The importance of Information Governance is being realized across all industries

The importance of Information Governance is being realized across all industries.

While some aspects of Information Governance are common to all industries, information governance cannot be applied in a “cookie-cutter” fashion. That is, there are certain characteristics or aspects of Information Governance that are unique to a given industry or discipline. And even within the same industry, a good information governance program must be tailored to fit each organization’s unique needs. The health care industry is no different.

It is undergoing comprehensive transformational change. Consequently, health care professionals are faced with new regulations and requirements that make effective information governance essential. Quick access to complete, comprehensive and accurate information is essential to the goal of healthcare services, for today and tomorrow. Healthcare providers are faced with the reality that information is a critical asset that must be managed in a way that optimizes safe, cost-effective and high quality care to the patient, while at the same time meeting the provider’s administrative and financial needs, reducing risk, and increasing availability for business needs such as analytics and for use on the health information exchange. Of course, the health care provider must do all of this while at the same time insuring that it is operating ethically, will be able to quickly and completely respond to e-discovery requests and holds, and that it is operating within the confines of both federal and state laws in all regards.

Information Governance initiates in the health care industry have been studied for more than a decade by a number of organizations and associations. A few of these organizations that have become industry leaders in advancing Information Governance in the healthcare industry in the United States over the past decade. Assume you are not a doctor and that you do not have “medical training” per se. Rather, you have a Masters’ Degree in Business Administration. In addition, you have a degree in Information Management. By coincidence, upon receiving your MBA you applied for and received a job in the records department at your local hospital. Over the years, you have advanced through the ranks, and have worked in various departments including finance, records management, billing, accounting, marketing, and IT.

Your employer, “CITY GENERAL HOSPITAL”, has no “formal” information governance program, although it has been dabbling with the idea of company-wide information governance. You have just been named Chief Financial Officer at your organization. You have agreed to chair the information governance committee that will be responsible for designing and implementing a “formal” information governance program for the organization. You have put together an Information Governance Committee (or “TEAM”) consists of representatives from health information management, (HIM), human resources, staff from the business office, accounting, risk management, legal, finance, IT, quality and compliance areas, as well as representatives from clinical areas including nursing staff as well as physicians, radiology and other diagnostic testing. Your team has had only one organizational meeting.

At that initial meeting, the team was asked to do two things. One was to identify what each team member perceives as worthy goals of the information governance program, and secondly, to identify areas that are in immediate need of improvement, from their own background and perspective. They team returned the following: The goal of the information governance program should include but not be limited to the following:

1. Developing processes to ensure better coordination of care throughout the entire organization;

2. Maintain a competitive advantage in the geographical regions served;

3. Ensuring that the organization is analytics-driven; 4. Improved performance and outcomes;

5. Becoming nimble enough to respond quickly and accurately to information requests related to patient care and diagnosis, legal holds, e-discovery and litigation, and for accountability and auditing;

6. Develop a viable retention and destruction schedule for active and inactive patient information;

7. Improve security and protect sensitive data while at the same time allowing necessary access to eliminate impediments for staff that make it difficult to accomplish their job duties; and,

8. Increase the accuracy of information related to outcomes, and financial leadership to ensure the organization will meet or exceed its financial goals. At its initial meeting, your newly formed Information Governance Committee, after some brainstorming and collaboration produced the following list, which is by no means complete, but which was identified by your team members as “high” on their list of problems facing the organization which the team members believed could be resolved and/or minimized through effective information governance:

1. A number of serious errors that adversely affect patient safely resulted from inadequate user training on how to use the system, as well as laziness of staff in documenting and charting; 2. Inability to capture information necessary for required reporting from the electronic health records (HER);

3. Inaccurate and incomplete release of information for litigation and business purposes that had resulted from poor systems integration and improper data retention policies;

4. Issues associated with a high rate of patient matching errors in master patient database;

5. Need for updating access controls that ensured appropriate security levels for those caring for patients and those having access to patient records for purposes of billing, diagnostics, and reporting, and; 6. Need for better security of protected health information in order to comply with stricter regulatory requirements

Abstract

Record inventory is essential part of any hospital. For the successful functioning of the Hospitals, health records are to be updated continuously. Major updates of the inventory include basic data collection and previous health records of the patients.  Record inventory are both paper based and computer based to satisfy the hospital requirements.  It also serves as a foundation to ensure safe and effective service to the clients and used in developing the plan for managing budgets, maintenance and finance related to hiring the technical staff.  The inventory may also be used to support assessment within the general hospital and to record the receipts, patient records and finances related to assets. Risk analysis and disaster planning is also supported by record inventory. This research mainly depends on three specific departments which are interconnected. 

