Unit 4 Assignment 1: Joint Commission Standards Case Study
For the Unit 4 Assignment 1, you will be considering accreditation bodies and how they affect healthcare and its delivery. The Joint Commission is one of healthcare’s accrediting bodies. You will consider the standards that it requires for its accreditation for a specific healthcare facility.
You are to read the case study for State Community Regional Hospital. You can find this document linked below and in Course Docs. You will also need to open up the Joint Commission standards list that is linked below and is also in Course Docs.
Imagine that you are the HIM director for a facility. Your role will be to review the findings of the consultant that visited your facility. You will then review the Joint Commission standards. List the findings of the consultant, noting the standard in violation, and share how this violation affects the department and the facility as a whole. Provide a brief summary of your findings and what improvements need to take place. Then share the focus of the improvement for the next improvement project for the department.
Unit Outcomes addressed in this assignment:
- Analyze standards and critique processes set up to meet the standards.
- Explain the performance improvement perspectives of accreditation, certification, and licensure organizations.
- Evaluate how health care policy-making both directly and indirectly impacts the national and global healthcare delivery systems.
- Perform quality assessment including quality management, data quality, and identification of best practices for health information systems.
Course outcomes assessed in this assignment:
HI230-3: Explain the principles of quality assurance in health information management.
PC-2.3: Demonstrate integrity through the application of relevant codes of conduct and social responsibility within one’s profession.
Introduction
It will be critical for you to be able to understand how accreditation, certification, and licensing standards provide a framework for establishing a level of quality and performance in a healthcare organization. For this Assignment, you will analyze a case study describing an IT evaluation for a healthcare facility. You will identify the Joint Commission standards that are in question at the facility.
Instructions
- Read the Case Study of SCR.
- Download the JC Standards.
- Create a table that lists each of the issues the consultant found at the hospital. Then, analyze each issue and decide which Joint Commission IM standard is in question. Then, in the Excerpt column, provide a short statement from the standard or intent to describe why you chose the IM Standard that you did.
Example:
Table 1: Issues and Applicable IM Standards
Issue
IM Standard
Excerpt
The department’s plan for backup procedures is not detailed.
IM.01.01.03
Note: You should have at least 10 issues presented.
- Summarize your findings in 1-2 paragraphs. Your summary should:
- describe where this hospital needs the most improvement and why.
- describe what you think the most important opportunity for improvement is.
- recommend where to focus the next performance improvement project.
