To complete this assignment please follow the instruction given: (open the documents)?

Course Project: Hospital Data Analysis and Reporting

Objective

The purpose of this Course Project is to apply the knowledge gained in analyzing various performance indicators of a hospital, analyzing trends, determining compliance or poor performance areas, and providing recommendations for improvement or solutions.

Guidelines

For this Course Project, you are asked to analyze a number of status reports for General Hospital, determine compliance with indicators provided to you, and provide suggestions or make recommendations for improvement where needed.

Data on the following indicators are provided in a Microsoft Excel document.

1. Release of Information Reports (ROI)

2. Record Completion: Physician Orders (PO)

3. Record Completion: History and Physical (H & P)

4. Record Completion: Discharge Summary (DC Summary)

5. Report Completion: Operative Report (OP Report)

6. Incident Reports (IR)

7. Standards

8. Rubric (grading rubric)

Part 1: Data Calculations, Standards, and Compliance Notes

Turn the General Hospital status data given for the month of January into meaningful information by performing the following.

Point Values	General Criteria	Specific Data Calculation, Standards, and Compliance Rate Components
40 points 5 points for each type of calculation listed in the last column	Calculations necessary to find completion timeliness for the following on the next column	1. Release of information for all 20 requests (how many days it took to release the information requested) 1. Physician orders (how many days it took every physician to sign each of his or her orders) 1. History and physical dictation (how many days it took to dictate the H & P for each admission?subtract date of admission from the date of dictation) 1. History and physical transcription (how many days it took to transcribe the H & P?subtract date of dictation from the date of transcription) 1. Discharge summary dictation (how many days it took to dictate the DC for each admission?subtract date of discharge from the date of dictation) 1. Discharge summary signature (how many days it took to sign the DC?subtract date of discharge from the date signed) 1. Operative report dictation (how many days it took to dictate the OP report for each admission?subtract date of surgery from the date of dictation) 1. Operative report signature (how many days it took to sign the OP report?subtract date of surgery from the date signed)
?15 points	Standards* for the following on the next column *Standards can be added in each worksheet applicable to the item being analyzed.	1. Completing ROI requests in the cases when records are on-site or off-site 1. Signing orders 1. Dictating a history and physical 1. Signing a discharge summary 1. Dictating an operative report
30 points 5 points for each of the items listed in the last column	Compliance rates based on the standards identified for the following on the next column	1. ROI requests 1. Physician orders 1. Dictation of History and Physical 1. Signing of Discharge Summary 1. Dictation of Operative Report
85 points total	?	Meets all of the components listed above

Part 2: Report

Write a two-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 prior analysis and other insight from analyzing the incident report, core measure, and meaningful use data. For full credit, the memo should include the following.

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, and incident reports. Paragraph should start with a summary sentence and then provide more details (including data) on each area the hospital is performing well.
25 points	A paragraph that addresses noncompliance, which should include the items below ? A summary of the areas of noncompliance. ? Any trends identified regarding a specific type of document (such as H & P or orders, certain physicians, core measures, 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
25 points	A paragraph that explains at least three recommendations for improvement, which need to apply knowledge gained about performance improvement activities, tools, techniques, and information systems or other technology, as well as processes and working with people. Recommendations for improvement should be specific to issues identified in the prior paragraph.
5 points	Grammar and formatting. Memo format is required.
5 points	Content of the memo is well organized. Information in the paragraphs is well connected and supported with data. For example, if you identify an area of non-compliance, it will be expected to provide a recommendation for improvement for that particular issue.
85 points	Meets all of the components listed above

Grading Rubric

Category	Points	%	Description
Deliverable: Part 1	?	?	Part 1: Data Calculations, Standards, and Compliance Notes
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*	?85	?50%
		?	?
Deliverable: Part 2	?	?	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 addressing areas of noncompliance as described above
?Recommendations	?25	?	Minimum of three recommendations for improvement with justification
?Grammar and Formatting	?5	?	Memo format is to be followed and writing should be free of grammar errors
?Organization and Cohesiveness	?5	?	Content is well organized, connected, and supported by data.
*Total points for Week 7*	*?85*	?50%
Total	?170	100	A quality project will meet or exceed all of the above requirements.?

