HIM 440 SNHU The Current Issue Facing New HIM Department Manager Analysis

HIM 440 Module Two Assignment Template
Write a two- to three-paragraph summary of the current issues facing you as the new HIM department manager. In your analysis, consider
staffing, departmental relationships, productivity, and compliance. Make sure to address all the critical elements.
Note: To complete this template, replace the bracketed text with the relevant information.
SWOT Matrix
For your unified HIM department SWOT analysis, you will need to first analyze each of the hospitals. Use this template to help you organize your
thoughts and complete your unified SWOT analysis and SMART goals.
St. Catherine’s
Strengths
[Insert text.]
Opportunities
[Insert text.]
Weaknesses
[Insert text.]
Threats
[Insert text.]
St. Luke’s
Strengths
[Insert text.]
Opportunities
[Insert text.]
Weaknesses
[Insert text.]
Threats
[Insert text.]
Hickman
Strengths
[Insert text.]
Opportunities
[Insert text.]
Weaknesses
[Insert text.]
Threats
[Insert text.]
Use the template below to create a combined SWOT analysis for the new Gateway Healthcare Systems HIM department.
Unified HIM Department SWOT Analysis
Strengths
[Insert text.]
Opportunities
[Insert text.]
Weaknesses
[Insert text.]
Threats
[Insert text.]
SMART Goals
Using your final SWOT analysis, formulate at least three SMART goals, one in each of the following areas: cultural diversity, human resources,
and compliance.
1. Cultural Diversity: [Insert text.]
2. Human Resources: [Insert text.]
3. Compliance: [Insert text.]
HIM 440 Gateway Healthcare Systems Case Study
St. Catherine’s Medical Center recently announced it will be merging with St. Luke’s Hospital
and Hickman Community Hospital to form Gateway Healthcare Systems, all located within the
same metropolitan area in the Midwest. You have just been hired as the healthcare system’s
HIM director overseeing all three hospitals. Each facility’s department manager or supervisor
will report to you.
Hospital Profiles
St Catherine’s Medical Center
HIM Department Mission: Grounded in the Catholic mission of service, we strive to provide
accurate patient health information services to all patients with care, concern, and dignity.
HIM Department Vision: Provide patients with their health information with sensitivity and
respect to their privacy.
Profile: St. Catherine’s is affiliated with the Catholic faith and includes an active convent on its
campus. It is an 850-bed acute care level-one trauma facility located in the suburbs. The staff
and patients come from a variety of ethnic backgrounds and are linguistically diverse. About
60% of St. Catherine’s staff is Catholic, but the hospital abides by legal hiring practices and
insists that all employees are treated with respect, including those who fall outside the tenets
of Catholicism. In fact, the HIM department has two staff members with hearing impairment
who work in the coding section. They have been investigating ways to offer more opportunities
to potential employees with physical needs, but with the high volume of reading and direct
customer service provided to patients, it has been difficult to accommodate.
St. Catherine’s has a reputation of providing quality care to all patients and will not turn away a
patient based on ability to pay. It is located in one of the wealthier suburbs of the city and has a
strong record of employment retention, even though the average salary level is lower than
those of its competitors. St. Catherine’s implemented a new EHR last year and continues to
work out new policies and procedures for the new system. Its dictation system was
implemented seven years ago. The productivity level has been critically low since implementing
the new system.
Due to recent budget cuts, St. Catherine’s cannot offer overtime to staff. The HIM department
has many long-term employees that do not have formal health information education or
credentials. The current coding productivity level is, on average, two inpatient charts per hour
per coder, and 10 outpatients (including ED patients) per hour per coder. The coding quality
consistently exceeds 95%, per the internal coding auditor.
Coding productivity standards were established six years ago using ICD-9 standards, at four
inpatient charts per hour. The productivity standards remain at four inpatient charts per hour,
despite complaints from coders that the standards are unreasonable.
St. Catherine’s last TJC site visit was in October of last year. Overall, the hospital fared well on
inspection; however, the HIM department was cited for not having a time stamp on orders in
the EHR. (For more information, review regulations RC.01.01.01, EP19 in The Joint Commission
E-dition Manual).
There have been complaints in the department that some staff do not abide by the break
schedule, and some take longer lunches than allowed. Management has not addressed this
with staff for fear of losing some of their most knowledgeable and credentialed staff. It has
been reported that some of the seasoned coders who have been on staff for more than 25
years are still using the manual coding book rather than the encoder that was implemented five
years ago, stating that this saves them valuable time; however, the more recently hired coders
are using the encoder system.
