Mathematics
Healthcare Statistics

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Week 7 Course Project Part 2 Write a two- to three-page report formatted as a memo detailing areas of noncompliance and at least three recommendations for improvement. The content of the report should be based on your prior calculations, highlights, and compliance notes from the Week 6 deliverable. For full credit, the memo should include the following. Memo Components Point Value Memo Components 10 points Short introductory paragraph identifying the purpose and scope of the report 15 points A paragraph highlighting areas that the hospital is in compliance with, including release of information, record documentation and completion, incident reports, core measures, and Meaningful Use A paragraph that addresses noncompliance, which should include the items below 30 points • • • • A summary of the areas of noncompliance. Any trends identified regarding a specific type of document (such as H & P or orders, certain physicians, etc.) Emphasis on two to three noncompliant items that are most serious or important in your opinion Clear details on all noncompliant items by using tables, graphs, or bullet points 30 points A paragraph that explains at least three recommendations for improvement, which needs to apply knowledge gained about performance improvement activities, tools, techniques, and information systems or other technology, as well as processes and working with people 85 points Meets all of the components listed above Grading Rubrics Category Points % Description Part 1: Data Calculations, Standards, and Compliance Notes Week 6 Deliverable Completion Timeliness Calculated for the Hospital 40 Calculations necessary to find completion timeliness for each of the items listed above Compliance Standards Identified 15 Standards for each item as listed above identified Compliance Rates Calculated for the Hospital 30 Compliance rates calculated based on the standards identified for each item listed Total points for Week 6 85 Week 7 Deliverable 50% Part 2: Report Introduction 10 Short introductory paragraph identifying the purpose and scope of the report Areas of Compliance 15 Paragraph highlighting areas of compliance as described above Areas of Noncompliance 25 Paragraph that addresses noncompliance as detailed in the guidelines section above Recommendations 25 Minimum of three recommendations for improvement with justification Category Points % Description Grammar and Formatting 5 Memo written by following the format provided and free of grammar errors Organization and Cohesiveness 5 Content well organized, connected, and supported Total points for Week 7 85 50% Total 170 100 A quality project will meet or exceed all of the above requirements. HIT 226 Course Project: Hospital Data Analysis and Reporting The data below is from General Hospital. Calculate the turnaround time for each request. Assume that the acceptable turnaround time is Release of Information Report for January 2015 # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Date Received 01/01/15 01/04/15 01/05/15 01/09/15 01/10/15 01/11/15 01/11/15 01/15/15 01/17/15 01/18/15 01/20/15 01/21/15 01/21/15 01/21/15 01/25/15 01/25/15 01/27/15 01/28/15 01/31/15 01/31/15 Client Name Jones, Johnny King, Samantha Piazza, Anthony Legend, Mary Stepnowski, Joseph Largent, Khalif Williams, Michael Teller, Aiden Hower, Layla Cartwright, Renee Perez, Stacey Santoso, Susan Williams, William Abrams, Jonah Stern, Kimberly Sran, Timothy Berger, Mark Romano, Maria Smith, Jennifer Martinez, Alonso Requestor Name PCP St. Lawrence PCP Attorney Robert Wood Johnson Mother PCP PCP Bayonne Medical Center Robert Wood Johnson PCP Attorney St. Lawrence St. Lawrence Robert Wood Johnson PCP PCP Attorney St. Lukes PCP Info Disclosed H&P D/C Summary D/C Summary D/C Summary X-rays D/C Summary H&P D/C Summary D/C Summary Lab reports X-rays X-rays D/C Summary