Tools and Resources

? Access to Microsoft Word and Excel

? Professional memo template to use for your report

? All project-related documents available in Doc Sharing formatted as Word, Excel, or PDF files

? Access to the Internet

? Medicare Conditions of Participation requirements pertaining to documentation and clinical quality

? Meaningful Use Requirements for Hospitals, Stage 1

? HIPAA requirements in relation to release of information (ROI). A good resource to check out is http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/healthit/eaccess.pdf

? The Joint Commission requirements pertaining to documentation, core measures, and national patient safety goals

Best Practices

? Remember that the goal is to practice good data management skills?understanding, calculations, comparisons, analysis, and evaluation.

? Read detailed instructions for each item (more than once) until you gain clarity, and ask the instructor early if you have any questions.

? Familiarize yourself with the various formats of data and use of formulas in Excel.

? Practice good critical thinking skills.

? Take clear and consistent notes as you are doing your calculations.

? Use all the resources provided to you and do extra research to gain clarity on the compliance standards for all areas of review.

? Practice good writing skills?clear and concise statements, well-organized details to support your findings, and justifications for your recommendations.?

Submitting Course Project Deliverables

Submit your assignment to Dropbox for it section.

Release of Info Reports (ROI)

Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with the Release of Information Standards. Areas of noncompliance should be identified as well as the standard. Hint: You may use your own state’s Department of Health standards in addition to HIPAA requirements.
Release of Information Report for January
	Date Received	Client Name	Requestor Name	Info Disclosed	Purpose of Disclosure	Date Disclosed	Records Offsite	Staff ID #
1	1/1/14	Jones, Johnny	PCP	H & P	Continuity of Care	1/21/14	N	14571
2	1/4/14	King, Samantha	St. Lawrence	D/C Summary	Continuity of Care	1/17/14	N	14571
3	1/5/14	Piazza, Anthony	PCP	D/C Summary	Continuity of Care	2/8/14	N	25148
4	1/9/14	Legend, Mary	Attorney	D/C Summary	Litigation	3/3/14	Y	25148
5	1/10/14	Stepnowski, Joseph	Robert Wood Johnson	X-rays	Continuity of Care	1/14/14	N	25148
6	1/11/14	Largent, Khalif	Mother	D/C Summary	At the request of the individual	2/28/14	N	14571
7	1/11/14	Williams, Michael	PCP	H & P	Continuity of Care	1/17/14	N	14571
8	1/15/14	Teller, Aiden	PCP	D/C Summary	Continuity of Care	1/20/14	N	25148
9	1/17/14	Hower, Layla	Bayonne Medical Center	D/C Summary	Continuity of Care	2/26/14	N	14571
10	1/18/14	Cartwright, Renee	Robert Wood Johnson	Lab reports	Continuity of Care	2/1/14	Y	14571
11	1/20/14	Perez, Stacey	PCP	X-rays	Continuity of Care	3/5/14	Y	25148
12	1/21/14	Santoso, Susan	Attorney	X-rays	Litigation	3/1/14	N	14571
13	1/21/14	Williams, William	St. Lawrence	D/C Summary	Continuity of Care	1/28/14	N	14571
14	1/21/14	Abrams, Jonah	St. Lawrence	D/C Summary	Continuity of Care	4/5/14	N	25148
15	1/25/14	Stern, Kimberly	Robert Wood Johnson	H & P	Continuity of Care	1/31/14	N	25148
16	1/25/14	Sran, Timothy	PCP	Lab reports	Continuity of Care	2/5/14	N	25148
17	1/27/14	Berger, Mark	PCP	X-rays	Continuity of Care	2/9/14	N	25148
18	1/28/14	Romano, Maria	Attorney	D/C Summary	Litigation	2/1/14	N	14571
19	1/31/14	Smith, Jennifer	St. Lukes	D/C Summary	Continuity of Care	3/3/14	N	14571
20	1/31/14	Martinez, Alonso	PCP	D/C Summary	Continuity of Care	5/4/14	Y	25148

Record Completion (PO)

Course Project: Hospital Data Analysis and Reporting

The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state’s Department of Health standards.