St Luke’s Hospital
HIM Department Mission: To provide providers, residents, and staff with timely access to
patient health information for purposes of treatment, research, and reimbursement.
HIM Department Vision: Promoting research through state-of-the-art health information
management and technology.
Profile: St. Luke’s, established in 1942 as a Methodist hospital but no longer a faith-based
facility, is a very busy, 400-bed inner-city teaching hospital that provides critical care services to
many patients without healthcare coverage. It services the most diverse patient population in
the city in terms of ethnicity, religion, class, ability, sexuality, and age; however, its staff
diversity is low except in the area of age diversity. The youngest employee is 19 years old and
the oldest is 72.
St. Luke’s has experienced a high volume of staff turnover during the past three years and does
not currently have a HIM manager or director on staff. While it does have credentialed HIM
staff, it has difficulty keeping them on board for more than two years.
St. Luke’s is using a first-generation EHR that was implemented seven years ago and has
difficulty communicating with the other systems in the department and organization. Because
of the issues with interoperability, the lab sends down daily batches of paper lab reports that
are scanned into the EHR. The encoder was just implemented last year; however, only one
coder was thoroughly trained on the new encoder, and she resigned over a year ago. Coding
staff frequently use the manual coding books because they cannot seem to find the accurate
codes with the encoder. They spend a great deal of time looking up codes in the coding book,
then going to the paper binders with the coding clinics to ensure that they are assigning the
correct codes. Coding productivity standards were revised after the implementation of ICD-10.
Current productivity standards are set at two inpatient charts per hour.
The coding supervisor is a new graduate with less than a year of inpatient coding experience.
She does not get along well with her subordinates, who are older and have much more
experience. Coding productivity is being met per the performance expectations established ten
years ago; however, coding quality is consistently rated at 85%, per the external auditing firm.
Hickman Community Hospital
HIM Department Mission: To assure protection of patient health information at all times.
HIM Department Vision: Committed to serving the local community’s health information needs
and ensuring patient information is secure.
Profile: Hickman is a non-faith-based, 90-bed community hospital located in the oldest part of
the city. It has historically served a predominantly low-income, Caucasian patient population,
which is comprised mostly of Medicare and Medicaid payers. It has recently been seeing a rise
in Muslim patients due to a new mosque in the neighborhood. Hickman Community Hospital
has provided services to its local community since 1922, and it is the oldest facility of the three
merging organizations.
This facility has accessibility issues and was deemed noncompliant with ADA guidelines during
the last Joint Commission accreditation survey. Since the hospital staff and patient population
are primarily of one ethnicity, the hospital has not seen the need to address cultural diversity
training, and therefore it was found noncompliant with TJC standards on leadership.
The employees of Hickman are like family—they stick together. While Hickman is the lowestpaying hospital in the area, the family culture has contributed to the longevity of its staff.
The HIM department does not currently have any AHIMA-credentialed staff members and does
not have any coding quality or quantity expectations in place for the part-time staff members
responsible for coding the charts. Hickman is still using paper-based records and manual coding
books and resources for coding and billing resources. Hickman currently has a ten-day
turnaround time from discharge to final bill dropped, and there is currently no specified
number of charts that should be completed on an hourly or daily basis by coders.
The acting HIM manager has been employed by Hickman for 35 years and is very fond of her
staff; she insists they do the best job in town. Her job as acting HIM manager was meant to be
temporary while Hickman searched for a credentialed replacement. The one candidate who
met all qualifications was determined “not a good fit” by the hiring committee. He was a 32-
year-old African American male and a wheelchair user. Currently, the HIM department does not
have any diversity in ethnicity or physical ability among staff members.
Preliminary Observations
During the first month in your new position as HIM director of Gateway Healthcare Systems,
you spent a week at each hospital getting to know staff, reviewing policies and procedures, and
making general observations.
While visiting with staff at St. Catherine’s, you noticed a few staff members were discarding
paper forms with patient-identifying information into the trash can underneath their desks,
instead of disposing of the forms in the document shredder located in the front office. You also
noticed that the “release of information” staff did not log out of their computers when they
were away from their desks.
