Capella University Assessment

Assessment 4 Instructions: Recommendations and Action Plans

Prepare a final risk report (5-7 pages) that identifies privacy and security-related risks from throughout the quarter. Include evidence-based recommendations; action plans; and best practices, policies, and procedures to support the recommendations and action plans.

Throughout this course you have examined health care’s legal landscape, considering security and privacy safeguards set forth by the Health Insurance Portability and Accountability Act (HIPAA). The HIPAA standards protect the security and privacy of health information. Health care organizations are responsible to ensure proper controls are in place to make data available, but also to protect patients. Privacy and security violations must be identified; preventive policies and procedures need to be put in place to mitigate risks related to those violations. Health care organizations often use risk reports to identify, assess, and monitor risks throughout the organization.

In this final assessment, the risk management director has asked you compile a report based on all of your findings throughout the quarter. The director has an executive meeting with various stakeholders and would like to discuss recent risk issues identified throughout the hospital. In addition to identifying the risks, you will also make evidence-based recommendations and develop action items for identified privacy and security risks.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

  • Competency 3: Analyze the relationship between privacy and security in health care.
    • Create evidence-based recommendations to avoid privacy and security violations identified in audit results.
  • Competency 4: Analyze legal and ethical implications related to Health Information Management.
    • Develop action plans to accompany recommendations.
    • Describe best practices, policies, and procedures that directly support the recommendations and action plans.
    • Summarize the use of HIPAA standards and legal and ethical implications relating to the recommendations and action plans.
  • Competency 5: Communicate effectively in a professional and ethical manner.
    • Create a clear, well-organized, professional final risk report that is generally free of errors in grammar, punctuation, and spelling.
    • Follow APA style and formatting guidelines for citations and references.

Preparation

To successfully prepare to complete this final course assessment:

  • Review these three Vila Health media pieces:
  • Review your three previous assessments:
    • Assessment 1: You prepared a SWOT analysis focused on privacy and security-related issues.
    • Assessment 2: You developed a release of patient information compliance checklist for hospital staff members to follow.
    • Assessment 3: You wrote a security report that identified potential security and technical safeguard violations in Valley City Regional Hospital’s audit report. Your security report included evidence-based recommendations to address these potential violations and prevent them from occurring in the future.

Based on the content presented in these media pieces and the work you completed in your previous assessments, you will compile evidence-based recommendations; action plans; and best practices, policies, and or procedures to remedy the privacy and security issues that have surfaced at Valley City Regional Hospital.

Instructions

In this final assessment, the risk management director has asked you to compile a final risk report based on all of your findings related to privacy and security. The director has an executive meeting with various stakeholders and would like to share the recent risk issues identified throughout the hospital. In addition to identifying the risks, you will also make evidence-based recommendations and develop action items for the identified privacy and security related risks.

Download the Final Risk Report Template and use it to complete your assessment. Follow these guidelines when completing your final risk report template:

  • Introduction (1 to 2 paragraphs)
    • The point of the introduction is to orient the reader to the information presented in the final risk report.
    • Summarize the main types of risks identified at Valley City Regional Hospital.
    • Summarize the mains types of recommendations; action plans; and best practices, policies, and procedures provided.
    • Consider including a brief explanation of the differences among recommendations; action plans; and best practices, policies, and procedures.
  • Identified Privacy or Security Risk (Column 1)
    • In Column 1 you will create a master list of the privacy and security risks you uncovered throughout the quarter.
    • Consider grouping the privacy risks together and the security risks together.
  • Evidence-Based Recommendations (Column 2)
    • In Column 2 enter your evidence-based recommendations to address the identified risk and prevent it from occurring in the future.
    • Include three recommendations for each identified risk.
  • Action Plans (Column 3)
    • In Column 3 enter the action plans associated with each recommendation.
    • Include three action plans for each recommendation. This will be a total of nine action plans for each identified risk.
  • Best Practices, Policies, and/or Procedures to Support Recommendations and Actions Plans (Column 4)
    • Pay attention to the distinctions among recommendations; action plans; and best practices, policies, and/or procedures when constructing your plan.
      • Recommendations indicate what must be done.
      • Action plans show how it must be done.
      • Best practices, policies, and/or procedures outline how, by whom, and in which settings and circumstances the recommendations and action plans will be put into effect.
  • Summary (1 to 2 paragraphs)
    • Briefly summarize the use of HIPAA standards and legal and ethical implications relating to the recommendations and action plans.
    • Help Valley City Regional Hospital prioritize the most critical recommendations to implement first. Provide the rationale for your prioritization and substantiate your rationale with references to current, scholarly, and/or authoritative sources.

Additional Requirements

  • Format: Complete your assessment using the Final Risk Report Template provided. Use Times Roman, 12-point type.
  • Length: 5 to 7 pages.
  • References: Follow APA style and formatting guidelines for citations and references. Include a separate works cited page for your references. For an APA refresher, consult this resource: APA Style and Format.
  • Writing: Create a clear, well-organized, professional final risk report that is generally free of errors in grammar, punctuation, and spelling.

Resources: Best Practices


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Capella University Assessment

Assessment 1 Instructions: Analysis of Electronic Health Records System


  • Develop an 8-12 slide PowerPoint presentation accompanied by an audio recording of the presentation that is a maximum 15 minutes. The presentation will focus on an explanation of Meaningful Use Guidelines and how the current HIM system could be optimized to ensure compliance and improved outcomes.This assessment should be completed first.

