Health Information Committee
Quality improvement in healthcare is an elaborate and systematic process by various healthcare facilities to assess and improve standards of care provision and performance. Patient data handling is a broad area under quality improvement that forms part of performance enhancement as a quality improvement strategy. Patient data handling as a component of health information management is prescribed by law and regulated by legal and policy provisions that guide healthcare operationalizations. This report details Central City Hospital’s position on health information management ahead of the scheduled review by the Joint Commission. This report will highlight various components of health information management, such as privacy, security, and confidentiality, as outlined by multiple legal statutes, as well as the role of the Joint Commission in this regard.
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Importance of Being Accredited by the Joint Commission
The Joint Commission is a non-profit, tax-exempt organization whose primary responsibility is to accredit and certify healthcare organizations and programs within the U.S. The establishment of the Joint Commission came against the backdrop of the need to continuously and constantly improve care for the American public. This organization has since been working with other stakeholders in the healthcare system to evaluate healthcare organizations and programs offered in the U.S. to inspire them to excel in providing quality and safe care and subsequently enhance patient experiences and outcomes.
Accreditation by the Joint Commission is essential as it improves the quality of care provision and helps establish a consistent approach to care interventions. Accreditation also helps in the establishment of a framework for structuring and programming healthcare operations to maintain quality services. Additionally, the joint commission promotes a culture of excellence within the organization and strengthens the community’s confidence and faith in the healthcare system. In specific states, accreditation by the Joint Commission is a baseline requirement for healthcare operationalizations. As this hospital is awaiting review by the Joint Commission, it is essential to note that losing accreditation may have significant financial implications as the hospital will not be able to bill federal payers. Maintaining accreditation is vital to ensuring economic viability and patient safety within this hospital.
Differences between Licensing and Accreditation
Licensing in healthcare is the process of granting healthcare providers the authority to execute their roles in a specific legal jurisdiction. A license can only be awarded to individuals by the government upon meeting a criterion set by it. Licensure requirements differ by state and are defined by the legal statutes of that state. Accreditation, on the other hand, is the acknowledgment that a healthcare organization has either met or surpassed the standards for healthcare practices consistent with quality healthcare provision. While licensing is a government mandate, accreditation is not affiliated with any level of government and is often provided by independent non-governmental organizations.
Difference between Privacy, Confidentiality, and Security
Privacy, confidentiality, and security are vital provisions that underpin health information management. Privacy in healthcare addresses the handling of patient health data from its collection, storage, and use. Privacy confines critical health information to its collectors and handlers as well as to the patients themselves and gives justification for the use of this information by its handlers. Of significance to note in patient data privacy is that patients have the authority over their information and decide whom to use it for and for what purpose.
Confidentiality refers to the framework of safeguarding patient health information collected in the context of mutual and intimate agreement. Confidentiality often comes up between the patient and the healthcare provider since patients often confide their private health information to healthcare providers during treatment. Confidentiality addresses how to keep this information between the parties and not disclose it to a third party. It is a moral obligation for all staff within the Central City Hospital to maintain confidentiality; breaches in confidentiality erode the moral fabric of care provision and destroy trust between the patient and their caregivers. It may also have legal ramifications.
Lastly, security is a systematic and technical approach to safeguarding patient health information from unauthorized parties. Security can either be in the form of preventing access to, dissemination, and modification of patient data stored in computer systems or other healthcare storage tools or in the form of avoiding any intentional denial of care services to a patient. It can also be in the form of preventing interferences or harm to hospital storage systems.
Importance of PHI and the Function of the HIPAA Privacy Rule
Protected health information (PHI) refers to all data collected by a healthcare provider to identify an individual presenting for care intervention, used to determine appropriate care. PHI encompasses demographic information, medical and medication histories, diagnostics data, insurance information, and mental health conditions, among others. PHI is essential as it identifies and outlines patients’ private information and gives a framework for how healthcare providers can handle such information (Lutkevich, 2022). The Health Information Portability and Accountability Act (HIPAA) rule is the primary rule in America that oversees the use of, access to, and disclosure of PHI.
The HIPAA regulates how HIPAA-covered entities collect, store, maintain, and transmit PHI. Essentially, HIPAA functions to minimize or eliminate healthcare fraud and abuse by introducing medical liability reforms and fraud/abuse controls. It also ensures the security and privacy of protected health information via its privacy rules. HIPAA also enforces standards for collecting and storing health information. It guarantees health insurance portability and access by prohibiting patient discrimination based on health status and eliminating exclusions due to preexisting health conditions.