At St. Luke’s, you overheard a discussion in the main lobby elevator between two nurses
discussing patient Mary Smith’s prognosis. When you arrived in the HIM department, there
were stacks of paper forms and old paper records scattered throughout the department with
the patient information openly displayed. In the connecting hallway that patients frequently
travel through, you found several carts of records that revealed patient-identifying information.
At Hickman Hospital, you arrived to find the staff sitting around having coffee while several
patients were waiting to be assisted with obtaining copies of their health records. The releaseof-information clerk came running into the office with a paper copy of a record to hand to one
of the patients in line, and said, “Here you go, Mrs. Brown; here’s the copy of your record from
Dr. Taylor’s office. He’s our best psychiatrist on staff! You’re in good hands!” Once all of the
patients had been waited on, the staff began discussing each patient’s requests along with their
diagnoses, medical treatment, and prognosis. At this point, you called an urgent staff meeting.
Current Facility Staffing
Name of
Facility
Number of
FTEs/PTEs
St. Catherine’s
St. Luke’s
Hickman
55 FTEs/15 PTEs
40 FTEs/5 PTEs
3 FTEs/10 PTEs
Number of
Management
Staff
5
10
1
Number of
Credentialed
Coders
4
10
0
Number of
Transcriptionists
6
8
2
Number
of
ROI Staff
6
1
0
National Performance Measurement Standards


ICD-10 Coding Productivity Study Highlights Emerging Standards
New Study Illuminates the Ongoing Road to ICD-10 Productivity and Optimization
Number of
Support Staff
FT/PT
49
16
10
Top Five Diagnoses by Hospital
St. Catherine’s
Diagnoses
Average Length of Stay
(ALOS)
Average Time to Code
in Minutes
Chronic Obstructive
Pulmonary Disease
(COPD) with Major
Complication/
Comorbidity (MCC)
10
39
Gastrointestinal (GI)
Hemorrhage with
Comorbid Condition
(CC)
11
45
Pulmonary Edema and
Respiratory Failure
9
43
Septicemia or Severe
Sepsis without
Mechanical Ventilation
(MV), 96+ Hours with
MCC
17
53
Spinal Stenosis, Lumbar
Region with Combined
Anterior/Posterior
Spinal Fusion with MCC
12
130
St. Luke’s
Diagnoses
ALOS
Average Time to Code
in Minutes
Intracranial
Hemorrhage or
Cerebral Infarction with
Comorbid Condition
(CC) or Tissue
Plasminogen Activator
(tPA) in 24 hours
6
38
Renal Failure with MCC
8
42
Spinal Stenosis, Lumbar
Region with Combined
Anterior/Posterior
Spinal Fusion with MCC
10
121
Sepsis, Unspecified
18
Organism,
Tracheostomy with MV
> 96 hours or Principal
Diagnosis Excludes (PDX
EXC) Face, Mouth &
Neck without Major
O.R.
65
Septicemia or Severe
Sepsis without
Mechanical Ventilation
(MV), 96+ Hours with
MCC
43
13
Hickman
Diagnoses
ALOS
Average Time to Code
in Minutes
COPD with MCC
8
46
Heart Failure and Shock
with MCC
10
55
Normal Newborn
1.5
30
Renal Failure with MCC
10
62
Vaginal Delivery w/o
Complicating
Diagnoses
2
45
HIM 440 Module Two Assignment Guidelines and Rubric
Overview: Stepping into a new position can be challenging under the best of circumstances, but trying to merge three distinct departmental cultures under one
HIM department adds an additional dimension to the job.
In this assignment, you will conduct a full analysis of all three HIM departments, summarizing the issues facing you as the new manager of the merged HIM
department. The first step in strategic planning is to ensure you have a full understanding of the current situation. No strategic plan, no matter how detailed it is,
will be successful if you are not working with an accurate picture of your starting point.
As a next step, you will complete a SWOT analysis, a commonly used strategic planning tool that allows managers to consider both internal and external factors
in their department’s organizational strategy.
Prompt: Review the case study and analyze all three hospitals not only independently but also with an eye toward a successful and smooth merger. Then,
summarize the current issues facing you as the new HIM department manager. In your analysis, consider staffing, departmental relationships, productivity, and
compliance.
Next, conduct a SWOT analysis of the Gateway Healthcare Systems HIM department using a SWOT matrix. To compile your unified SWOT analysis, you will need
to analyze each of the three hospitals. Your SWOT analysis should consider current workflow processes, as well as the current state of EHR, cultural diversity,
staffing issues, and compliance issues. Once your SWOT analysis is complete, write at least three SMART goals addressing the following areas: cultural diversity,
human resources, and compliance.
