Health Information Management Technology: An Applied Approach 6th Edition by Nanette B. Sayles, ISBN-13: 978-1584267201

Health Information Management Technology: An Applied Approach 6th Edition by Nanette B. Sayles, ISBN-13: 978-1584267201

[PDF eBook eTextbook]

• Publisher: ‎ AHIMA; 6th edition (April 1, 2020)
• Language: ‎ English
•  816 pages
• ISBN-10: ‎ 1584267208
• ISBN-13: ‎ 978-1584267201

The sixth edition of Health Information Management Technology: An Applied Approach transforms and enhances the education and training for health information management (HIM) professionals.

The content in this book supports the American Health Information Management Association’s (AHIMA)current curricula competencies, and the chapters are mapped to AHIMA’s Registered Health Information Technology (RHIT) domains. The organization of the information provides students with a logical flow for skill development and knowledge building.

Each chapter is written by a distinguished leader in the HIM field using clear, accessible language to ensure concepts are easy to understand and reflect a solid foundation that is essential for every entry-level HIM professional. All chapters reflect current HIM trends, practices, standards, and legal issues.

Key Features:

– Expanded – Topical coverage expanded in the Clinical Terminologies, Classifications, and Code Systems; Data Management; Data Security; Research and Data Analysis; Healthcare Statistics; and Fraud and Abuse Compliance chapters

– New – Management and leadership topics reorganized to better reflect their dynamic relationship

– New – Rationales added to appendix A, check your understanding answer key, that appears in the back of the book

– Check your understanding questions throughout each chapter reinforce concepts to improve comprehension

– Real-world cases at the end of each chapter present actual scenarios faced by HIM professionals and are designed to initiate discussions that will elaborate on chapter topics

– Chapter content is mapped to AHIMA’s curricula competencies

Table of Contents:

About the Volume Editors and Chapter Authors
Preface
Student and Instructor Online Resources
Acknowledgements
Foreword
Part I Foundational Concepts
Chapter 1 Health Information Management Profession
Nanette B. Sayles, EdD, RHIA, CCS, CDIP, CHDA, CHPS, CPHI, CPHIMS, FAHIMA
Early History of Health Information Management
Hospital Standardization
Organization of the Association of Record Librarians
Approval of Formal Education and Certification Programs
Evolution of Practice
Traditional Practice
Information-Oriented Management Practice
The Future of HIM
Check Your Understanding 1.1
Today’s Professional Organization
AHIMA Mission and Vision
AHIMA Membership
AHIMA Structure and Operation
Association Leadership
Engage
National Committees
House of Delegates
State and Local Associations
Staff Structure
Accreditation of Educational Programs
Certification and Registration Program
Fellowship Program
AHIMA Support of Training and Education
AHIMA Career Map
AHIMA Foundation
Commission on Accreditation for Health Informatics and Information Management Education
Health Information Management Specialty Professional Organizations
Healthcare Information and Management Systems Society
Association for Healthcare Documentation Integrity
American Academy of Professional Coders
National Cancer Registrars Association
Check Your Understanding 1.2
Real-World Case 1.1
Real-World Case 1.2
References
Chapter 2 Healthcare Delivery Systems
Kelly Miller, MA, RHIA
Healthcare Providers
Medical Practice
Physician Assistants
Nursing Practice
Allied Health Professions
Check Your Understanding 2.1
Organization and Operation of Modern Hospitals
Types of Hospitals
Functionality
Location
Number of Beds
Specialization
Types of Ownership
Safety Net Hospitals
Critical Access Hospitals
Organization of Hospital Services
Board of Directors
Medical Staff
Administrative Staff
Patient Care Services
Diagnostic Services
Rehabilitation Services
Ancillary Support Services
Check Your Understanding 2.2
Other Types of Healthcare Services
Managed Care Organizations
Accountable Care Organizations
Ambulatory Care
Private Medical Practice
Medical Home
Hospital-Based Ambulatory Care Services
Community-Based Ambulatory Care Services
Public Health Services
Home Healthcare Services
Voluntary Agencies
Subacute Care
Long-Term Care
Long-Term Care in the Continuum of Care
Delivery of Long-Term Care Services
Biomedical and Technological Advances in Medicine
Telehealth
Electronic Health Records and Health Data
Artificial Intelligence
Check Your Understanding 2.3
Policy Making and Healthcare Delivery
Healthy People 2020
The National Institutes of Health
National Academy of Medicine Reports
Centers for Disease Control and Prevention
Local, State, and Federal Policies
Patient-Centered Outcomes Research Institute
Check Your Understanding 2.4
Modern Healthcare Delivery in the United States
Social Security Act of 1935
Public Law 89–97 of 1965
Public Law 92–603 of 1972
Utilization Review Act of 1977
Peer Review Improvement Act of 1982
Tax Equity and Fiscal Responsibility Act of 1982
Public Law 98–21 of 1983
Health Insurance Portability and Accountability Act of 1996
American Recovery and Reinvestment Act of 2009
Patient Protection and Affordable Care Act of 2010
Check Your Understanding 2.5
Real World Case 2.1
Real-World Case 2.2
References
Chapter 3 Health Information Functions, Purpose, and Users
Nanette B. Sayles, EdD, RHIA, CCS, CDIP, CHDA, CHPS, CPHI, CPHIMS, FAHIMA
Purposes of the Health Record
Primary Purposes
Secondary Purposes
Formats of the Health Record
Users of the Health Record
Individual Users
Institutional Users
Check Your Understanding 3.1
Overview of HIM Functions
Medical Transcription and Voice Recognition
Disclosure of Health Information
Clinical Coding and Reimbursement
Record Storage and Retrieval Functions
Master Patient Index
Record Storage and Retrieval Functions in a Paper Environment
Check Your Understanding 3.2
Record Storage and Retrieval in an Electronic Environment
Identification Systems
Paper Health Record – Serial Numbering System
Paper Health Record – Unit Numbering System
Paper Health Record – Serial-Unit Numbering ­System
Paper Health Record – Alphabetic Filing System
Electronic Health Record
Statistics and Research
Registries
Birth and Death Certificates
HIM Interdepartmental Relationships
Virtual HIM
HIM Information Systems
Disclosure of Health Information
Chart Tracking
Coding
Registries
Billing
Quality Improvement
Electronic Health Records
Personal Health Records
Check Your Understanding 3.3
Real-World Case 3.1
Real-World Case 3.2
References
Part II Data Content, Structures and Standards
Chapter 4 Health Record Content and Documentation
Megan R. Brickner, MSA, RHIA
Role of Documentation
Documentation Standards
Standards
Medical Staff Bylaws
Accreditation
Joint Commission
State Statutes
Legal Health Record
Check Your Understanding 4.1
General Documentation Guidelines
Check Your Understanding 4.2
Documentation by Settings
Inpatient Health Record
Medical and Surgical
Obstetric
Newborn
Emergency Department Record
Ambulatory Record
Ambulatory Surgery Record
Ancillary Departments
Physician Office Record
Long-Term Care
Rehabilitation
Behavioral Health
Home Health
Check Your Understanding 4.3
Federal and State Initiatives on Documentation
Health Information Media
Paper Health Record Documentation
Electronic Health Record Documentation
Web-Based Document Imaging
Check Your Understanding 4.4
Healthcare Providers in Documentation
Physicians
Nurses
Allied Health Professionals
HIM and Documentation
Check Your Understanding 4.5
HIM Roles
Real-World Case 4.1
Real-World Case 4.2
References
Chapter 5 Clinical Terminologies, Classifications, and Code Systems
Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA
History and Importance of Clinical Terminologies, Classifications, and Code Systems
Clinical Terminologies