Records Inventory at City General Hospital

Introduction

This report entails a description of the record inventory that was done at City General hospital. It has various sections that include record inventory, records inventory survey form, who to receive the survey developed, rationale for the questions that were included in the Survey, initial set of interview questions and record retention schedule. It focuses on three departments that include pharmacy, outpatient and general accounts. Information Governance (IG) is a strategic approach to maximizing the value while mitigating the risks associated with creating, using, and sharing enterprise information. It recognizes that information is an organizational asset and as such requires high level coordination and oversight to assure accountability, integrity, appropriate preservation, and protection of enterprise information. The aim of IG is to break down silos and avoid fragmentation in the management of information so that it is trustworthy and that so that organizations experience a real return on the investments they make in the people, processes, and technology used to manage information. Information is an essential resource in any business or organization, without which operations and running the business is not possible. Accordingly, investments are made in people, process, and technology to assure that information can support the business or enterprise. Because of the significant investments associated with creating, using, protecting and sharing information, information should be viewed as a type of organizational asset, not unlike the buildings, equipment and financial resources necessary to run the business.

Record Inventory

The departments that will be considered for the records inventory will be pharmacy, outpatient department and general accounting department. The three departments play a key role in this organization as outpatient department retains data of every patient that has used the hospital facilities. Pharmacy department retains data of medications given to the individual patients prescribe by the physicians. The general account department maintains the record of patient activities and their financial records related to patient. Since this three departments acts as a pillars for City General Hospital. Below is a table that shows the record types, responsible department and the events that caused the creation of the record type.

Pharmacy Department

Pharmacists are required to keep records of the prescriptions for all the prescriptions dispensed and the prescriptions medicines that are supplied. It must have information such as the prescription reference number, amount that is dispensed, date of dispensing as well as the name and the address of the pharmacy. These record types have events that lead to the creation of the record types as indicated in the table below.

Table 1: Record types for Pharmacy Department

Record Types

Responsible Department

Events

Prescription reference Number

Pharmacy Procurement

To enable easy trace of the drugs in a pharmacy.

Amount Dispensed

Pharmacy Department

To enable easy accountability of the amount of drugs those are sold.

Date of dispensing

Pharmacy Department

To determine the exact dates that the drugs in the pharmacy were sold.

Name and Address of the Pharmacy

Pharmacy Department

To enable easier identification of the place where the drugs were purchased.

Outpatient Treatment Department/ Treatment Records Department

Outpatient department is the sections of the hospital that is designed for the treatment of the patients who does not stay in the hospital. The patients get treatment and go home without admission. The record types that are present in the outpatient department include: demographics that contain the age of the patient, place of resident, names, marital status. It also has the vital signs, diagnosis, medication, treatment plans, progress notes, radiology images and laboratory test results. The table below shows the record types, the responsible departments as well as the events that triggered the record types.

Table 2: Record types Treatment Records Department

Record Types

Responsible Department

Events

Demographics

Pharmacy Procurement

To be able to trace the patient and know about the background of the patient.

Vital Signs

Treatment Records department

To know what possible disease the patient could be suffering from.

Diagnosis

Treatment Records Department

Need to know what the patient was diagnosed of.

Medication

Treatment Records Department

Need to know how the patient was treated.

Treatment Plans

Treatment Records Department

Need to know the plan that is there for treating the patients.

Progress notes

Treatment Records Department

Need to know how the patient is progressing.

Radiology images

Radiology Department

Need to examine the images of the patients’ organs for treatment.

Laboratory and Test Results

Laboratory Department

Test and have the history of the tested diseases.

General Accounting Department

Accounting records are any type of information that relates to the financial performance of the company. In the City General hospital, the record types which are available in the general accounts department included general ledger, general journal, cash book records as well as the banking records. The table below illustrates the record types in the general accounting department, the responsible departments as well as the events that triggered the creation of such record types.