D/C Summary H&P Lab reports X-rays D/C Summary D/C Summary D/C Summary Purpose of Disclosure Continuity of Care Continuity of Care Continuity of Care Litigation Continuity of Care Individual Continuity of Care Continuity of Care Continuity of Care Continuity of Care Continuity of Care Litigation Continuity of Care Continuity of Care Continuity of Care Continuity of Care Continuity of Care Litigation Continuity of Care Continuity of Care t the acceptable turnaround time is 21 days. Date Disclosed 01/11/15 01/24/15 02/04/15 02/18/15 01/11/15 03/02/15 01/17/15 01/20/15 02/26/15 02/01/15 03/05/15 03/01/15 01/28/15 04/05/15 01/31/15 02/05/15 02/09/15 02/01/15 03/03/15 05/04/15 5 points Records Offsite Staff ID # Turnaround Time N 14571 10 N 14571 20 N 25148 30 Y 25148 40 N 25148 1 N 14571 50 N 14571 6 N 25148 5 N 14571 40 Y 14571 14 Y 25148 44 N 14571 39 N 14571 7 N 25148 74 N 25148 6 N 25148 11 N 25148 13 N 14571 4 N 14571 31 Y 25148 93 HIT 226 Course Project: Hospital Data Analysis and Reporting The data below is from General Hospital. Calculate the turnaround time for each order. Assume that the acceptable turnaround time is 0 Physician Order Report for January 2015 Physician : Dr. Jones Client Medical Record #: 123456 Date of Admission: 1/6/15 Date of Discharge: 1/9/15 Date of Order Date Signed 01/06/15 01/06/15 01/06/15 01/06/15 01/06/15 01/07/15 01/07/15 01/08/15 01/07/15 01/07/15 01/08/15 01/08/15 2 points Turnaround Time 0 0 1 1 0 0 Physicians: Dr. Huffman Client Medical Record #: 654789 Date of Admission: 1/10/15 Date of Discharge: 1/15/15 Date of Order Date Signed 01/10/15 01/10/15 01/10/15 01/10/15 01/10/15 01/11/15 01/10/15 01/11/15 01/11/15 01/11/15 01/12/15 01/12/15 01/12/15 01/14/15 01/12/15 01/14/15 01/12/15 01/14/15 3 points Turnaround Time 0 0 1 1 0 0 2 2 2 HIT 226 Course Project - Data Analysis and Identification of Noncompliance - Due in Week 6, day 7 (Sunday midnight) The data below is from General Hospital. Assume the acceptable turnaround (TAT) for dictating the H&P is 0 day and signing is 1 day. History and physical dictation (how many days it took to dictate the H&P for each admission — subtract date of admission from the date o History and physical signature (how many days it took to sign the H&P — subtract date of admission from the date signed) History and Physical Report for January 2015 5 points # MR # Physician Date of Admission Date Dictated Date Transcribed Date Signed Dictated TAT 1 789321 Leiberman 01/04/15 01/04/15 01/04/15 01/04/15 0 2 456321 Huffman 01/04/15 01/05/15 01/05/15 01/06/15 1 3 741852 Patrikus 01/06/15 01/07/15 01/08/15 01/08/15 1 4 963321 Johns 01/07/15 01/08/15 01/07/15 01/09/15 1 5 144558 Huffman 01/10/15 01/10/15 01/11/15 01/10/15 0 6 695852 Leiberman 01/10/15 01/10/15 01/10/15 01/10/15 0 7 124536 Huffman 01/12/15 01/12/15 01/12/15 01/12/15 0 8 379152 Leiberman 01/15/15 01/16/15 01/16/15 01/16/15 1 9 685982 Jones 01/16/15 01/16/15 01/16/15 01/17/15 0 10 558844 Jones 01/17/15 01/17/15 01/17/15 01/18/15 0 11 415287 Johns 01/20/15 01/22/15 01/22/15 01/24/15 2 12 919125 Patrikus 01/20/15 01/20/15 01/20/15 01/22/15 0 13 744445 Patrikus 01/21/15 01/21/15 01/21/15 01/25/15 0 14 111111 Patrikus 01/21/15 01/21/15 01/21/15 01/22/15 0 15 145281 Huffman 01/26/15 01/26/15 01/27/15 01/27/15 0 16 144417 Leiberman 01/26/15 01/26/15 01/26/15 01/27/15 0 17 695833 Patrikus 01/27/15 01/27/15 01/27/15 01/31/15 0 18 335588 Johns 01/28/15 01/31/15 01/31/15 02/02/15 3 19 457924 Jones 01/31/15 01/31/15 01/31/15 02/01/15 0 20 414519 Huffman 01/31/15 01/31/15 01/31/15 02/01/15 0 unday midnight) &P is 0 day and signing is 1 day. t date of admission from the date of dictation) om the date signed) 5 points Signed TAT 0 2 2 2 0 0 0 1 1 1 4 2 4 1 1 1 4 5 1 1 HIT 226 Course Project - Data Analysis and Identification of Noncompliance - Due in Week 6, day 7 (Sunday midnight) The data below is from General Hospital. Assume the acceptable turnaround (TAT) for dictating the discharge summary is 14 days and sign Discharge summary completion (how many days it took to dictate the DC for each admission — subtract date of discharge from the date o Discharge summary signature (how many days it took to sign the DC — subtract date of discharge from the date signed) Discharge Summary Report for January 2015 5 points # MR # Physician Date of Discharge Date Dictated Date Transcribed Date Signed Dictated TAT 1 789321 Leiberman 01/07/15 02/01/15 02/01/15 02/15/15 25 2 456321 Huffman 01/08/15 01/28/15 01/30/15 02/13/15 20 3 741852 Patrikus 01/10/15 01/25/15 01/18/15 02/12/15 15 4 963321 Johns 01/28/15 02/07/15 02/08/15 02/10/15 10 5 144558 Huffman 01/12/15 01/17/15 01/29/15 02/28/15 5 6 695852 Leiberman 01/11/15 01/11/15 01/31/15 02/12/15 0 7 124536 Huffman 01/18/15 02/15/15 02/15/15 02/21/15 28 8 379152 Leiberman 01/17/15 02/07/15 02/08/15 03/01/15 21 9 685982 Jones 01/19/15 01/19/15 01/20/15 01/21/15 0 10 558844 Jones 01/18/15 01/25/15 01/25/15 01/28/15 7 11 415287 Johns 01/21/15 01/24/15 01/25/15 01/31/15 3 12 919125 Patrikus 01/26/15 01/31/15 02/01/15 02/15/15 5 13 744445 Patrikus 01/24/15 02/04/15 02/04/15 02/06/15 11 14 111111 Patrikus 01/23/15 01/26/15 01/26/15 01/31/15 3 15 145281 Huffman 01/28/15 01/31/15 01/31/15 03/08/15 3 16 144417 Leiberman 01/31/15 02/28/15 02/28/15 03/04/15 28 17 695833 Patrikus 02/01/15 02/15/15 02/15/15 02/21/15 14 18 335588 Johns 02/01/15 02/15/15 02/15/15 02/19/15 14 19 457924 Jones 02/10/15 02/10/15 02/11/15 02/12/15 0 20 414519 Huffman 02/06/15 02/07/15 02/07/15 04/01/15 1 ge summary is 14 days and signing is 21 days. e of discharge from the date of dictation) 5 points Signed TAT 39 36 33 13 47 32 34 43 2 10 10 20 13 8 39 32 20 18 2 54 HIT 226 Course Project - Data Analysis and Identification of Noncompliance - Due in Week 6, day 7 (Sunday midnight) The data below is from General Hospital. Assume the acceptable turnaround (TAT) for dictating the operative report is 0 days, transcribing Operative report completion (how many days it took to dictate the OP report for each admission — subtract date of surgery from the date Operative report signature (how many days it took to sign the OP report — subtract date of admission from the date signed) Operative Report for January 2015 5 points # MR # Physician Date of Operation Date Dictated Date Transcribed Date Signed Dictated TAT 1 789321 Leiberman 01/04/15 01/04/15 01/04/15 01/06/15 0 2 456321 Huffman 01/05/15 01/05/15 01/05/15 01/07/15 0 3 741852 Patrikus 01/06/15 01/07/15 01/07/15 01/07/15 1 4 963321 Johns 01/08/15 01/09/15 01/09/15 01/09/15 1 5 144558 Huffman 01/10/15 01/10/15 01/10/15 01/10/15 0 6 695852 Leiberman 01/10/15 01/10/15 01/10/15 01/10/15 0 7 124536 Huffman 01/13/15 01/13/15 01/13/15 01/13/15 0 8 379152 Leiberman 01/15/15 01/17/15 01/17/15 01/19/15 2 9 685982 Jones 01/16/15 01/17/15 01/17/15 01/20/15 1 10 558844 Jones 01/18/15 01/20/15 01/20/15 01/27/15 2 11 415287 Johns 01/21/15 01/22/15 01/22/15 01/22/15 1 12 919125 Patrikus 01/20/15 01/21/15 01/21/15 01/21/15 1 13 744445 Patrikus 01/22/15 01/22/15 01/22/15 01/23/15 0 14 111111 Patrikus 01/21/15 01/21/15 01/21/15 01/21/15 0 15 145281 Huffman 01/27/15 01/27/15 01/27/15 01/27/15 0 16 144417 Leiberman 01/26/15 01/31/15 01/31/15 02/02/15 5 17 695833 Patrikus 01/28/15 01/28/15 01/28/15 01/29/15 0 18 335588 Johns 01/28/15 01/29/15 01/29/15 01/29/15 1 19 457924 Jones 01/31/15 01/31/15 01/31/15 02/10/15 0 20 414519 Huffman 02/01/15 02/01/15 02/01/15 02/02/15 0 Sunday midnight) perative report is 0 days, transcribing is 1 day, and signing is 1 day. ubtract date of surgery from the date of dictation) n from the date signed) 5 points Signed TAT 2 2 1 1 0 0 0 4 4 9 1 1 1 0 0 7 1 1 10 1 HIT226 Course Project: Hospital Data Analysis and Reporting The data below is from General Hospital. Indicate which of the following are covered by The Joint Commission's Hospital Patient Safety Go