    Introduction

    Meaningful Use Guidelines play a very important role in guiding and directing the path of health information management (HIM) systems in many health care organizations. Along with Meaningful Use Guidelines, other regulations and quality measures drive how health care organizations choose, implement, and utilize their health information systems. In this assessment, the primary focus will be on meaningful use compliance, quality assurance, and the regulatory environment related to HIM. Electronic health records (EHR) are playing an important role in improving quality, accessing important patient data, and improving communication amongst providers. They are a very important part of any HIM. However, new incentive programs such as Meaningful Use Guidelines require that health care organizations pay much closer attention to how patient data is gathered, shared, and collected. In this assessment, you will have the opportunity to work through an interactive scenario at a fictitious hospital and assess an EHR system. You will be tasked with explaining Meaningful Use Guidelines as they relate to the system, making recommendations based on best practices for maintaining meaningful use, and other regulatory compliance.The importance of understanding meaningful use in EHR and HIM systems is to understand the standardization of the exchange of information, to improve the overall quality of health care delivered, and to reduce costs. As a master’s prepared healthcare professional you will be called upon to help organizations to reduce costs and time to bring safe and effective practices to professionals and patients. It is also incumbent upon the master’s prepared healthcare professional to bring relatable information to patients to assist them in making informed decisions about their healthcare. By completing a review and recommendation cycle of an existing EHR you will gain valuable practice in applying this knowledge and skills.As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as a part of your assessment.For this assessment, you will need to complete the review of an existing EHR system and provide an overview of current Meaningful Use Guidelines and incentive programs, as well as recommend ways to change either the EHR or workflow processes to ensure continuous improvement and sustainable compliance.

    • Why are EHR systems important and how do they address the changing health care marketplace?
    • What are the current relevant Meaningful Use Guidelines?
      • What are the current incentive programs related to these guidelines?
    • How are privacy and security of patient records maintained in an EHR system?
    • How can EHR systems impact the experience and quality of patient care?
    • What are the future trends for EHR systems and HIM best practices?

    This assessment should be completed first.

    Scenario

    In this scenario, you will assume the role of Quality Assurance Manager at Vila Health’s Independence Medical Center. You have been asked to review the current electronic health record (EHR) system after some concerns were raised about the system not being fully compliant with new regulations and Meaningful Use Guidelines. After your review, you will present your findings and recommendations to the leadership team.

    Preparation

    Capella Multimedia

    Click the following link to work through the media piece.

    HARDWARE

    • A headset with headphones and a built-in microphone, or some other hardware with audio capability.

    If you do not already have audio capability with your computer system, a headset is recommended as an inexpensive option. Please set up and test your headset to verify the compatibility of the hardware as soon as possible. Refer to the manufacturer’s directions for installing and connecting the device to your computer.

    USING KALTURA

    Note: In this assessment, you will be required to create an audio recording to accompany the PowerPoint presentation. You may use Kaltura or, with instructor approval, you may use an alternative technology to record and deliver your presentation.In preparation for recording your presentation, complete the following:

    • If you have not already done so, set up and test your headset or built-in microphone, using the installation instructions provided by the manufacturer.
    • Practice recording to ensure the audio quality is sufficient.
    • Refer to the Using Kaltura [PDF] tutorial for directions on recording and uploading your presentation in the courseroom.

    Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact Disability Services to request accommodations.Review the Vila Health: Analysis of an EHR System media simulation and the information provided to learn more about the Vila Health organization.Before reviewing the EHR system, you will want to familiarize yourself with Meaningful Use Guidelines. Take a moment to review these sources and conduct an additional research as needed on the Centers for Medicare & Medicaid Services (CMS) incentive program from EHR: Meaningful Use. Refer to the Meaningful Use section of this assessment for links to different resources you might use.Next, review the Vila Health EHR system. While analyzing the EHR, you will want to think about not only the flow of data, how it moves through the system, and compliance with Meaningful Use Guidelines, but also about the patient experience and implications on quality of care. Consider privacy and security of patient records as well.To prepare for this assessment, use the Capella University Library and the resources provided for this assessment to research the following topics:

    • Digitization of the nation’s medical records and the privacy challenges.
    • EHR incentive program requirements.
    • Best Practices for compliance with Meaningful Use Guidelines.
    • EHR and HIM best practices for quality, privacy, and regulatory compliance.
    • Types of information technologies that are used to improve the quality of patient care.

    Instructions

    To complete this assessment, you will prepare an 8–12 slide PowerPoint presentation of best practices and emerging models in HIM and EHRs. Your presentation will be assessed using the following criteria:

    • Explain Meaningful Use Guidelines and what they mean to an organization’s current state of compliance.
    • Explain an organization’s current electronic health record system and its data process to meet regulatory guidelines.
    • Analyze how an electronic health record system could improve the quality of care, simplify existing processes, and improve patient outcomes.
    • Explain best practices for an organization to maintain meaningful use compliance as it relates to current incentive programs and policies.
    • Recommend evidence-based approaches for implementing new practices for the end user functions, training, and ongoing compliance.
    • Communicate analysis and recommendations of an electronic health records system in a manner that is clear and concise.
    • Integrate relevant sources to support assertions, correctly formatting citations and references using current APA style.

    Below is one potential outline for the presentation that could help you to address the assessments grading criteria.