Table 3: Record types for General Accounts Department

Record Types

Responsible Department

Events

General Journal

General Accounts Department.

This was created to sort, store an summarize the transactions of a company

General Ledgers

General Accounts Department.

This was created to record the transactions that was relating to adjustment entries, opening stock and the accounting errors.

Cash Book Records

General Accounts Department

The need to know the receipts as well as the payments made in the hospital.

Banking Records

General Accounts Department

To enable trace the bank and credit cards statements, deposit books and bank reconciliations.

Table 3

Record Inventory Survey Form

The departments that were used in the Survey and the interview included: pharmacy department, outpatient department and general accounting department. It has the sections for the department that was mostly accessing the records, the place where the records can be accessed physically (MTAS, 2019).

The system where the records were created and date of creation of the system date last changed (Planning a Health Record Department, 2012). It also indicates whether the record is vital and whether there are duplicate or any other forms of the records.

Pharmacy Department

In the pharmacy department, the department that was able to access the record types was general accounts department and the records department. CRM was used to create the records. The records still can be got physically in the pharmacy. The CRM was first created and installed with the record types for pharmacy on 1.2.2000. It was last changed on 15.12.2108. The records are very vital. Other forms of records are also available.

Table 4: Pharmacy Inventory Survey Form

Record Types

Department Accessing the record

What applications create the record

Where the record is Accessed Physically

Date created

Last changed

Whether it is a vital record

Any forms of record?

Prescription reference Number

General Accounts Department

Customer Relationship Management ( CRM)

Pharmacy

1.2.2000

15.12.2018

Yes

Yes

Amount Dispensed

General Accounts Department

CRM

Pharmacy

1.2.2000

15.12.2018

Yes

Yes

Date of dispensing

General Accounts Department

CRM

Pharmacy

1.2.2000

15.12.2018

Yes

Yes

Name and Address of the Pharmacy

Records Department

CRM

Pharmacy

1.2.2000

15.12.2018

Yes

Yes

Table 4

Outpatient Treatment Department

In the outpatient department, the records that are there can be accessed by the information technology department. The Customer Relationship Management (CRM) was used to create the records. The records can as well be accessed physically at the outpatient department. The CRM was first created and installed with the record types for pharmacy on 2.3.2000. It was last changed on 28.12.2108. The records are very vital. Other forms of records are also available

Table 5: Outpatient treatment Inventory Survey Form                   

Record Types

Department Accessing the record

What applications create the record

Where the record is Accessed Physically

Date created

Last changed

Whether it is a vital record

Are there any forms of record?

Demographics

All departments

Customer Relationship Management ( CRM)

Outpatient treatment Department

2.3.2000

28.12.2018

Yes

Yes

Vital signs

Information technology

CRM

Outpatient treatment Department

2.3.2000

28.12.2018

Yes

Yes

Diagnosis

Information technology

CRM

Outpatient treatment Department

2.3.2000

28.12.2018

Yes

Yes

Medication

Information technology

CRM

Outpatient treatment Department

2.3.2000

28.12.2018

Yes

Yes

Treatment plans

Information technology

CRM

Outpatient treatment Department

2.3.2000

28.12.2018

Yes

Yes

General Accounting Department

 The General accounting inventory survey form is specific to the IT department to store different types of records like Journal, Ledger, Cashbook and Banking Records. This department mainly interacts with patient financials related to patient treatment cost analysis and invoicing. This department has a good track record in using the Customer Relationship Management (CRM) tool to maintain and update the data of their customers. CRM applications was first installed on 1.3.2000 and last modified on 5.1.2019. The table below shows the general accounts department. The records are very vital and other forms of the records are available.

Table 6: General Accounts Inventory Survey Form

Record Types

Department Accessing the record

What applications create the record

Where the record is Accessed Physically

Date created

Last changed

Whether it is a vital record

Are there any forms of record?

General Journal

Information Technology

Customer Relationship Management ( CRM)

General Accounts Department

1.3.2000

5.1.2019

Yes

Yes

General Ledger

Information Technology

CRM

General Accounts Department

1.3.2000

5.1.2019

Yes

Yes

Cash Book Records

Information Technology

CRM

General Accounts Department

1.3.2000

5.1.2019

Yes

Yes

Banking Records

Information Technology

CRM

General Accounts Department

1.3.2000

5.2.2019

Yes

Yes

Table 6

Who to receive the survey developed

The head of the Information Management at City General hospital will receive the survey that was developed and will dispatch the survey forms to pharmacy, outpatient and general accounts departmental heads.  He would be responsible for compiling the reports on the surveys. The surveys are majorly developed to collect and disseminate accurate, representative data that can explain the health conditions in the hospitals.