http://www.jointcommission.org/hap_2015_npsgs/ Incident Report for January 2015 Type of Incident Falls from bed Patient elopement Allergic reaction Blood transfusion reaction Hospital acquired infections Medication error Number of Incidents 15 10 20 2 12 22 5 points Covered by TJC PSGs No No No No No Yes HIT226 Course Project: Hospital Data Analysis and Reporting The data below is from General Hospital. Populate columns I, J, and K. Evaluate each measure to determine whether it is better or worse. Core Measure Report for January 2015 - MI & CHF (Myocardial Infarction & Congestive Heart Failure) Heart Attach Care Average number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital General Hospital 57 National Average 59 Average number of minutes before outpatients with chest pain or possible heart attack got an ECG 9 7 Outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrival 43% 57% Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival 95% 96% Heart attack patients given fibrinolytic medication within 30 minutes of arrival 37% 58% Heart attack patients given PCI within 90 minutes of arrival 94% 96% Heart Failure Care Heart Failure patients given discharge instructions Heart Failure patients given an evaluation of left ventricular systolic (LVS) function Heart Failure patients given an ACE inhibitor or ARB for left ventricular systolic dysfunction (LVSD) General Hospital 94% 100% 75% National Average 94% 99% 97% sure to determine whether it is better or worse. 5 points 5 points General Hospital's Results Minimum Expected 60 Worse than the National Average Worse than the Minimum Expected 10 Better than the National Average Worse than the Minimum Expected 50% Worse than the National Average Worse than the Minimum Expected 90% Worse than the National Average Better than the Minimum Expected 50% Worse than the National Average Worse than the Minimum Expected 80% Worse than the National Average Better than the Minimum Expected Minimum Expected 80% 80% 80% General Hospital's Results Equal to the National Average Better than the Minimum Expected Better than the National Average Better than the Minimum Expected Worse than the National Average Worse than the Minimum Expected 5 points Comment on areas that need improvement Transportation of patient's with spicalized care for heart conditions need to be addressed The number of minutes needed for a heart condition patient to have a EKG needs to addressed. Possibly having my EKG machines and staf Number of minutes of when a heart consition patient recieves medication for blood clots need to be reaccessed. Possibly retarianing with Although worse that the National average, General Hospital is better than the Minimum Expected of heart condition patients having aspiri Fibrinolytic medication timeframe need to be addressed. Staff need to administer medication quicker Worse than the National Average but better than the Minimum Expected, administering medication for heart patients should be addressed Comment on areas that need improvement Equal to the National Average and better than the Minimum Expected, General Hospital is going very wll with their discharge instructions f Heart failure care at General Hospital is going excellent in terms of evaluating the left ventrical systolic (LVS) function Needs improvemtnt in giving patient ACE inhibitor or ARB for LVSD aving my EKG machines and staff need to be on their toes more. essed. Possibly retarianing with staff can improve this timeframe HIT 226 Course Project; Hospital Data Analysis and Reporting The data below is from General Hospital. Analyze the data to determine compliance with Meaningful Use Requirements Stage 1 for Eligibl Hospitals. Use the Attestation Worksheet for Stage 1 of the Medicare Electronic Health Record (EHR) Incentive Program, provided as a sep document in doc sharing. Selected Meaningful Use Measures for January 2015 Selected Meaningful Use Measures Percentage