    • Introduction:
      • Present what Meaningful Use Guidelines are and what they mean to the organization.
      • Present Independence Medical Center’s current state of compliance.
    • Current HIS:
      • State the current EHR being used in this organization.
      • Present your findings on the evaluation of the EHR.
      • Explain how the EHR could improve the quality of care, simplify existing processes, and improve patient outcomes.
      • Discuss how the data are currently captured, tracked, analyzed, and shared and whether each area meets regulatory policy and incentive guidelines.
    • Upgrades and Improvements:
      • Present your findings from your research on maintaining Meaningful Use Guidelines.
      • Present best practices for long-term compliance to current incentive programs and policy.
      • Make additional recommendations on the EHR system including end user functions, training, and ongoing compliance to the department heads.
      • Provide evidence-based recommendations for implementing new practices and emerging models in the identified departments.

    Audio Recording

    Use Kaltura, or other instructor-approved alternative technology, to record an audio to accompany your presentation. Before you begin recording, you may find it beneficial to write a script or detailed outline that you can refer to as you record. Your recorded audio should be no more than 15 minutes in length.Include the notes or script of your audio recording. You may choose to include these in the “Notes” sections of the presentation slides, the script you may have used when you created your recording, or a detailed outline. This will serve to clarify any insufficient or unclear audio, or if you cannot complete the audio recording.Note: If you did not include your notes or script in the presentation, please include them in a separate document along with the other presentation elements.

    Additional Requirements

    Your presentation should meet the following requirements:

    • Written communication: Written communication is free from errors that detract from the overall message.
    • APA formatting: Resources and citations are formatted according to current APA style and formatting guidelines.
    • Number of resources: At least one APA formatted in-text citation and accompanying, congruent APA formatted reference.
    • Length of presentation: 8–12 slides.
    • Duration of audio recording: Maximum of 15 minutes.
    • Font and font size: Arial, 18 point or above for headings and explanatory text and 24 point and above for slide titles.

    Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact Disability Services to request accommodations.

    Competencies Measured

    By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

    • Competency 1: Apply emerging models or best practices to implement a health information system that improves operations and patient outcomes. (L8.4, L12.2, L14.3)
      • Explain Meaningful Use Guidelines and what they mean to an organization’s current state of compliance.
      • Analyze how an electronic health record system could improve the quality of care, simplify existing processes, and improve patient outcomes.
    • Competency 2: Analyze administrative, clinical, management, and decision-support information technology tools. (L12.1, 12.2, 14.3)
      • Explain an organization’s current electronic health record system and its data process to meet regulatory guidelines.
    • Competency 3: Apply best practices relative to the financial assessments and decisions required for the implementation of health information systems. (L 8.1, 8.2, 8.4)
      • Explain best practices for an organization to maintain meaningful use compliance as it relates to current incentive programs and policies.
    • Competency 4: Apply evidence to influence buy-in from all stakeholders. (L10.5)
      • Recommend evidence-based approaches for implementing new practices for end user functions, training, and ongoing compliance.
    • Competency 5: Communicate in a manner that is scholarly, professional, and consistent with expectations for professionals in health care administration. (L6.1, L6.2, L6.3, and L6.4)
      • Communicate analysis and recommendations of an electronic health records system in a manner that is clear and concise.
      • Integrate relevant sources to support assertions, correctly formatting citations and references using current APA style.

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Capella University Assessment

Assessment 5 Instructions: Process Improvement Proposal

Generate recommendations for process improvement and organizational fitness for a selected organization in the form of a 6-8 page proposal that is targeted for its management team.

Introduction

Note: The assessments in this course build upon each other, so you are strongly encouraged to complete them in a sequence.

Health care leaders function within a complex, high-risk environment where errors can lead to injury and death. The goal of any health care leader is to assess and manage risk, while concurrently promoting a culture of patient safety.

Patient safety is the cornerstone of high-quality care.

Youngberg (2011) addresses the need for leaders to create a systemic mindfulness of patient safety within the high-risk health care delivery environment. Further, the author discusses high-reliability organizations, which attain next to zero error rates, despite a great propensity for error or catastrophic events.

Read further in the Assessment 5 Context [PDF] document, which contains important information on the following topics related to change leadership, risk management, and patient safety:

  • Themes for Success in Leadership.
  • The National Patient Safety Goals and Strategic Direction.
  • Personal Reflection.
  • Ethical Leadership.
  • Professional Communication.

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as a part of your assessment.

  • How does a health care leader establish a culture of patient safety?
  • How are risks to patient safety assessed and managed in your current or future work setting?
  • What are the other types of risks that are assessed and managed?
  • What are the important factors that need to be monitored in your selected work setting?
  • How can you contribute to risk management and patient safety within your job?

Imagine that you are the new CEO of your organization, and are charged with transforming the previous status quo to an efficient, high-performing accountable care organization.

  • Which tools would you put to work in your new position?
  • What types of individuals would be needed for your executive leadership team?
  • What competencies might be important to the team members?
  • What processes, structural models, or frameworks from this course might help you as a transformational leader?
Reference

Youngberg, B. J. (2011). Principles of risk management and patient safety. Jones and Bartlett.

Preparation

BALANCED SCORECARD

The following resources are required to complete this assessment.

This article introduces the concept of a balanced scored to motivate and measure a business unit performance.

The following reading is available full-text in the Capella University Library. Search for each article by clicking the linked title and following the instructions in the Library Guide. This article explores measure that drives performance using a balanced scorecard.

Note: You should complete this assessment last.

The goal of this assessment is to generate recommendations, in the form of a proposal for process improvement and organizational fitness. Make your recommendations for the organization you selected in Assessment 4 for the balanced scorecard presentation. Apply the concepts of balanced scorecards to create your recommendations.