Rationale for the questions that were included in the survey

The survey had various questions that were from the three departments. They were included on the basis of the record types that are available in the various departments at the City General hospital. The questions were considered to be relevant as they will be useful in monitoring the performance of the various departments.

The questions that were selected were based on the gap that is available in the various departments of the hospitals so that a possible solution can be sought to solve the problems that might occur.

Initial set of interview questions

The set of the interview questions that are developed to follow the survey questions included the following:

Outpatient Department Interview Questions

·      Do the nurses treat with courtesy and respect?

·      Do the nurses listen carefully? 

·      Do the nurses explain things in an understandable way?

·      Do the doctors treat with courtesy?

·      Do the Doctors listen carefully? 

·      Do the doctors explain things in an understandable way 

·      Is the outpatient department clean?

·      Are the bathrooms and latrines clean?

·      Is there enough time to discuss the medical problem with the doctor or nurse? 

Pharmacy Department Interview Questions

·      Do the pharmacists read well the prescriptions?

·      Do the pharmacists give patients correct drugs?

·      Is the pharmacy clean at all times?

·      How long does each pharmacist serve each patient?

·      Does the pharmacy stock all types of drugs?

General Accounts Interview Questions

·      Does the account department bank all the cash they receive from the patients?

·      Does the book of account at the department balance?

·      How does the patients’ pay their money?

·      Who much does the hospital receive per day?

Record Retention Schedule

This is a document that provides a mandatory instruction for the disposition of records that involves the transfer of records and that are permanent as well as disposal of temporary records. When the hospital no longer needs the records, the data should be removed (Achampong, 2012).

Records retention is the continued storage of the data of an organization for the purposes of compliance as well as for the business purposes. It has the policies that describe well which data should be archived and the duration in which it should be kept. The table describes the length of the time the data will be retained as an active record, the reason for the disposal of the data as well as the final disposition. The length of time the records retained in three different selected departments are listed as minimum seven to ten years, because the patient may have had done the entire body checkup and physician has noticed a minor disease which can affect the patient majorly after few years. Therefore surgeon or physician needs to have the past several years of patient health and medication history to understand and start the treatment. For this reason, there should be a proper data retention and governance policies in place.

Table 7: Records retention schedule table

Records

Length of time they will be retained as an active record

Reason for disposal

Final Disposition

Pharmacy Records

10 years

Legal and Fiscal

Archival

Outpatient Records

7 years

Legal, Historical and Fiscal

Archival

General Accounts Records

10 years

Legal, Historical and Fiscal

Destruction

Table 7

Legal Requirements and Compliance Considerations

The hospitals have been advised by lawyers to maintain the legal records permanently since these records are important in cases of litigation as well as the government investigation. The records retention schedule should be well developed in a systematic manner; the schedule must cover all the records that include all the reproductions (Akyut & Jürgen, 2008). The hospitals have to comply with the policies that are in place that related to the duration in which every data should be retained in the hospital as active record and to dispose the data when it is required to do so.

Recently, Health Insurance Portability and Accountability Act (HIPAA) have given various guidelines to ensure protected health information (PHI) is secured and private. This regulation helps to protect the data of the customer which is store in the computer to take necessary installations of firewalls and anti-virus software, take a constant backup of all present records in various departments to make sure the active compliance is met abiding the laws requirements (Jim, 2016).

Conclusion

In any hospital, any simple ignorance is the choice of life or death for their patients. With  high pressure for perfect operations, an Record Inventory is essential. A record inventory provides access to  critical information which is important resource in hospitals. The need is important in an industry where operations are complex and record values change frequently. So, Record Inventory in General Hospitals is important is scalable to best fit the needs.

