Accreditation

IM standards continue to challenge in hospital surveys

Briefings on The Joint Commission, April 1, 2006

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3.10, 6.10, and 6.50 on JCAHO's list of most-cited standards for 2005

Learning objectives: After reading this article, you will be able to

  • list the JCAHO's most-cited information management (IM) standards for 2005
  • explain strategies to comply with the most-cited standards

    Organizations preparing this year for JCAHO surveys should take a close look at the health information management (HIM) department. The JCAHO in January released its list of most-cited standards during surveys it conducted January-July 2005, and three IM standards made the top 10 list.

    The JCAHO's list reflects data from surveyed hospitals, with the percentages of hospitals receiving noncompliance findings. The list includes

  • IM.3.10 (processes to manage information)-44%
  • IM.6.10 (every patient has complete medical record)-15%
  • IM.6.50 (verbal orders handled appropriately)-15%

    IM.3.10, which includes the unapproved abbreviations requirement, topped the list for the second straight year. In 2004, 27% of hospitals were cited, according to the JCAHO.

    The inclusion of the three IM standards on the JCAHO's list makes it more important than ever for HIM staff to understand what the standards require and maintain compliance. For guidance, we turned to Jean S. Clark, RHIA, service line director for HIM at Roper Saint Francis Hospital in Charleston, SC, and author of HCPro, Inc.'s Information Management: The Compliance Guide to the JCAHO Standards, Fifth Edition.

    IM.3.10

    IM.3.10 provides requirements for collecting, processing, storing, retrieving, reporting, and disseminating data and information. The standard can be applied to a paper or electronic environment in any type of healthcare setting and has the following 11 elements of performance (EP):

  • The hospital requires the identification and use of uniform data definitions and data capture methods.
  • The hospital must standardize abbreviations, acronyms, and symbols and publish a list of those that are not to be used. This EP is a former National Patient Safety Goal that has been incorporated into the standards.
  • The hospital has quality control systems in place to monitor data content and collections activities.
  • The hospital has storage and retrieval systems to meet the users' needs.
  • The hospital retains data and information as required by law.
  • The hospital retains data and information for quality of care and other hospital needs.
  • The hospital has the expertise and tools for collecting, retrieving, and analyzing data and transforming data into information.
  • Data is organized and transformed into formats that are useful to decision-makers.
  • Data and information is disseminated in an accurate and timely manner.
  • The hospital uses standard formats and methods for data and information dissemination to meet user needs and make it easy to retrieve and interpret.
  • Data display and transmission must use industry or hospital standards whenever possible.

    • This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

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