Instructions

In your proposal, use specific language and include evidence-based concepts from peer-reviewed literature, including a minimum of four outside peer-reviewed sources. Communicate information and ideas clearly, accurately, and concisely, including reference citations and using correct grammar. Include the following in your proposal:

  • Describe the selected organization, including its vision and mission.
  • Analyze the company using any adaptation of the Kaplan and Norton balanced scorecard framework that fits your selected organization. Refer to the Balanced Scorecard section of this assessment for links to different resources you might use.
  • Communicate vision, strategy, objectives, measures, targets, and initiatives for each of the following four elements through a macro-level discussion:
    • Financial performance measures.
    • Internal business processes.
    • Learning and growth.
    • Customer satisfaction.
  • Convey the organization’s values through an ethical, organizational, and directional strategy.
  • Recommend evidence-based and best practices for monitoring and improving discussions.
  • Generate one recommendation for each of the following:
    • Process improvements.
    • Quality improvements.
    • Organizational efficiency.
    • Learning implementation.
    • Implementation and evaluation.

Additional Requirements

  • Written communication: Written communication should be free from errors that detract from the overall message.
  • APA formatting: Resources and citations should be formatted according to APA style and formatting guidelines. Use APA format for all of the following:
    • Cover page.
    • Abstract.
    • Table of contents, including a list of figures and tables.
    • Headings and subheadings.
    • Reference list.
  • Number of resources: A minimum of 6 resources. The following Norton and Kaplan articles will serve as two resources.
    • The Balanced Scorecard: Measures that Drive Performance.
    • Linking the Balanced Scorecard to Strategy.
  • Length of paper: 6–8 typed double-spaced pages.
  • Font and font size: Arial, 10-point.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:


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Capella University Assessment

Identify the benchmarks and quality measures used to compare with the office data for your proposal (Excel spreadsheet). Assess the compatibility of the proposed data and examine potential issues related to information quality (1-3 pages).

Introduction

A key part of your proposal will be to identify benchmarks and trends for the topic you have chosen for your documentation review. Benchmarks can come from national or state quality standards or trends. If your proposal is approved, you as the office manager will want to try to answer this question: How does our office data compare to national or state trends?

You need to identify your benchmarks before you can collect and then compare the data. You decide what your benchmarks are. They could be based on national averages, state averages, or quality standards. For example, here is one quality standard: All patients with chronic, stable coronary artery disease are on an antiplatelet therapy or have supporting documentation as to why they cannot take an antiplatelet therapy. For instance, they may have an allergy.

Another question to consider when establishing benchmarks is this: Are you comparing apples to apples or apples to oranges? In addition, if you are retrieving information from a national database or data from an HIE, how do you know your office data is comparable to the information you are retrieving? Consult your suggested resources for answers to these questions.

For this second assessment, you are to:

  • Analyze statistical trends and assess quality measures relevant to your proposal.
  • Assess the compatibility of data drawn from multiple sources.
  • Determine the effects of health information quality on an HIE.

This assessment is completed in three steps:

  1. Step One – Preparation: Locate data related to quality measures or trends relevant to your topic from specific websites.
  2. Step Two – Data Collection: Create a data collection tracking spreadsheet and dashboard.
  3. Step Three – Data Compatibility: Write a short paper on data compatibility and quality.

Please study this assessment’s scoring guide to better understand the performance levels relating to each criterion on which you will be evaluated.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

  • Competency 4: Determine how a health information exchange (HIE) affects the management of patient data, clinical knowledge, and population data.
    • Assess the compatibility of data from multiple sources.
    • Explain the effects of health information quality on an HIE.
  • Competency 5: Integrate quality and change management strategies.
    • Analyze statistical trends relevant to a selected condition.
    • Assess quality measures relevant to a selected condition.
  • Competency 6: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others, and consistent with the expectations for health care professionals.
    • Write clearly, with correct spelling, grammar, and syntax, and good organization.
    • Apply proper APA formatting and style to citations and references.

Instructions

Step One: Preparation

Locate data related to quality measures relevant to your topic from one or more of these websites:

Step Two: Data Collection

Using the Data Collection Spreadsheet Guide [XLSX] as an example, create a spreadsheet containing three tabs: Dashboard Tracking, Data Collection, and Trending.

On the first tab, Dashboard Tracking, draw from the information you gathered in Step One as part of your preparation for this assessment:

  • Identify the specific benchmark data you will compare with your office data. Remember it is up to you to establish your benchmarks.
  • Organize or create a spreadsheet to display the totals, percentages, averages, and so on of your office data and of the national or state data you will be using for comparison. Note: Your Office Data column will be blank because you are not collecting any office data. This is only a proposal to do an information review of the quality of care provided by the physician group. Data does, however, need to appear in the Benchmark (national/state) data column.
  • Include at least one comparison graph of your choice on this tab.

On the second tab, Data Collection, draw from the information you gathered in Step One as part of your preparation for this assessment:

  • Create a form you will use to collect specific data from the patients’ records.
  • Include a row for each patient.
  • Provide a column for each data collection point (quality measure) you will be comparing.

Note: The information on this page is totaled, averaged, et cetera, with the results linked to the first tab.

To create your third tab, Trends, you will need to do some additional research. Identify national benchmarks for the condition you have chosen that could be compared to your office data. For example, if the trend in your office is that you are seeing more patients with asthma, but the national trend is decreasing, you have discovered a discrepancy that needs to be investigated.

