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Quiz your staff to prepare for the JCAHO survey

HIM Connection, August 10, 2004

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Quiz your staff on the following questions:

1. Leadership and CEO
   • How do IM services meet the needs of the organization?
   • What types of aggregate data are used in decision-making?
2. All department directors
   • Has an information needs assessment been conducted for your department?
   • Has IM training and education been provided to you and your staff?
   • How do you use aggregate data in decision-making and performance improvement?
   • Do you have access to the information you need?
   • How do you protect patient confidentiality and security of information technology?
   • Is knowledge-based information available? How do you use it?
3. Medical staff and nursing
   • Do you have appropriate access to your patient's medical records?
   • Are diagnostic test reports, history and physical reports, and operative reports completed in a timely manner?
   • What types of aggregate data do you use in decision making and professional improvement?
   • Do you have access to the knowledge-based information you need?
   • How do you use comparative data?
4. Environment of care services
   • How do you use aggregate data?
   • Do you have the Drug Enforcement Administration and poison control information you need?
   • Is the hospital formulary available to you?
5. Library staff
   • Is the accessibility and timeliness of knowledge-based information appropriate?
   • What were the findings from your information-needs assessment?
6. Emergency and ambulatory care services
   • What is your control register process?
   • Are patient records and reports available and completed in a timely manner?
   • Do you use the summary list?
   • How do you protect the confidentiality and security of patient information?
7. Performance improvement council
   • How do you use aggregate data in performance improvement?

What to do:
Plan a training session for all staff, especially the individuals, groups, or departments mentioned above. These sessions should include specifics on the information management process in the department and the organization. Prepare a handout with sample questions and answers for distribution at the training sessions. It's a good idea to conduct mock surveys and mock patient tracers to identify and correct breaches of confidentiality and security issues.

Editor's Note: Remember, surveyors may ask additional questions related to other IM functions.

This excerpt is adapted from the book Information Management: The Compliance Guide to the JCAHO Standards.

Questions? Comments? Contact:

Andrea Dickey
Editorial Assistant
adickey@hcpro.com

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