HIM 440 Module 6 Accreditation Readiness Short Paper Example

Ready Any Day: Keeping the Record Survey-Ready at Kettle Creek Medical Center

[Student Name]

Southern New Hampshire University

HIM 440: Management of Health Information Services

Module Six Short Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Ready Any Day: Keeping the Record Survey-Ready at Kettle Creek Medical Center

Kettle Creek Medical Center's next accreditation survey is expected within ten months, but hospital surveys arrive unannounced, so the real deadline could be next week. Record delinquency is above the hospital's threshold, and a mock tracer last month found documentation gaps that surveyors would notice. This paper explains what surveyors examine in the health record, how the survey process reaches the health information department, what the mock tracer showed and how the department will build readiness into ordinary work.

What Surveyors Look For in the Record

Accreditation standards for the record of care expect a complete, accurate and timely record for every patient: entries dated, timed and authenticated by their authors, required elements such as the history and physical, operative reports and discharge summaries present, verbal orders authenticated within the required time and a process for monitoring delinquent records. For hospitals that bill Medicare, the federal conditions of participation set parallel requirements, including a history and physical documented within 24 hours of admission and record completion within 30 days of discharge. Because the accrediting body's survey can serve as the basis for Medicare certification, a record problem can become a certification problem.

How the Survey Reaches Health Information

Surveyors use tracer methodology. In an individual patient tracer, a surveyor follows one patient's care through the hospital, reading the record at each stop and asking staff to show where information is documented. In system tracers, surveyors examine processes that cross departments, such as data management, which can bring them to the health information department to ask how records are completed, corrected, released and protected. Surveyors will also ask for the hospital's delinquency data and how it is monitored. Health information staff therefore need to explain their processes and show evidence, not only keep records in order.

What the Mock Tracer Found

In a mock tracer last month, the director and a nurse educator followed ten current inpatients the way a surveyor would. Table 1 summarizes the findings. The most serious were histories and physicals documented late, verbal orders not authenticated in the required time and copied text in progress notes that contradicted the day's vital signs. Each finding points to a process rather than to one careless person.

Table 1. Mock Tracer Findings, Ten Inpatient Records

Note. Mock tracer conducted by the director and a nurse educator; composite data.

Does Accreditation Improve Care?

Preparing for a survey takes time that could go elsewhere, so it is fair to ask what accreditation achieves. Brubakk et al. (2015) could not find consistent proof in the published research that accreditation lifts quality or outcomes, and they pointed out how difficult it is to isolate the effect of a program with so many moving parts. Lam et al. (2018) set privately accredited American hospitals beside hospitals inspected by state agencies alone and saw little difference in patient mortality or readmissions. Tracking a single hospital across the years around its survey, Devkaran and O'Farrell (2015) saw improvement leading up to its survey, a decline afterward and a plateau, which they described as an accreditation life cycle. The lesson for Kettle Creek is that a pre-survey sprint may pass the survey without lasting benefit, while continuous readiness is more likely to improve the record.

Building Continuous Readiness

Instead of a sprint, the department will build readiness into monthly routines. Each month, health information staff will review 30 open inpatient records against a checklist based on the mock tracer findings, share results with unit and physician leaders and repeat until each measure stays above 95%. Delinquency will be reported monthly by physician to the medical records committee, as planned in Milestone Two. Nursing informatics will add a reminder for unauthenticated verbal orders, the physician advisor will address copied text with hospitalists and outdated forms will be removed from every unit. Mock tracers will continue every quarter, led by different staff each time.

The Role of Delinquency Control

Record delinquency deserves particular attention because surveyors ask for the data and because Kettle Creek is currently above its threshold. The delinquency plan from Milestone Two, with weekly physician lists, monthly reports by service and escalation through the medical records committee, is also the department's most important survey preparation. The director will add one step: a standing agenda item at the medical executive committee whenever the rate rises above threshold, so that medical staff leaders, not only health information staff, own the response. The health information team will also check that deficiencies are assigned to the right physician, since misassigned deficiencies inflate counts and frustrate physicians who are blamed for records they never touched.

Preparing Staff

Surveyors often ask front-line staff how they do their work. Health information staff will practice answering common questions in plain language, such as how a late entry is made, how a record is corrected, how a patient requests a copy and how the department knows records are complete. Each supervisor will keep a one-page evidence binder, electronic or paper, with the latest delinquency report, audit results and policies, so staff can show evidence rather than describe it from memory.

Measures

Readiness will be tracked through four measures reported monthly: the delinquency rate against threshold, the share of reviewed records meeting all checklist items, the share of verbal orders authenticated on time and the number of mock tracer findings per ten records. Progress on these measures will be reported to the quality committee so that leaders see readiness as a continuing responsibility.

Conclusion

An unannounced survey rewards organizations that are ready every day. Kettle Creek's mock tracer showed gaps in timing, authentication and copied text that no last-minute effort would reliably fix. Research suggests that accreditation's benefits fade when preparation is a sprint, so the department will rely on monthly record review, delinquency reporting, quarterly mock tracers and staff who can explain their work with evidence.

References

Brubakk, K., Vist, G. E., Bukholm, G., Barach, P., & Tjomsland, O. (2015). A systematic review of hospital accreditation: The challenges of measuring complex intervention effects. BMC Health Services Research, 15, Article 280. https://doi.org/10.1186/s12913-015-0933-x

Devkaran, S., & O'Farrell, P. N. (2015). The impact of hospital accreditation on quality measures: An interrupted time series analysis. BMC Health Services Research, 15, Article 137. https://doi.org/10.1186/s12913-015-0784-5

Lam, M. B., Figueroa, J. F., Feyman, Y., Reimold, K. E., Orav, E. J., & Jha, A. K. (2018). Association between patient outcomes and accreditation in US hospitals: Observational study. BMJ, 363, Article k4011. https://doi.org/10.1136/bmj.k4011