To perform your analysis:

  • Visit one or more of the following websites containing national data:
  • Locate and analyze statistical data relevant to the selected condition.
    • Examine trends:
      • What other meaningful trends exist? For example, consider the number of new cases, increases or decreases of cases within a specific age range or location, et cetera.
      • How do the national and state trends compare?
      • Is the national trend increasing or decreasing?
      • What is the percentage of cases who expire from the disease?
  • Identify the trending of one statistical result relating to the condition you selected over the last 5–10 years.
  • Create a line graph on the third tab of your spreadsheet, Trends, that illustrates the national and/or state trending of the disease you selected over the past 5–10 years.

Note: Remember you have not collected your office data yet for comparison purposes. You could add that data at a later time.

Step 3: Data Compatibility

Write a short section to add to the proposal you will complete in Assessment 3. Be sure this section of your proposal includes all of the following headings and your narrative addresses each of the bullet points.

Introduction
  • Provide a brief 1–2-sentence high-level summary explaining data compatibility.
Data Compatibility
  • Assess the compatibility of the data:
    • How can you ensure data from multiple sources is compatible?
    • How do you know the data you are using for comparison is compatible with your office data?
    • What challenges are associated with data standardization? We do not want to compare apples with oranges. You want to be sure data from multiple sources:
      • Represents the same condition.
      • Uses similar statistical analysis.
      • And so on.
Effects of Health Information Quality on the HIE
  • Explain the difference between an HIE and a national database.
  • Explain what problems can develop if facilities submit incomplete or inaccurate information to an HIE.
  • Explain what problems can develop if facilities submit incomplete or inaccurate information to a national database.
  • Explain how incomplete or inaccurate data may affect your proposal.
Conclusion
  • Briefly reinforce your paper’s main points.

Additional Requirements

Your assessment should meet the following requirements:

  • Excel spreadsheet: Your spreadsheet must contain three tabs, be organized, contain appropriate graphs, and have correct spelling.
  • Written communication: Your paper does not need to be in APA format. It does need to be clear and well organized, with correct spelling, grammar, and syntax, to support orderly exposition of content.
  • Title page: Develop a descriptive title of approximately 5–15 words. It should stir interest yet maintain professional decorum.
  • References: Include a minimum of two citations of peer-reviewed sources in current APA format.
  • Length: 1–3 typed, double-spaced content pages, not including the title page and references page.
  • Font and font size: Times New Roman, 12 point.

    Resources: Data Collection

  • As you review these resources, please keep these questions in mind:
    • What is the difference between a national benchmark and a quality measure?
    • How are benchmarks used in healthcare information?

    Data Collection

    Review the following:

    • Oachs, P. K., & Watters, A. L. (2016). Health information management: Concepts, principles, and practice (5th ed.). Chicago, IL: AHIMA Press. Available from the bookstore.
      • Chapter 12, “Health Information Technologies,” pages 343–384.
      • Chapter 13, “Health Information Systems Strategic Planning,” pages 385–421.
    • Health Care Administration Undergraduate Library Research Guide.
    • Resources: Data Compatibility

    • As you review these suggested resources, please consider these questions:
      • What are data standards?
      • How can you ensure data compatibility?

      Data Compatibility

      Review the following:

      • Oachs, P. K., & Watters, A. L. (2016). Health information management: Concepts, principles, and practice (5th ed.). Chicago, IL: AHIMA Press.
        • Chapter 5, “Clinical Classifications, Vocabularies, Terminologies, and Standards,” pages 141–168.
        • Chapter 14, “Consumer Health Informatics,” pages 423–447.
      • Penoyer, D. A., Cortelyou-Ward, K. H., Noblin, A. M., Bullard, T., Talbert, S., Wilson, J., . . . Shaw, G. (2014). Use of electronic health record documentation by healthcare workers in an acute care hospital system. Journal of Healthcare Management, 59(2), 130‒144.
      • Törnqvist, J., Törnvall, E., & Jansson, I. (2016). Double documentation in electronic health records. Nordic Journal of Nursing Research, 36(2), 88‒94.

        Resources: Effects of Information Quality on the HIE

      • Please consider these questions as you review the suggested resources for this assessment:
        • How does documentation affect the quality of patient care?
        • What is the difference between an HIE and a national database?

        Effects of Information Quality on the HIE

        Review the following:


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Capella University Assessment

Develop a section (3-5 pages) of a proposal to study whether a group of physicians provided quality of care related to an identified disease or condition and population. Include a plan to manage the information from collection to destruction and an analysis of legal considerations.

Introduction

For this assessment and others in this course, you will assume the role of an office manager for a physician group. In most fields, whether manufacturing, the service industry, or health care, organizations are looking for ways to improve the quality of service they provide to their customers. An eye on quality helps them remain competitive in the marketplace and stay in business. Otherwise, their customers will go elsewhere. This is especially true in the health care field where people’s health and lives are at stake.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

  • Competency 1: Outline the steps of the health care information life cycle.
    • Apply steps of the health care information life cycle.
  • Competency 2: Apply laws governing health information confidentiality, privacy, and security.
    • Differentiate between required confidentiality and security measures.
    • Apply laws governing health information confidentiality, privacy, and security.
  • Competency 3: Assess system applications used to operationalize health information.
    • Evaluate which information system or systems best provide needed information.
  • Competency 6: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others, and consistent with the expectations for health care professionals.
    • Write clearly with correct spelling, grammar, and syntax, and good organization.
    • Apply proper APA formatting and style to references and citations.