The Importance of Patients Knowing Their Health Information Will Not be Shared without the Authorization for Release of Information
There is high value in protecting the privacy and confidentiality of vital patient information. Floridi (2016) describes a nexus between human dignity and privacy and asserts that human dignity is the fundamental concept on which data protection regulations and privacy rules are based. Privacy not only dignifies humans but also has intrinsic value and, therefore, remains a basic human right. Respecting human privacy recognizes their values and attributes moral uniqueness to them. In healthcare, identifying patients’ intrinsic value also describes the acknowledgment that they are human beings first and that their suffering or incarceration is due to factors other than themselves. Patients tend to have more trust and faith in the healthcare system when they feel their PHI is secure. Research findings reveal that patients are most comfortable knowing that their information is protected and their consent is obtained before their data is used for any reason.
Importance of Ethics and Ethical Behavior in Healthcare
Ethics in healthcare details a set of principles, values, and beliefs that guide decision-making processes in healthcare. Ethical behavior is a standard of healthcare practice that is expected of all healthcare professionals. The code of ethics of medical practice outlines ethical provisions and principles that guide ethical medical practices. Ethics and ethical behavior in healthcare are essential because they help healthcare providers recognize healthcare dilemmas presented within the clinical environment. These ethical provisions also help caregivers make sound clinical judgments and decisions based on moral values and considerations while abiding by the legal provisions of healthcare practice. Ethical behavior also enables caregivers to practice with integrity and competently towards enhancing patient experiences and clinical outcomes (Varkey, 2020). therefore, all staff of the Central City Hospital must demonstrate ethical behavior in their practices and abide by the ethical provisions of their profession.
Risk Management and Why It Is Important in Healthcare
Risk management in healthcare defines an elaborate and systematic process to identify, assess, monitor, and mitigate apparent risks in the clinical environment. Risk management is targeted at enhancing patient safety and eliminating factors that may jeopardize the hospital’s ability to achieve its mission. Risk management measures in healthcare include reduction in medication errors, clinical research on apparent risks, emergency preparedness, and the establishment of a framework for incident management.
Risk management in healthcare helps healthcare organizations improve the safety of patients. It also safeguards patient data security by keeping patient data protected in case of external interference. Risk management also enables healthcare organizations to plan for catastrophic events that may jeopardize patients’ safety and quality of care (Huang et al., 2018). Lastly, risk management also shelves healthcare organizations from financial liabilities and losses accustomed to operational inefficiencies.
Conclusion
The Central City Hospital has a role in managing patients’ health information and enhancing its preparedness for the Joint Commission accreditation. Several improvement areas still exist in the handling of patient’s health data. Healthcare staff within this organization should be knowledgeable on the significance of the Joint Commission accreditation as well as the HIPAA provisions of privacy, confidentiality, and security of vital patient information. They should also be knowledgeable on risk management and its importance in the hospital.
References
Floridi, L. (2016). On Human Dignity as a Foundation for the Right to Privacy. Philosophy &Amp; Technology, 29(4), 307-312. https://doi.org/10.1007/s13347-016-0220-8
Huang, C., Iqbal, U., & Li, Y. (2018). Healthcare improvement measures in risk management and patient satisfaction. International Journal for Quality in Health Care, 30(1), 1-1. https://doi.org/10.1093/intqhc/mzx192
Lutkevich, B. (2022). What is PHI (Protected/Personal Health Information)? SearchHealthIT. They were retrieved on 27 August 2022 from https://www.techtarget.com/searchhealthit/definition/personal-health-information.
Varkey, B. (2020). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice, 30(1), 17-28. https://doi.org/10.1159/000509119
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Question 
Overview
This assignment covers all the regulations, policies, and laws that govern healthcare—medical and health records—and regulatory compliance. For this assignment, you will develop a report that will cover information regarding HIPAA, patient privacy, release of information, healthcare licensing, accreditation, safety, and risk assessment. It is essential to understand how all these components work together to protect the healthcare provider and the patient.
Health Information Committee
Instructions
View the Health Information Committee Scenario for Central City Hospital and then develop a five-page report detailing each of the components listed below.
Explain the importance of being accredited by The Joint Commission.
Discuss the difference between licensing and accreditation.
Explain the difference between privacy, confidentiality, and security in the healthcare setting.
Discuss the importance of PHI and the Function of the HIPAA Privacy rule.
Explain the importance of patients knowing their health information will not be shared without the Authorization for Release of Information.
Discuss the importance of ethics and ethical behavior in healthcare.
Explain risk management and why it is essential in healthcare.
For help with research, writing, and citation, access the library or review library guides.
This course requires the use of Strayer Writing Standards. For assistance and information, please refer to the Strayer Writing Standards link in the left-hand menu of your course. Check with your professor for any additional instructions.
The specific course learning outcome associated with this assignment is:
Assess how administrative, legal, regulatory, and professional standards impact patient care delivery and outcomes.