Week 11....

I will begin this weeks topics by chatting about accreditation, licensure, and standards.

Accreditation is actually a voluntary act performed by facilities to meet a certain set of standards. Once these standards are met, the facility is accredited by an independent accrediting agency, such as TJC (The Joint Commission) which is a common accrediting agency for healthcare facilities.

Getting licensed is usually achieved on a state or county level. This means the facility has reached a certain legal or formal permission to perform certain duties by meeting standards that are set by the entity that would grant them a license.

Standards are something in-house a facility would have to make sure the staff is performing their duties to a certain level of care. Employees know what those standards are by knowing the policies and procedures the facility has in place.

Anyone in the HIM department must abide by strict policies and procedures for the facility. I never realized how strict some of these policies were until we visited St. Rita's in Lima, OH. the HIM Manager, Lisa, told us that is the physician does not complete their record in a certain period of time, they will no longer be able to schedule surgeries, see patients, and will not be able to perform other duties within the facility until they are in compliance. This shocked me. I thought they would get to it when they get to it if it was not completed prior to the HIM department receiving the documents. I found out otherwise very quickly....physicians are help to a very strict time frame in order to stay compliant so the records can be completed and sent to billing in a timely manner.

In HIT 2000 we discussed mandated reporting in Ohio. There are also very strict guidelines for mandated reporting of various situations: WHO must report, WHEN (time frame) they must report, TO WHOM they must report, and the situation involved that must be reported.
This is what I came across while researching mandated reporting:

• Health care providers must include the following information upon reporting:
  

  • Name of patient
  • Diagnoses or suspected diagnoses
  • Date of birth
  • Sex
  • Telephone number of pt.
  • Street address, city, state and zip
  • Supplemental surveillance information
  • Health care provider name, telephone number, and street address with city, state, and zip code

  A laboratorian must report the following information:
  

  • Name of pt.
  • Date of birth of pt.
  • Sex of pt.
  • Street address of pt. with city, state, and zip code
  • Laboratory test information
    • Specimen identification number
    • Specimen collection date
    • Specimen type
    • Test name
    • Test result
    • Organism and serotype, as applicable
    • Health care provider name, telephone number and street address with city, state, and zip code.

  A report must be made for a class A disease-disease of major public health concerns because of severity or potential for an epidemic (includes anthrax, diphtheria, smallpox, and SARS)-must be reported immediately by phone; class B1 disease-diseases of a public health concern that could potentially become an epidemic (includes malaria, meningitis, west Nile virus, and hepatitis A)-must be reported by the end of next business day; class B2 disease-diseases of significant public health concern (includes chlamydia, gonococcal infections, hepatitis C, and typhus fever)-must be reported by the end of the business week; and class C disease-outbreaks, unusual incidences, or epidemic (includes pediculosis, scabies, histoplasmosis, and staphylococcal infections)-must be reported by the end of the next business day.
  
  
  

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    http://www.odh.ohio.gov/pdf/idcm/intro1.pdf.
    
    
    

The implementation of EHRs have  greatly increased the workflow within facilities. Prior to EHRs, everything had to be done be hand. Charts were all written out by hand and put into files one paper at a time after they papers were punched so they could be affixed in the files. Not only the documentation aspect, but charts had to be pulled for patients, and re-filed after the patient care was completed. This all took a great deal of time.....which cost a great deal of money. EHRs are instant once signed onto a computer and the patient records are requested. No more running to records or anyplace else to get files. Not to mention the completeness of EHRs. When lab tests are done, the results are there in the record immediately upon completion.
With EHRs nurses document on a computer which goes directly into the patients healthcare record. Nurses used to sit at the end of their shifts and catch up on all the paper work and files that needed completed. EHRs also save space as paper records took up a great deal of space within facilities.