Preparation

Your physician group is no different than other organizations. It wants to find ways to improve the quality of care it provides to patients. This, in turn, helps the physician group remain profitable and stay in business. As a result, the senior leaders of your physician group have asked you to provide a documentation review of the quality of care provided by the office. As the office manager, you are the one responsible for the management of the health information within the office and the review of information to determine whether providers met quality of care standards. Determining this will require you to:

  • Identify a disease or condition served by the physician group.
  • Determine what patient information is needed and from where to retrieve it.
  • Compare your overall office data to the national benchmarks.

Typically, in the workplace, the physician group’s specialty area (cancer, diabetes, dermatology, et cetera) would dictate the disease or condition for which you would be collecting information. For the purpose of this assessment, however, you may select the disease or condition that interests you from this list:

  • Asthma.
  • Diabetes.
  • Myocardial infarction.
  • HIV/AIDS.
  • Cancer.

Select the disease or condition that is important to you and that you want to study. Perhaps, you have the disease or condition. Perhaps, a family member or friend does. Remember you will be working with this condition in the remaining course assessments.

Now that you have determined the disease or condition you are going to study, you will need to begin collecting protected health information (PHI) for the patients treated by your physician group who have the condition you are studying. You will need to consider carefully the privacy, security, and confidentiality of the information within the patients’ office records. Determining how you as the office manager will maintain data security is a key aspect of your work. You are responsible for knowing and understanding the types of documentation, applications, and information systems used within and outside of the office. All information moves through a life cycle from creation to destruction. Regulations, policies, and procedures strictly control this ongoing process. The office manager needs to know this life cycle and where to locate information when it is needed.

For this assessment, you will write a section of a proposal about how the documentation on previous patient care will be retrieved, from where it will be retrieved, and how that data will be kept secure during retrieval and review. Remember that you are focusing on retrieving and analyzing existing documentation within the office.

For this section of your proposal:

  • Identify the disease or condition and the population that will be the focus of your study.
  • Explain your plan to manage this information from collection to storage to destruction.
  • Identify legal considerations and a plan for compliance for the PHI you are collecting.

In later assessments in this course, you will continue on with your proposal and begin to plan for how you will compare the office data you have collected to the national benchmarks. Remember: You will not be able to actually do this comparison. You are simply preparing a proposal for senior leaders about how you would go about performing this work.

Please read the scoring guide for this assessment to better understand the performance levels relating to each criterion on which you will be evaluated.

Instructions

You will not be writing the entire proposal for this assessment, only parts of it. You will add to your proposal in later assessments and complete it in Assessment 3. Be sure this part of your proposal includes all of the following headings, and your narrative addresses each of the bullet points:

Introduction
  • Identify the disease or condition from the following list for which you will review the quality of care:
    • Asthma.
    • Diabetes.
    • Myocardial infarction.
    • HIV/AIDS.
    • Cancer.
  • Explain the reasons for your choice.
Information Collection

Complete the following:

  • Determine the patient population to be reviewed.
  • Evaluate which information system or systems best provide the needed information.
  • Determine the specific documentation you are looking for. Explicitly state the reasons for each and all of your choices. Be sure to answer all of the following questions in your narrative:
    • Do you want to review information only from your office? Or do you also want to review information for hospital admission and/or emergency room visits?
    • Do you wish to review all patients who have ever been treated for the selected condition? Or only those treated within a specific time frame? Will you only review patients within certain demographic parameters?
    • What type of documentation do you want to review? This may include:
      • History and physical (H&P).
      • Discharge summary.
      • Progress notes.
      • Labs.
      • Radiology.
      • Others.
  • Identify where you are going to find the information you need. Which information system or systems would be best to use, and what information can you collect from each system? Possibilities include:
    • Pharmacy.
    • Point of care (POC).
    • Results management.
    • Computerized physician order entry (CPOE).
  • Determine the type of system or systems (financial, administrative, clinical, et cetera) you would use.
Information Life Cycle

Complete the following:

  • Describe how you plan to manage this information from collection to destruction. Be sure to address all of these questions in your narrative:
    • How will the information be collected and documented? By whom? In what context?
    • How will the information be stored?
    • How will you control access to the information?
    • How can you ensure the documentation meets interoperability standards?
    • What are the advantages and disadvantages of integrating your office information with an HIE?
    • What challenges exist regarding the standardization of health information?
    • When and how will the information be destroyed?
Legal Considerations

Complete the following:

  • Differentiate between the legal aspects of health information confidentiality, privacy, and security, as it applies to your proposal.
  • Apply laws governing health information confidentiality, privacy, and security.
  • Determine whether the information you are retrieving requires the use of PHI.
    • If not, why not?
    • If so, summarize how the PHI will be used.
  • Plan for how the Health Insurance Portability and Accountability Act (HIPAA) will impact health care personnel, policies, and procedures in your proposal.
Conclusion

Briefly summarize the value of the documentation review you are proposing to be performed.

Additional Requirements

Your assessment should meet the following requirements:

  • Written communication: Your paper does not need to be in APA format. It does need to be clear and well organized, with correct spelling, grammar, and syntax, to support orderly exposition of content.
  • Title page: Develop a descriptive title of approximately 5–15 words. It should stir interest yet maintain professional decorum.
  • References: Include a minimum of two citations of peer-reviewed sources in APA format.
  • Length: 3–5 typed, double-spaced pages, not including the title page and references page.
  • Font and font size: Times New Roman, 12 point.

