed the auditing process of health records. There had been discussion of including the new position of clinical documentation specialist on that committee, but it had not yet been formalized.
Diane could not locate a policy in her department addressing backup of electronic information systems. She thinks there may be one in the IT policies.
Diane’s review of release of information (ROI) policies for her department need updating to accommodate release of those documents only stored electronically.
Diane needs to check the contract language for the vendor that destroys their electronic data.

Joint Commission Information Standards
Revised 12/2010
INFORMATION MANAGEMENT
Standard IM.01.01.01 – INFORMATION MANAGEMENT PLANNING
The hospital plans for managing information.
1. The hospital identifies the internal and external information needed to provide safe, quality care.
2. The hospital identifies how data and information enter, flow within, and leave the organization.
3. The hospital uses the identified information to guide development of processes to manage information.
4. Staff and licensed independent practitioners selected by the hospital participate in the assessment, selection, integration, and use of information management systems for the delivery of care, treatment, and services.
Standard IM.01.01.03 – CONTINUITY OF INFORMATION
The hospital plans for continuity of its information management processes.
1. The hospital has a written plan for managing interruptions to its information processes (paper-based, electronic, or a mix of paper-based and electronic).
2. The hospital’s plan for managing interruptions to information processes addresses the scheduled and unscheduled interruptions of electronic information systems.
3. The hospital’s plan for managing interruptions to information processes addresses the training for staff and licensed independent practitioners on alternative procedures to follow when electronic information systems are unavailable.
4. The hospital’s plan for managing interruptions to information processes addresses the backup of electronic information systems.
5. The hospital’s plan for managing interruptions to electronic information processes is tested for effectiveness according to timeframes defined by the organization.
6. The hospital implements its plan for managing interruptions to information processes to maintain access to information needed for patient care, treatment, and services.
Standard IM.02.01.01 – PROTECTING PRIVACY OF HEALTH INFORMATION
The hospital protects the privacy of health information.
1. The hospital has a written policy addressing the privacy of health information.
2. The hospital implements its policy on the privacy of health information.
3. The hospital uses health information only for purposes permitted by law and regulation or as further limited by its policy on privacy.
4. The hospital discloses health information only as authorized by the patient or as otherwise consistent with law and regulation.
5. The hospital monitors compliance with its policy on the privacy of health
information.
Standard IM.02.01.03 – SECURITY & INTEGRITY OF INFORMATION
The hospital maintains the security and integrity of health information.
1. The hospital has a written policy that addresses the security of health information, including access, use, and disclosure.
2. The hospital has a written policy addressing the integrity of health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction.
3. The hospital has a written policy addressing the intentional destruction of health information.
4. The hospital has a written policy that defines when and by whom the removal of health information is permitted.
Note: Removal refers to those actions that place health information outside the hospital’s control.
5. The hospital protects against unauthorized access, use, and disclosure of health information.
6. The hospital protects health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction.
7. The hospital controls the intentional destruction of health information.
8. The hospital monitors compliance with its policies on the security and integrity of health information.
Standard IM.02.02.01 – COLLECTION OF HEALTH INFORMATION
The hospital effectively manages the collection of health information.
1. The hospital uses uniform data sets to standardize data collection throughout the hospital.
2. The hospital has a written policy that includes the following:
• Terminology and definitions approved for use in the hospital
• Abbreviations, acronyms, symbols, and dose designations approved for use in the hospital
• Abbreviations, acronyms, symbols, and dose designations prohibited from use in the hospital, which include the following:
U,u
IU
Q.D., QD, q.d., qd
Q.O.D., QOD, q.o.d, qod
Trailing zero (X.0 mg)
Lack of leading zero (.X mg)
MS
MSO4
MgSO4
Note: A trailing zero may be used only when required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size of lesions or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.
3. The hospital implements its policy regarding the terminology, definitions, abbreviations, acronyms, symbols, and dose designations permitted for use in the hospital and the abbreviations, acronyms, symbols, and dose designations prohibited from use in the hospital.
Note: The prohibited list applies to all orders, preprinted forms, and medication-related documentation. Medication-related documentation can be either handwritten or electronic.
Standard IM.02.02.03 – RECEIVAL AND TRANSMISSION OF HEALTH INFORMATION
The hospital retrieves, disseminates, and transmits health information in usable formats.
1. The hospital has written policies addressing data capture, display, transmission, and retention.
2. The hospital’s storage and retrieval systems make health information accessible when needed for patient care, treatment, and services.
3. The hospital disseminates data and information in useful formats within timeframes that are defined by the hospital and consistent with law and regulation.
Standard IM.03.01.01 – KNOWLEDGE-BASED RESOURCES
Knowledge-based information resources are available, current, and authoritative.
1. The hospital provides access to knowledge-based information resources 24 hours a day, 7 days a week.
2. The hospital makes cooperative or contractual arrangements with another institution(s) to provide knowledge-based information resources that are not available on site.
Standard IM.04.01.01 – ACCURACY OF HEALTH INFORMATION
The hospital maintains accurate health information.
1. The hospital has processes to check the accuracy of health information.