HIM 540 Module 3 Final Project Milestone One Example

Final Project Milestone One: Who Decides? A Governance Structure for Tidewater Crossing Health

[Student Name]

Southern New Hampshire University

HIM 540: Health Information Governance

Final Project Milestone One

[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.

Final Project Milestone One: Who Decides? A Governance Structure for Tidewater Crossing Health

Tidewater Crossing Health has governance problems that no one can solve because no one has the authority to solve them. The four readmission definitions, the three retention schedules and the growing number of duplicate patient records all persist because each former hospital can keep doing things its own way. This milestone designs the structure that will make decisions for the system: who sits where, what each body may decide and how disagreements are resolved.

Design Principles

Three principles guided the design. Authority must be real: a governance body that can only recommend will be ignored when a hospital disagrees. Stewardship must be close to the data: the people who know what a data element means should define and monitor it. And the structure must be light enough to act, with a small number of bodies that meet regularly. Rosenbaum (2010) argued that effective data stewardship requires defined authority, transparent processes and accountability, and each part of this structure is built to provide those three things.

The Structure

At the top, the chief operating officer serves as executive sponsor, since governance decisions cut across clinical, financial and administrative lines. The information governance council, chaired by the health information director, writes policy covering every kind of information from creation to destruction, from access rules to retention, disposal and legal holds. Its members include the privacy officer, compliance officer, chief information officer, chief medical information officer, a nursing leader, general counsel and one senior leader from each hospital. Beneath the council, a data governance committee led by the director of analytics manages data definitions, quality standards and the shared data dictionary. Data stewards for five domains, clinical, financial, patient identity, quality measures and operations, bring issues to the committee and maintain the definitions in their domain.

The Council Charter

The council's charter gives it authority to adopt system-wide policies on information and data, approve data definitions used in reports to the board and regulators, approve the retention schedule, resolve disputes escalated from the data governance committee and require hospitals to adopt approved standards within set timeframes. It meets monthly, keeps minutes, publishes its decisions to all staff and reviews its own effectiveness each year. The council aims for agreement but votes when agreement fails, with the executive sponsor able to break ties. The charter turns into working rules the professional association's view that governance belongs to the whole organization and needs an executive sponsor (AHIMA, 2014).

Who Does What

Table 1 shows responsibilities for three common governance decisions using a simple responsibility chart: who is responsible for doing the work, who is accountable for the decision, who is consulted and who is informed.

Table 1. Responsibility Chart for Governance Decisions

Note. Prepared by the author for the governance charter.

Decision and Escalation Path

Most issues begin with a steward who notices a problem, such as two reports using different definitions. The steward proposes a resolution to the data governance committee, which decides within 30 days. If a hospital or department objects, the issue goes to the council at its next meeting. If the council cannot agree, the executive sponsor decides. The path is published so that everyone knows how to raise a problem and how long an answer should take, which addresses a common complaint in the listening sessions that data questions disappeared into email.

How the Hospitals Keep a Voice

The former hospitals worry that system governance means losing control. The structure answers that concern in three ways. Each hospital has a senior leader on the council with a vote. Stewards are drawn from all four hospitals, so definitions are written by people who know each site's practice. And the council may approve local variations when a hospital shows a genuine need, such as a pediatric unit that requires different retention rules, as long as the variation is documented and does not affect system reports. These provisions aim to make governance feel like shared decision making rather than the flagship imposing its ways.

Resources

Governance needs modest but real resources. The plan funds a half-time governance coordinator in the health information department to manage agendas, the data dictionary and the decision log, and it protects about four hours a month of each steward's time. The analytics team will maintain the dictionary in a searchable tool already licensed by the system, so no new software is required in the first year.

First-Year Priorities

The council will begin with three priorities. First, adopt one readmission definition for all reports, the problem that exposed the need for governance. Second, adopt one retention schedule based on a legal requirements register. Third, launch a patient identity cleanup, since duplicate records undermine every other data effort and create safety risk. McCoy et al. (2013) found that large record systems contain many patients who share names and birth dates, which makes duplicate and overlaid records likely without careful identity management. Each priority has a steward, a target date and a measure, such as the master patient index duplicate rate falling from an estimated 7% to under 2%.

Making Governance Work in Practice

Structures fail when people see them as bureaucracy. Jalali and Kaiser (2018), studying cybersecurity in hospitals, traced success to how organizations worked, especially whether leaders paid attention and departments cooperated, and governance is no different. The council will therefore start with problems leaders already care about, report visible results to the board each quarter and keep stewards' duties to a few hours a month, with recognition in their performance goals.

Conclusion

Tidewater Crossing's governance structure gives one council authority over information policy, one committee authority over data definitions and quality and named stewards responsibility for five data domains, with a clear path for resolving disputes. Starting with the readmission definition, the retention schedule and patient identity ties governance to problems leaders already feel. Milestone Two will apply this structure to how the system collects data.

References

American Health Information Management Association. (2014). Information governance principles for healthcare (IGPHC). AHIMA.

Jalali, M. S., & Kaiser, J. P. (2018). Cybersecurity in hospitals: A systematic, organizational perspective. Journal of Medical Internet Research, 20(5), Article e10059. https://doi.org/10.2196/10059

McCoy, A. B., Wright, A., Kahn, M. G., Shapiro, J. S., Bernstam, E. V., & Sittig, D. F. (2013). Matching identifiers in electronic health records: Implications for duplicate records and patient safety. BMJ Quality & Safety, 22(3), 219-224. https://doi.org/10.1136/bmjqs-2012-001419

Rosenbaum, S. (2010). Data governance and stewardship: Designing data stewardship entities and advancing data access. Health Services Research, 45(5, Pt. 2), 1442-1455. https://doi.org/10.1111/j.1475-6773.2010.01140.x