HIM 510 Milestone One – Kristen DeKeyser
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Southern New Hampshire University *
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Jan 9, 2024
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HIM 510 Milestone One – Kristen DeKeyser
Two Policy Statements for Mercy Vale
Write two clear, comprehensive
policy statements, explaining the reasons for the policy, the procedures (exactly what should and should not be done), and the policy’s intended goals.
A.
Protecting PHI on public and clinical computers
All employees of Mercy Vale Medical Center will be responsible for securing their computers and workstations. This includes, but is not limited to, locking computers when stepping away, securing documents containing PHI, etc. Additionally, while accessing data on computers, employees are required to ensure that the information they are accessing is pertinent to performing their daily job functions. While accessing and using the data within the system, employees will ensure that it is not visible to others within the area and follow all necessary safeguards to ensure the protection of the data. The intent of this is to ensure that the facility remains compliant with HIPAA laws pertaining to the security of PHI. According to the Office for Civil Rights (OCR), “a major goal of the Security Rule is to protect the privacy of individuals' health information while allowing covered entities to adopt new technologies to improve the quality and efficiency of patient care” (Office for Civil Rights, 2022). Finally, employees will not be permitted to use Mercy Vale Medical Center computers for personal use. This will prevent harmful viruses from getting into the facility network. B.
Completing discharge paperwork fully and correctly
Mercy Vale Medical Center staff will complete all patient discharge paperwork within 30 days from the date of discharge. The completion of this paperwork will be done accurately and timely to avoid issues with billing
guidelines. Patient demographic information, patient contact information, and patient addresses must all be
updated routinely in addition to having the patient verify the information upon discharge of the facility. This information will be reported as part of the discharge paperwork. Additionally, all medication and follow-up appointment information must be included to maintain proper record keeping as well as ensure that the patient remains educated on the service(s) rendered while at Mercy Vale.
Security of Patient Health Information Explain how your policies guide staff in keeping patient health information secure.
The purpose of these policies will be to help guide the staff on proper procedures and requirements pertaining to the security of PHI as well as completing discharge documentation. These policies will help Mercy Vale Medical
Center
ensure that employees are held accountable for the work that they perform as well as ensure the overall safety of the data and information stored within the facility network. Finally, these policies will help the employees further develop their skills within the healthcare industry.
Procedures for Management to Track Access
Explain how your policies provide procedures for management to track access to patient health information.
By utilizing the new EHR system, management will be able to track everything that an employee does on their computer within the network. They will be able to monitor which patient files are being accessed and what information is being reviewed. Additionally, the policies that are created will allow for management to take any necessary disciplinary actions if there is misuse of data or machinery identified. IT will be able to completely monitor every site accessed within the network and ensure network security and safety. Finally, it is imperative that the staff are properly trained in the appropriate procedures for handling and managing healthcare data. Upon the completion of this training, the staff will be required to sign off indicating that they agree to abide by the policies and procedures pertaining to data safety.
Alignment With Appropriate Health Laws Explain how your policies align with appropriate health laws to further improve the organization's compliance with standard-setting agencies.
According to the Office of Civil Rights, “the Security Rule requires covered entities to maintain reasonable and appropriate administrative, technical, and physical safeguards for protecting e-PHI” (Office for Civil Rights, 2022). By enforcing the policies outlined above, the facility will remain in compliance with the security rules by ensuring all staff maintain secure workstations. Furthermore, the facility will need to perform routine audits on employee usage to ensure that the security policies are being followed. IT will also be responsible for maintaining the integrity of the data stored on the network and preventing any cyber
threats (i.e., viruses, malware, hackers, etc.). Ethical Practices
Explain how your training plan recommends leadership strategies that foster improved ethical practices of employees when working with health information.
The training plan reinforces the ethical practice of maintaining patient confidentiality and data security. The primary goal of the plan is to protect PHI as best as possible. This not only will ensure that the facility remains compliant with privacy laws, patient information is secured, but also that employees are abiding by the policies outlines by the organization. The policy helps to hold staff accountable for their role in data security and provides specific guidance on what is acceptable within the organization. Effective Collaboration
Recomend leadership strategies that encourage effective collaboration between members of the health information management team and other staff members in the organization.
Some strategies that are recommended for leadership to encourage effective collaboration would be to set clear and concise goals for the staff. This will provide a clear understanding of what is expected from the
staff and what they need to work towards during the year. Another strategy that would benefit the leadership team would be to make sure they provide constructive feedback and recognition so that the employees can understand where they can improve in addition to being recognized when they perform a task correctly. Finally, leadership should incorporate diversity and inclusion to help their staff work closely together and collaborate.
Steps of New Procedures
Explain how your training plan clearly demonstrates to employees the steps of new procedures that employees must now perform and follow, supporting with examples of how employees will act out procedures.
The training plan outlines all expectations of the employees pertaining to the new procedures that must be followed. Employes can utilize available resources both during, and after training for any questions. Additionally, employees can work with each other to assist with questions on the new procedures. For example, if an employee is unsure if they are completing the discharge paperwork appropriately, they can reach out to a coworker or the available training resource to verify that everything is filled in correctly. Improving Compliance Explain how your training plan clearly demonstrates how these new procedures will improve compliance with regulations and standard-setting agencies.
The purpose of this training plan is to cover the new procedures being implemented that will help the facility
improve their compliance with safety laws and regulations. By ensuring that patient data is secured as well as enforcing compliance with filling out discharge paperwork, the facility will no longer be at risk of noncompliance. This training will help to reinforce the new policies with the staff.
Importance of New Procedures Explain how your training plan clearly demonstrates the importance of these new procedures in terms of patient safety and security of patient information.
Given that all employee activity within the network will be able to be monitored by IT, ensuring that employees fully understand the new policies is critical in helping them to be successful. It is more important than ever to reinforce teamwork within the facility so that the employees can utilize each other as a resource during the learning process. By implementing these new procedures, the facility will be able to guarantee patient data is being protected and provides a necessary safeguard. Compliance with security and privacy laws is required and, if not followed, can result in fines and/or jailtime. It is important that employees prioritize the new procedures.
Disseminating and Enforcing New Procedures Explain how your training plan recommends leadership strategies that could be used by management in disseminating and enforcing these new procedures.
The training plan relies heavily on leadership participation. This means that the leadership team will need to help enforce the new policies being implemented as well as to help foster employee success. This can be done through multiple collaborative measures. The leadership team will be relied on to take an active role in
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the implementation by providing support throughout the training and post-training period. Additionally, the leadership team will need to ensure their employees utilize the training and follow the new policies and procedures to remain in compliance. Training Plan Outline
Outline a training plan to gain buy-in from staff on complying with the new policies. What agenda will you follow? What methods will you use? Which presentation tool? What, if any, ancillary materials will you create?
To ensure proper training, the facility will need to utilize a training program that utilizes multiple different methods of learning to help keep employees engaged. The training program will be interactive and utilize small quizzes throughout to ensure the employee is following along and understands the material. The training curriculum will begin with the patient data safety procedures and then transition to the discharge documentation. To help support employees after they have completed the training, info graphics will be created and placed around the office to reiterate the changes. Finally, employees will need to attest that they understand the new policies and agree to comply with them.
References
Office for Civil Rights. (2022, October 20). Summary of the HIPAA security rule
. Department of Health and Human
Services (DHS). https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html