References

Achampong, E.K. (2012). Electronic Health Record System: A Survey in Ghanaian Hospitals. Hospital Pharmacy Management, 4(1). (pp. 1-4). Retrieved from http://dx.doi.org/10.4172/scientificreports.164

Aykut, M.U., & Jürgen, S. (2008). Value of electronic patient record: An Analysis of the Literature. Journal of Biomedical Informatics, 41(4), (pp. 675-678). Retrieved from https://doi.org/10.1016/j.jbi.2008.02.001

Jim, G. (2016). Hospital Security: Structure of HIPAA Compliance. Victory Security. Retrieved from https:// M. (2015). The Importance of Health Record. Scientific Research Publishing, 7 (5). (pp. 617-627). Retrieved from http://dx.doi.org/10.4236/health.2015.75073

Planning a Health Record Department. (2012). Education Module for Health Record Practice.  Retrieved from https://ifhima.files.wordpress.com/2014/08/module-8-planning-a-health-record-dept.pdf.

Record Inventory Worksheet, MTAS. (2019). Institute for Public Service, Knoxville, TN. Retrieved from https:// to work on Phase 3 

INSTRUCTIONS FOR PHASE III

During residency weekend your team worked on an outline for an overall Information Governance

Plan/Program for the hospital. It is your task to now add the “content” to the outline for the Information Governance Plan/Program. That is you are to prepare an Information Governance Policy/Program for CITY GENERAL HOSPITAL. All IG policies or programs are somewhat different and unique to the industry and to the organization. There are a number of sample Information Governance Policy/Program templates and samples on the internet. Attached to the end of this document is a sample Information Governance Policy template that was copied verbatim from the website https://

Please feel free to browse the internet to get a flavor for what an actual IG Policy/Program might look like. If you desire, use the template attached to the end of this document as an outline for how you might choose to format your IG Policy/Program for CITY GENERAL HOSPITAL and what you might want to include in your IG policy/program. Alternatively, you may use the outline for the IG Plan that your team developed during residency weekend. You may also use the work the group performed during residence weekend as a “starting point” for developing your own IG plan, if you liked portions of what the group did but believe it still needs work.

It is certainly not a requirement that you use the attached sample as a guideline for formatting your own, or that you use anything that your team prepared during residency weekend. It makes no difference how you arrived at the final format for the IG Plan that you submit as long as you give credit to all source(s), if any, that you looked to in formulating your IG Plan or any portion of your plan.

You may determine that you have developed on your own something superior to the outline herein below, the outline developed by your team during residency weekend, and anything you have found as part of your research. If that is the case, then use your own model! The sample at the

end of this document is merely attached for your convenience as one example of what might be contained in your IG policy/program, and in what format. Do as much research from all sources you have access to or can locate to determine how you want to format your own IG Policy/program, and the types of things you will include. If you decide to use the attached sample, or the outline created by your group during residency weekend, still you are required to customize them to meet the distinct characteristics and needs of CITY GENERAL HOSPITAL and to add the detail required. Please know, this assignment DOES NOT consist of submitting an outline as you did during residency weekend. This assignment is to submit “THE” Information Governance Plan for CITY GENERAL HOSPITAL.

Please do not misconstrue the sample/example format attached hereto or the outline that your team developed during residency weekend. Both are merely outlines. They are skeletons that contain only headings for the types of things you will discuss as part of your IG Plan. In this assignment, you must include actual content or provide instruction for each section listed, and include your own additional subsections where appropriate. For example, you will see on one portion of the attached example the following:

Roles and Responsibilities

The first major section of most frameworks clearly define key roles and their responsibilities, including:

Information Governance Committee Information Governance Team Information Risk Management Information Asset Management Records Manager

Line-of-Business Managers Employees

“Roles and Responsibilities” is merely a category or heading for one portion of the IG policy/program. The sentence that reads, “The first major section of most frameworks clearly define key roles and their responsibilities including:” is nothing more than an instruction from me to you describing the section. Then the 7 lines that follow is just an example of the key players for this particular example. In your IG Plan that you submit to me, if you have a section that looks like this, then you must also include a description of the roles and responsibilities for each entity/position described herein above. You will not include in your IG policy/program that you turn in to me the descriptions of what each category is used for, which is what I gave to you through what was intended to be nothing more than a “tip” to you on what to put in that section.

Please remember that I said I want you to use sentence form. Please don’t just give me listings like that which is included in the outline for Roles and Responsibility example abov

 
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