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HI 230 PUG Issue & Excerpt Joint Commission Standards Worksheet
Instructions: I have attached all needed documents to aid with assignment
Part 1:
- Read the Case Study of SCR.
- Download the JC Standards.
- Create a table that lists each of the issues the consultant found at the hospital. Then, analyze each issue and decide which Joint Commission IM standard is in question. Then, in the Excerpt column, provide a short statement from the standard or intent to describe why you chose the IM Standard that you did.
Example
Issue |
IM Standard |
Excerpt |
The department’s plan for backup procedures is not detailed. |
IM.01.01.03 |
Note: You should have at least 10 issues presented.
Part 2:
Imagine you are the HIM Director and write a memo to the Quality Improvement Manager about your findings. Your memo should:
- describe where this hospital needs the most improvement and why.
- describe what you think the most important opportunity for improvement is.
- recommend where to focus the next performance improvement project.