Note: Section 4-3g of your textbook outlines the steps for a SWOT analysis, as does the SWOT: The High-Level Self Exam that Boosts Your Bottom Line resource.
Use the provided Module Two Assignment Template (linked in Module Two of your course) to complete this assignment.
Specifically, the following critical elements must be addressed:
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
Summarize current staffing and departmental relationship issues in each of the three hospitals.
Summarize productivity concerns in each of the three hospitals.
Summarize compliance challenges in each of the three hospitals.
Summarize any other issues that you deem important as you move forward to create a unified HIM department.
Identify the strengths of the unified HIM department.
Identify the weaknesses of the unified HIM department.
Identify opportunities for the unified HIM department.
Identify threats to the unified HIM department.
Formulate at least three SMART goals, one in each of the following areas: cultural diversity, human resources, and compliance.
Rubric
Guidelines for Submission: Your summary of the current issues should be 2 to 3 paragraphs long. Your SWOT analysis and SMART goals should be submitted
using the provided outline in the Module Two Assignment template (linked in Module Two of your course). References should be in APA format.
Critical Elements
Staffing and
Departmental
Relationship
Productivity
Compliance
Other Issues
Strengths
Weaknesses
Opportunities
Threats
Proficient (100%)
Summarizes the staffing and
departmental relationship issues of the
three hospital HIM departments based
on details provided in the case study
Summarizes the productivity issues of
the three hospital HIM departments
based on details provided in the case
study
Summarizes the compliance issues of the
three hospital HIM departments based
on details provided in the case study
Summarizes the other relevant issues in
the three hospital HIM departments
based on details provided in the case
study
Accurately identifies the strengths of the
health information management
department
Accurately identifies the weaknesses of
the health information management
department
Accurately identifies the opportunities of
the health information management
department
Accurately identifies the threats to the
health information management
department
Needs Improvement (75%)
Summarizes the staffing and departmental
relationship issues of the three hospital HIM
departments based on details provided in the
case study, but response contains inaccuracies
Summarizes the productivity issues of the
three hospital HIM departments based on
details provided in the case study, but
response contains inaccuracies
Summarizes the compliance issues of the three
hospital HIM departments based on details
provided in the case study, but response
contains inaccuracies
Summarizes the other relevant issues in the
three hospital HIM departments based on
details provided in the case study, but
response contains inaccuracies
Identifies the strengths of the health
information management department, but
response contains inaccuracies or is
incomplete
Identifies the weaknesses of the health
information management department, but
response contains inaccuracies or is
incomplete
Identifies the opportunities of the health
information management department, but
response contains inaccuracies or is
incomplete
Identifies the threats to the health information
management department, but response
contains inaccuracies or is incomplete
Not Evident (0%)
Does not summarize the staffing and
departmental relationship issues of
the three hospital HIM departments
using the provided case study
Does not summarize the productivity
issues of the three hospital HIM
departments using the provided case
study
Does not summarize the compliance
issues of the three hospital HIM
departments using the provided case
study
Does not summarize the other
relevant issues in the three hospital
HIM departments using the provided
case study
Does not identify the strengths of the
health information management
department or does not utilize the
case study
Does not identify the weaknesses of
the health information management
department or does not utilize the
case study
Does not identify the opportunities
of the health information
management department or does
not utilize the case study
Does not identify the threats to the
health information management
department or does not utilize the
case study
Value
11
11
11
11
10
10
10
10
Critical Elements
SMART Goals
Proficient (100%)
Formulates relevant SMART goals in the
areas of cultural diversity, human
resources, and compliance
Articulation of
Response
Submission has no major errors related
to citations, grammar, spelling, syntax,
or organization
Needs Improvement (75%)
Formulates SMART goals, but response is
illogical and/or irrelevant or does not cover the
areas of cultural diversity, human resources,
and compliance
Submission has major errors related to
citations, grammar, spelling, syntax, or
organization that negatively impact readability
and articulation of main ideas
Not Evident (0%)
Does not formulate SMART goals in
the areas of cultural diversity, human
resources, and compliance
Value
11
Submission has critical errors related
to citations, grammar, spelling,
syntax, or organization that prevent
understanding of ideas
Total
5
100%

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