Compliance Status of Nightingale Community Hospital: Information Management
Nightingale Community Hospital
Memo
To: From: Date: Re:
Executive Management, Nightingale Community Hospital Brittany Amon, Senior Audit Administration
September 29, 2012
Compliance Status of Nightingale Community Hospital: Information Management
The following pages will provide a summary of the current compliance status of Nightingale Community Hospital based on the Information Management Priority Focus Area. From the information provided by Nightingale Community Hospital [the hospital] or readily available to the audit team, many Joint Commission standards are not currently being met and will require corrective action prior to an audit to ensure success. The next Joint Commission visit is anticipated in 13-months, and the hospital should focus on fixing these areas before then. These three standards include multiple Elements of Performance [EPs] that the hospital should be sure are implemented within policies or procedures that are able to be referenced by the Joint Commission. These standards were chosen by the hospital as the items to be internally pre-audited because it is understood that these are key issues in the proper operation of the hospital and protection of the patient’s data: 1) IM.02.02.02 – This standard ensures the hospital is effectively managing the collection of health information. This standard was chosen for this section because this is the very start of the hospital’s responsibility to maintain accurate and secure information for a patient. The process of Information Management starts with this standard being met. 2) RC.01.01.01 – This standard ensure the hospital maintains complete and accurate medical records for each patient. This standard carries over importance from the previous mentioned standard. This ties into Information Management for the hospital because after the data is collected, the hospital must maintain it properly to be within compliance and protect their patients’ information. 3) RC.01.04.01 – This standard
Memo
To: From: Date: Re:
Executive Management, Nightingale Community Hospital Brittany Amon, Senior Audit Administration
September 29, 2012
Compliance Status of Nightingale Community Hospital: Information Management
The following pages will provide a summary of the current compliance status of Nightingale Community Hospital based on the Information Management Priority Focus Area. From the information provided by Nightingale Community Hospital [the hospital] or readily available to the audit team, many Joint Commission standards are not currently being met and will require corrective action prior to an audit to ensure success. The next Joint Commission visit is anticipated in 13-months, and the hospital should focus on fixing these areas before then. These three standards include multiple Elements of Performance [EPs] that the hospital should be sure are implemented within policies or procedures that are able to be referenced by the Joint Commission. These standards were chosen by the hospital as the items to be internally pre-audited because it is understood that these are key issues in the proper operation of the hospital and protection of the patient’s data: 1) IM.02.02.02 – This standard ensures the hospital is effectively managing the collection of health information. This standard was chosen for this section because this is the very start of the hospital’s responsibility to maintain accurate and secure information for a patient. The process of Information Management starts with this standard being met. 2) RC.01.01.01 – This standard ensure the hospital maintains complete and accurate medical records for each patient. This standard carries over importance from the previous mentioned standard. This ties into Information Management for the hospital because after the data is collected, the hospital must maintain it properly to be within compliance and protect their patients’ information. 3) RC.01.04.01 – This standard
References: The Joint Commission. (2012). Accreditation requirements. Retrieved 09 25, 2012, from The joint commision e-dition: https://e-dition.jcrinc.com/MainContent.aspx Page 5 of 5