Survey Result Action Plan
Topic: Survey Result Action Plan
You are the new Health Information Management Director at Wildcat Hospital. During the last accreditation survey, the hospital had findings related to quality and timing of documentation. The facility is due for another survey very soon. You have assigned one of your staff do a quality audit on documentation timeliness for the month of December. She has provided you with the attached spreadsheet. For this assignment, you need to:
Review the collected data TimelinessExercise.xlsxPreview the documentView in a new window
Assign the appropriate quality code
Analyze the data
Which code is most common?
Is there one service that seems to be a problem?
What can you conclude from the data?
Establish a plan. How are you going to fix the problem?
You have scheduled an in-service with the physicians to address this topic. Create a PowerPoint to present to the physicians. The presentation should include:
Regulations governing the issues found (Regulations can be found here: Joint Commission 2015 Standards.pdfPreview the documentView in a new window )
Hospital policies that address the regulations (You will need to write these)
Presentation of the data that has been collected and coded
Plan for continued monitoring
For this assignment, you upload your PowerPoint along with the spreadsheet showing how you classified each finding.
Accurate assignment of quality code
Analysis of data
Presentation of regulations
Hospital policies established
Presentation of data
Presentation of plan
Overall quality of presentation including grammar and readability
I have provided you the current 2015 Joint Commissions standardsPreview the documentView in a new window for you, the link to the CMS Conditions of Participation (Links to an external site.), and the Utah Health Facility Licensure Rules (Links to an external site.).