Resources: Legal Considerations

As you review the suggested readings listed below, please keep these questions in mind:

  • What is PHI?
  • What are the HIPPA privacy and security rules?

Legal Considerations

Review the following:

  • Oachs, P. K., & Watters, A. L. (2016). Health information management: Concepts, principles, and practice (5th ed.). Chicago, IL: AHIMA Press. Available from the bookstore.
    • Chapter 2, “Legal Issues in Health Information Management,” pages 43–95.
    • Chapter 10, “Organizational Compliance and Risk,” pages 291–304.
    • Chapter 11, “Data Privacy, Confidentiality, and Security,” pages 305–339.
    • Chapter 28, “Ethical Issues in Health Information Management,” pages 909–926.
  • Health Care Administration Undergraduate Library Research Guide.

    Resources: Information Collection

  • As you review these suggested readings, please keep these questions in mind:
    • What are three application systems? What documentation does each system contain?
    • How do application systems optimize the use of health information?
    • How does the design of application systems support integration into an HIE?

    Information Collection

    Review the following:

    • Oachs, P. K., & Watters, A. L. (2016). Health information management: Concepts, principles, and practice (5th ed.). Chicago, IL: AHIMA Press.
      • Chapter 4, “Health Record Content and Documentation,” pages 97–127.
      • Chapter 6, “Data Management,” pages 169–200.
      • Resources: Information Life Cycle

      • As you review these suggested readings, please consider these questions:
        • What are three different forms of documentation? How are these created?
        • What are the regulations regarding the retention and destruction of health care records?

        Information Life Cycle

        Review the following:

        • Oachs, P. K., & Watters, A. L. (2016). Health information management: Concepts, principles, and practice (5th ed.). Chicago, IL: AHIMA Press.
          • Chapter 4, “Health Record Content and Documentation,” pages 128–139​.

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Capella University Assessment

Assessment 4: Training Plan

Prepare a 5-7 page training and development plan for a challenge that would be appropriate to present for executive approval.

Introduction

Your ability to create a well-formed training plan that addresses both employee and organizational needs and concerns ensures that the workforce is current, relevant, and responsive to environmental market forces and community needs.

Overview and Preparation

Choose one of the challenges below (or one of your own) as the focus of an HR training or development plan for a department in a health care organization.

Possible challenges:

Teamwork is lacking in some functional units. Many employees are operating as individuals in areas where teamwork is essential. Poor or inadequate goals and objective-setting seem to be a key issue.

There is a lack of preparation and orientation for newly hired employees. Many are not prepared for their job within the organization because of inadequate job-related training on company policies or procedures.

  • Employees appear to be wasting time and working inefficiently. Time management seems to be a problem for many.
  • Burnout is a very significant issue in the organization, especially among nursing staff. Supervisors are struggling to deal with the issue.
  • Or choose and define a comparable challenge of your own.
  • Use the Capella library and professional or academic resources on the Internet to research training and development strategies for addressing HR needs.
  • Deliverable

Prepare a training and development plan for your chosen challenge that would be appropriate to present for executive approval. Include the following:

A description of how the proposed training addresses the identified challenge within an organization of your choice.

A list of employee types who should be included in the training and why.

A detailed description of the training topics and vector (seminar, online, conference, workshop, brown bag, et cetera). The budget and schedule should accurately reflect this choice.

  • A budget (personnel, equipment, supplies, et cetera). Make sure to document any assumptions you make.
  • A schedule with milestones associated with content creation and training delivery.
  • Additional Requirements
  • Your assessment should meet the following requirements:
  • Written communication: Your assessment artifacts should be professionally written in a form and style appropriate for the various stakeholders. Consider the purpose of the document, its intended use, and the setting in which your plan will be presented.

Resources: Performance Appraisals

MHA Program Library Guide can help direct your research.Review the following:

Farndale, E., & Kelliher, C. (2013). Implementing performance appraisal: Exploring the employee experience. Human Resource Management, 52(6), 879–897.

O’Boyle, I. (2013). Traditional performance appraisal versus 360-degree feedback. Training & Management Development Methods, 27(1), 201–207, 705.

  • Resources: Employee Training
  • MHA Program Library Guide can help direct your research.Review the following:
  • Fallon, L. F., Jr., & McConnell, C. R. (2014). Human resource management in health care: Principles and practices (2nd ed.). Jones & Bartlett Learning. Available in the courseroom via the VitalSource Bookshelf link.
  • Chapter 7, “Employee Training,” pages 129–142.

This article examines the teaching-learning experiences of registered nurses who work exclusively at night:

  • Mayes, P., & Schott-Baer, D. (2010). Professional development for night shift nurses. The Journal of Continuing Education in Nursing, 41(1), 17–24.
  • This article argues that training and education should be connected more closely to the actual delivery of care:

Ricketts, T. C., & Fraher, E. P. (2013). Reconfiguring health workforce policy so that education, training, and actual delivery of care are closely connected. Health Affairs, 32(11), 1874–1880.

  • Resources: Designing Training Programs

MHA Program Library Guide can help direct your research.Review the following:

M Libraries. (n.d.). Designing a training program. http://open.lib.umn.edu/humanresourcemanagement/ch…

Nathan, A. (2016). 7 key steps for better training and development programs. https://www.shrm.org/resourcesandtools/hr-topics/o…

Resources: Training Delivery

  • MHA Program Library Guide can help direct your research.This e-book explains how to set goals for first-time presenters, presents techniques for successful presentations, and provides solutions for problems that can arise for a presenter:

McArdle, G. (1993). Delivering effective training sessions: Techniques for productivity. Crisp Learning.