Physician Order Report for January

Physician : Dr. Jones

Physician: Dr. Johns

Physicians: Dr. Huffman

Physician: Dr. Patrikus

Physician: Dr. Leiberman

Client Medical Record #: 123456

Client Medical Record #: 987654

Client Medical Record #: 654789

Client Medical Record #: 321789

Client Medical Record #: 741852

Date of Admission: 1/6/14

Date of Admission: 1/7/14

Date of Admission: 1/10/14

Date of Admission: 1/18/14

Date of Admission: 1/28/14

Date of Discharge: 1/9/14

Date of Discharge: 1/15/14

Date of Discharge: 1/18/14

Date of Discharge: 2/2/14

Date of Order

Date Signed

Date of Order

Date Signed

Date of Order

Date Signed

Date of Order

Date Signed

Date of Order

Date Signed

1/6/14

1/7/14

1/9/14

1/10/14

1/18/14

1/21/14

1/28/14

1/6/14

1/7/14

1/9/14

1/10/14

1/18/14

1/21/14

1/28/14

1/6/14

1/7/14

1/9/14

1/10/14

1/18/14

1/21/14

1/28/14

1/7/14

1/9/14

1/10/14

1/11/14

1/29/14

1/7/14

1/8/14

1/9/14

1/11/14

1/30/14

1/8/14

1/9/14

1/12/14

1/13/14

1/30/14

1/9/14

1/10/14

1/9/14

1/12/14

1/13/14

1/31/14

1/9/14

1/12/14

1/13/14

2/1/14

1/12/14

1/13/14

2/2/14

1/13/14

1/15/14

2/2/14

1/14/14

1/15/14

Record Completion (H & P)

Course Project – Data Analysis and Identification of Noncompliance
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state’s Department of Health standards.
History and Physical Report for January
	MR #	Physician	Date of Admission	Date Dictated	Date Transcribed	Date Signed
1	789321	Leiberman	1/4/14	1/4/14	1/4/14	1/5/14
2	456321	Huffman	1/4/14	1/5/14	1/5/14	1/5/14
3	741852	Patrikus	1/6/14	1/7/14	1/8/14	1/8/14
4	963321	Johns	1/7/14	1/7/14	1/7/14	1/10/14
5	144558	Huffman	1/10/14	1/10/14	1/11/14	1/11/14
6	695852	Leiberman	1/10/14	1/10/14	1/10/14	1/10/14
7	124536	Huffman	1/12/14	1/12/14	1/12/14	1/13/14
8	379152	Leiberman	1/15/14	1/16/14	1/16/14	1/16/14
9	685982	Jones	1/16/14	1/16/14	1/16/14	1/17/14
10	558844	Jones	1/17/14	1/17/14	1/17/14	1/18/14
11	415287	Johns	1/20/14	1/22/14	1/22/14	1/24/14
12	919125	Patrikus	1/20/14	1/20/14	1/20/14	1/22/14
13	744445	Patrikus	1/21/14	1/21/14	1/21/14	1/25/14
14	111111	Patrikus	1/21/14	1/21/14	1/21/14	1/22/14
15	145281	Huffman	1/26/14	1/26/14	1/27/14	1/27/14
16	144417	Leiberman	1/26/14	1/26/14	1/26/14	1/27/14
17	695833	Patrikus	1/27/14	1/27/14	1/27/14	1/31/14
18	335588	Johns	1/28/14	1/31/14	1/31/14	2/2/14
19	457924	Jones	1/31/14	1/31/14	1/31/14	2/1/14
20	414519	Huffman	1/31/14	1/31/14	1/31/14	2/1/14

Record Completion (DC Summary)

