You are the director of HIM for Happy Valley Hospital, a 600-bed facility.

You are the director of HIM for Happy Valley Hospital, a 600-bed facility. The Joint Commission requires that all documentation for the medical record is to be completed within 30 days. Happy Valley’s rate of compliance with this requirement is 87%. More importantly, this is the second year that Happy Valley’s compliance rate is less than the required 100%. The organization’s current practice is that a letter is sent to physicians once charts have become delinquent at 30 days post-discharge. Follow-up letters continue weekly, and if charts were not completed, the previous director would call the physician office.

Since this represents a serious deficiency that affects Joint Commission accreditation, The Vice President of Quality has requested you to review the data, research the issue including causes and effects, make a project plan to increase the compliance rate of completed documentation to 100% at Happy Valley. You will present the project plan to the Vice President of Quality. Your plan should include:

the project charter

a project summary that includes a minimum of two options that could be implemented easily and have a positive impact on the record completion process and two options that will take longer to implement

an analysis of your proposed solutions including the pros and cons of each.

Questions 2 – 21 are found on pages 301 through 308 in Practice Exercise 7: Improving a Performance Gap in Your Organization. In a working document, answer these questions to complete the project charter and project summary. Your project charter should include:

Statement of the problem

Project team composition

Aim statement

Process statement

Proposed solutions

Measures of Success – specific outcome/process measures that will determine if the process changes are successfully increasing the completed record rates within the 30 day period as specified by the Joint Commission.

Use a minimum of three resources. 

Resources may be found on the internet using search terms such as “Joint Commission Standards Medical Records”, “Joint Commission Medical Record Requirements 2017”, etc.