of patients that had at least one medication order entered through the CPOE Results 50% The eligible hospital or CAH has enabled the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period No Percentage of patients who had at least one entry (or an indication that the patient has no known medical allergies) recorded as structured data 50% with Meaningful Use Requirements Stage 1 for Eligible th Record (EHR) Incentive Program, provided as a separate 5 points Meets the Meaningful Use Requirements No Yes Yes HIT 226 Course Project; Hospital Data Analysis and Reporting Populate the following using the Medicare Conditions of Participation http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr;sid=7cd2211cd5ed95616dae1fb3a1839d3f;rgn=div5;view=text;node=42:5.0.1.1.1;idno=42;cc= Medicare Conditions of Participation A medical history and physical examination be completed and documented for each patient no more than Final diagnosis with completion of medical records within 5 points 30 A preanesthesia evaluation must be completed and documented within days following discharge. 5 points 48 hours prior to surgery or a procedure requirin text;node=42:5.0.1.1.1;idno=42;cc=ecfr#se42.5.482_124 5 points 30 days before or 5 points 24 r to surgery or a procedure requiring anesthesia services. hours after admission or registration. Week 7 Course Project Part 2 Write a two- to three-page report formatted as a memo detailing areas of noncompliance and at least three recommendations for improvement. The content of the report should be based on your prior calculations, highlights, and compliance notes from the Week 6 deliverable. For full credit, the memo should include the following. Memo Components Point Value Memo Components 10 points Short introductory paragraph identifying the purpose and scope of the report 15 points A paragraph highlighting areas that the hospital is in compliance with, including release of information, record documentation and completion, incident reports, core measures, and Meaningful Use A paragraph that addresses noncompliance, which should include the items below 30 points • • • • A summary of the areas of noncompliance. Any trends identified regarding a specific type of document (such as H & P or orders, certain physicians, etc.) Emphasis on two to three noncompliant items that are most serious or important in your opinion Clear details on all noncompliant items by using tables, graphs, or bullet points 30 points A paragraph that explains at least three recommendations for improvement, which needs to apply knowledge gained about performance improvement activities, tools, techniques, and information systems or other technology, as well as processes and working with people 85 points Meets all of the components listed above Grading Rubrics Category Points % Description Part 1: Data Calculations, Standards, and Compliance Notes Week 6 Deliverable Completion Timeliness Calculated for the Hospital 40 Calculations necessary to find completion timeliness for each of the items listed above Compliance Standards Identified 15 Standards for each item as listed above identified Compliance Rates Calculated for the Hospital 30 Compliance rates calculated based on the standards identified for each item listed Total points for Week 6 85 Week 7 Deliverable 50% Part 2: Report Introduction 10 Short introductory paragraph identifying the purpose and scope of the report Areas of Compliance 15 Paragraph highlighting areas of compliance as described above Areas of Noncompliance 25 Paragraph that addresses noncompliance as detailed in the guidelines section above Recommendations 25 Minimum of three recommendations for improvement with justification Category Points % Description Grammar and Formatting 5 Memo written by following the format provided and free of grammar errors Organization and Cohesiveness 5 Content wel ...
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