Course Project – Data Analysis and Identification of Noncompliance
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state’s Department of Health standards.
Discharge Summary Report for January
	MR #	Physician	Date of Discharge	Date Dictated	Date Transcribed	Date Signed
1	789321	Leiberman	1/7/14	2/1/14	2/1/14	2/15/14
2	456321	Huffman	1/8/14	1/29/14	1/30/14	2/10/14
3	741852	Patrikus	1/10/14	1/17/14	1/18/14	1/19/14
4	963321	Johns	1/28/14	2/8/14	2/8/14	2/10/14
5	144558	Huffman	1/12/14	1/29/14	1/29/14	2/28/14
6	695852	Leiberman	1/11/14	1/31/14	1/31/14	2/12/14
7	124536	Huffman	1/18/14	2/15/14	2/15/14	2/21/14
8	379152	Leiberman	1/17/14	2/7/14	2/8/14	3/1/14
9	685982	Jones	1/19/14	1/19/14	1/20/14	1/21/14
10	558844	Jones	1/18/14	1/25/14	1/25/14	1/28/14
11	415287	Johns	1/21/14	1/24/14	1/25/14	1/31/14
12	919125	Patrikus	1/26/14	1/31/14	2/1/14	2/15/14
13	744445	Patrikus	1/24/14	2/4/14	2/4/14	2/6/14
14	111111	Patrikus	1/23/14	1/26/14	1/26/14	1/31/14
15	145281	Huffman	1/28/14	1/31/14	1/31/14	3/8/14
16	144417	Leiberman	1/31/14	2/28/14	2/28/14	3/4/14
17	695833	Patrikus	2/1/14	2/15/14	2/15/14	2/21/14
18	335588	Johns	2/1/14	2/15/14	2/15/14	2/19/14
19	457924	Jones	2/10/14	2/10/14	2/11/14	2/12/14
20	414519	Huffman	2/6/14	2/7/14	2/7/14	4/1/14

Record Completion (OP Report)

Course Project – Data Analysis and Identification of Noncompliance – Due in Week 6, day 7 (Sunday midnight)
The data below is from General Hospital. Perform any calculations necessary and analyze the data to determine compliance with clinical documentation completion standards. Areas of noncompliance should be identified as well as the standard. Hint: In addition to the Medicare Conditions of Participation and The Joint Commission requirements for documentation completion, you may also use your own state’s Department of Health standards.
Operative Report for January
	MR #	Physician	Date of Operation	Date of discharge	Date Dictated	Date Transcribed	Date Signed
1	789321	Leiberman	1/4/14	1/6/14	1/4/14	1/4/14	1/7/14
2	456321	Huffman	1/5/14	1/6/14	1/5/14	1/5/14	1/6/14
3	741852	Patrikus	1/6/14	1/10/14	1/7/14	1/7/14	1/7/14
4	963321	Johns	1/8/14	1/10/14	1/8/14	1/8/14	1/8/14
5	144558	Huffman	1/10/14	1/15/14	1/10/14	1/10/14	1/11/14
6	695852	Leiberman	1/10/14	1/11/14	1/12/14	1/12/14	1/13/14
7	124536	Huffman	1/13/14	1/16/14	1/13/14	1/13/14	1/14/14
8	379152	Leiberman	1/15/14	1/18/14	1/17/14	1/17/14	1/19/14
9	685982	Jones	1/16/14	1/20/14	1/17/14	1/17/14	1/20/14
10	558844	Jones	1/18/14	1/25/14	1/20/14	1/20/14	1/27/14
11	415287	Johns	1/21/14	1/23/14	1/22/14	1/22/14	1/22/14
12	919125	Patrikus	1/20/14	1/26/14	1/21/14	1/21/14	1/21/14
13	744445	Patrikus	1/22/14	1/23/14	1/22/14	1/22/14	1/23/14
14	111111	Patrikus	1/21/14	1/28/14	1/21/14	1/21/14	1/21/14
15	145281	Huffman	1/27/14	1/28/14	1/27/14	1/27/14	1/27/14
16	144417	Leiberman	1/26/14	1/30/14	1/31/14	1/31/14	2/2/14
17	695833	Patrikus	1/28/14	1/30/14	1/28/14	1/28/14	1/29/14
18	335588	Johns	1/28/14	1/31/14	1/29/14	1/29/14	1/29/14
19	457924	Jones	1/31/14	2/5/14	1/31/14	1/31/14	2/10/14
20	414519	Huffman	2/1/14	2/3/14	2/1/14	2/1/14	2/2/14

Incident Reports (IR)

Course Project: Hospital Data Analysis and Reporting
The data below is from General Hospital. Analyze the data in terms of the 2020 Hospital National Patient Safety Goals, by The Joint Commission. Identify three areas for improvement that the hospital should focus on during February and discuss in Part 2 of the Course Project.
Incident Report for January
Type of incident	Number of incidents
Falls from bed	15
Falls from toilet	8
Medication error	9
Allergic reaction	19
Blood transfusion reaction	2
Hospital acquired infections	12
Surgical errors	1

Standards

Standard list based on CMS & The Joint Commission Guidelines and requirements

Activity

Standard

Notes

Release of information for records stored onsite

30 days