Resources: Training Budgets

  • MHA Program Library Guide can help direct your research.This site provides a training budget spreadsheet using Excel:

My Excel Templates. (n.d.). Training budget spreadsheet. http://myexceltemplates.com/training-budget-spread…

This article discusses how to maximize training budgets by adding webinars as a training option:

Review the following:

Health Administration Masters Research Guide.


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Capella University Assessment

Assessment 3 Instructions: Labor Relations and Collective Bargaining

Create a 4-6 page action plan that addresses improvements in discriminatory practices and provides clearly defined policies that are intended to increase employee morale and workplace safety. The audience for the plan is senior management.

Introduction

When organizational leaders and union leaders work together collaboratively, both sides increase their capacity to deal with unionization issues in a proactive manner through strategy development and action planning, resulting in positive change that reflects all stakeholder interests.

The National Labor Relations Act is landmark legislation for business and industry in the United States, and has had a significant impact on the responsibilities and placement of HR management functions in organizations with respect to union formation and regulation.

Some experts believe organizational management will evolve from legalism to humanism in the future. What might be the primary forces that contribute to the evolution? Meanwhile, others disagree that such an evolution will occur. What forces might oppose an evolution from legalism to humanism in the future?

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

How are unions positive forces in the workplace? How are they negative?

What are the first steps HR management takes in anticipation of unionization?

  • What type of issue would lead you to choose arbitration as a method of resolution, as a company representative?
  • What factors are important to consider when selecting trials as a method of resolving workplace issues?
  • Scenario
  • As an HR manager in a unionized hospital or other health care organization, it has come to your attention that the collective bargaining process can be used as a focal point for the formation of policies and practices that will improve the organization’s employee-centered philosophy and, therefore, assist in the implementation and humanistic enforcement of key provisions of the National Labor Relations Act and the Civil Rights Act.

Deliverable

Complete the following parts of this assessment based upon your research and understanding of methods of addressing the scenario described above.

Part 1: Problem Description and Analysis

Complete the following:

Explain and suggest ways that collective bargaining and legal mandates can advance the strategy of improving working conditions and environmental ambience in a health care organization.

Explain how the collective bargaining process can be used to develop organizational policies and practices.

Include some of the obstacles inherent in the collective bargaining process that might hinder effective development of policies and practices.

  • Explain how the National Labor Relations Act provisions related to protected activities of employees can be used to foster improvements in workplace conditions.
  • Explain how the Civil Rights Act provisions related to discrimination based on gender can be employed to foster improvements in a safe and secure work environment.
  • Part 2: Recommendation: Action Plan
  • Recommend an employee-centered plan of action that will address improvements in discriminatory practices by:
  • Reducing workplace sexual harassment.
Fostering improvements in collaborative working arrangements.

Encouraging open and clear communication among staff and management.

Developing and maintaining a secure work environment.

  • The audience for this action plan is senior management and workplace union leadership. Base your recommendation on the following expansion of the scenario:
  • It has been determined that employee satisfaction and morale is due primarily to discriminatory practices and lack of clearly delineated policies that foster harmony in the workforce and provide a safe and secure working environment.
  • Part 3: External Stakeholder Considerations
  • Once you have senior leadership on board, you must also consider options for reformatting the action plan for external stakeholders, such as union leadership, regulatory boards, community members, et cetera.

Include a 2–4 paragraph reflection on how you would need to reformat this plan to meet the needs or requirements of external union leadership and other key external stakeholders.

Explain how the collective bargaining process can be used to develop organizational policies and practices.

Consider options for reformatting the action for external stakeholders.

Competency 5: Communicate in a manner that is scholarly, professional, and consistent with expectations for professionals in health care administration.

Write coherently to support a central idea in an appropriate format with correct grammar, usage, and mechanics.

  • Resources: Discriminatory Practices

MHA Program Library Guide can help direct your research.This article addresses critical issues regarding how organizational researchers and practitioners can contribute to eradicating employment discrimination:

MHA Program Library Guide can help direct your research.Review the following:

Twomey, D. P. (2013). Licensed practical nurses: Protected “employees” or statutory “supervisors” under the NLRA? The impact of the 11th circuit’s Lakeland Health Care decision. Labor Law Journal, 64(2), 57–66.

MHA Program Library Guide can help direct your research.Review the following:

Moody, K. (2014). Competition and conflict: Union growth in the US hospital industry. Economic and Industrial Democracy, 35(1), 5–25.

  • Fallon, L. F., Jr., & McConnell, C. R. (2014). Human resource management in health care: Principles and practices (2nd ed.). Jones & Bartlett Learning. Available in the courseroom via the VitalSource Bookshelf link.

Chapter 19, “Relations With Labor Unions,” pages 363–382.

  • Chapter 21, “Human Resources Arbitration,” pages 399–408.

National Labor Relations Board. (n.d.). National Labor Relations Act. https://www.nlrb.gov/guidance/key-reference-materi…

U.S. Equal Employment Opportunity Commission. (n.d.). Title VII of the Civil Rights Act of 1964. https://www.eeoc.gov/statutes/title-vii-civil-righ…

National Archives. (n.d.). The Civil Rights Act of 1964 and the Equal Employment Opportunity Commission. http://www.archives.gov/education/lessons/civil-ri…

  • Review the following:

Health Administration Masters Research Guide.


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