SNOMED Clinical Terms
SNOMED CT Purpose and Use
SNOMED CT Content and Structure
Current Procedural Terminology
CPT Purpose and Use
CPT Content and Structure
Nursing Terminologies
Nursing Terminologies Purpose and Use
Nursing Terminologies Content and Structure
Check Your Understanding 5.1
Classifications
International Classification of Diseases, Tenth Revision, Clinical Modification
ICD-10-CM Purpose and Use
ICD-10-CM Content and Structure
ICD-10-Procedure Coding System
ICD-10-PCS Purpose and Use
ICD-10-PCS Content and Structure
International Classification of Diseases 11th Revision
ICD-11 Foundation Component and ICD-11-MMS Purpose and Use
ICD-11 Foundation Component and ICD-11-MMS Content and Structure
International Classification of Functioning, Disability, and Health
ICF Purpose and Use
ICF Content and Structure
International Classification of Diseases for Oncology, Third Edition
ICD-O-3 Purpose and Use
ICD-O-3 Content and Structure
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
DSM-5 Purpose and Use
DSM-5 Content and Structure
Check Your Understanding 5.2
Code Systems
Logical Observation Identifiers, Names, and Codes
LOINC Purpose and Use
LOINC Content and Structure
Healthcare Common Procedure Coding System Level II
HCPCS Purpose and Use
HCPCS Content and Structure
RxNorm
RxNorm Purpose and Use
RxNorm Content and Structure
Check Your Understanding 5.3
Clinical Terminologies, Classifications, and Code Systems Found in Health Data and Information Sets
Outcomes and Assessment Information Set
Healthcare Effectiveness Data and Information Set
Uniform Hospital Discharge Data Set
Common Clinical Data Set
Database of Clinical Terminologies, Classifications, and Code Systems
Check Your Understanding 5.4
Real-World Case 5.1
Real-World Case 5.2
References
Chapter 6 Data Management
Danika E. Brinda, PhD, RHIA, CHPS, HCISPP
Data Sources
Data Management
Data Elements
Data Sets
Databases
Indices
Data Mapping
Data Warehousing
Check Your Understanding 6.1
Information Governance
Valued Strategic Asset
Business Intelligence
Situation, Background, Assessment, Recommendation (SBAR)
Enterprise Information Management
Information Governance Principles for Healthcare
AHIMA’s Information Governance Adoption Model Competencies
Check Your Understanding 6.2
Data Governance
Data Stewardship
Data Integrity
Data Sharing
Data Interchange Standards
Information and Data Strategy Methods and Techniques
Data Visualization and Presentation
Critical Thinking Skills
Check Your Understanding 6.3
Data Quality
AHIMA’s Data Quality Management Model
Accuracy
Accessibility
Comprehensiveness
Consistency
Currency
Definition
Granularity
Precision
Relevancy
Timeliness
Data Collection Tools
Screen Design
Forms Design
Check Your Understanding 6.4
Clinical Documentation Integrity
CDI Tools
Check Your Understanding 6.5
Data Management and Bylaws
Provider Contracts with Healthcare Organizations
Hospital Bylaws
Data Management and Technology
HIM Roles
Check Your Understanding 6.6
Real-World Case 6.1
Real-World Case 6.2
References
Chapter 7 Secondary Data Sources
Marcia Y. Sharp, EdD, MBA, RHIA
Differences between Primary and Secondary Data Sources
Purposes and Users of Secondary Data Sources
Internal Users
External Users
Check Your Understanding 7.1
Types of Secondary Data Sources
Facility-Specific Indexes
Disease and Operation Indexes
Physician Index
Registries
Cancer Registries
Trauma Registries
Birth Defects Registries
Diabetes Registries
Implant Registries
Transplant Registries
Immunization Registries
Other Registries
Healthcare Databases
National and State Administrative Databases
National, State, and County Public Health Databases
HIM Roles
Check Your Understanding 7.2
Real-World Case 7.1
Real-World Case 7.2
References
Part III Information Protection: Access, Disclosure and Archival, Privacy and Security
Chapter 8 Health Law
Laurie A. Rinehart-Thompson, JD, RHIA, CHP, FAHIMA
Basic Legal Concepts
Types and Sources of Laws
Constitutions
Statutes
Administrative Law
Judicial Decisions
Legal Process
Initiation of Lawsuit
Discovery
E-Discovery
Trial
Evidence
Causes of Action in Professional Liability
Patient Rights Regarding Healthcare Decisions
Advance Directives
Check Your Understanding 8.1
Overview of Legal Issues in Health Information Management
Creation and Maintenance of Health Records
Ownership and Control of Health Records, Including Use and Disclosure
Use and Disclosure Under State and Federal Law
Use of Health Records in Judicial Proceedings
Legal Health Record
Importance of the Legal Health Record
Content of the Legal Health Record
Retention of the Legal Health Record
AHIMA Retention Recommendations
Destruction
Medical Staff Credentialing
Licensure
Certification
Accreditation
HIM Roles
Check Your Understanding 8.2
Real-World Case 8.1
Real-World Case 8.2
References
Chapter 9 Data Privacy and Confidentiality
Laurie A. Rinehart-Thompson, JD, RHIA, CHP, FAHIMA
Use and Disclosure
State Laws—Privacy
HIPAA Privacy Rule and ARRA
HIPAA and ARRA Overview
Office of the National Coordinator for Health Information Technology (ONC)
Applicability of the Privacy Rule
Covered Entities
Business Associates
Workforce Members
Protected Health Information
Deidentified Information
Other Basic Concepts
Individual
Personal Representative
Designated Record Set
Minimum Necessary
Treatment, Payment, and Operations
Individual Rights
Right of Access
Right to Request Amendment of PHI
Right to Request Accounting of Disclosures
Right to Request Restrictions of PHI
Right to Request Confidential Communications
Right to Complain of Privacy Rule Violations
Check Your Understanding 9.1
HIPAA Privacy Rule Documents
Notice of Privacy Practices
Consent to Use or Disclose PHI
Authorization
Uses and Disclosures of Health Information: Authorization and Patient Right of Access
Patient Has Opportunity to Agree or Object
Patient Does Not Have Opportunity to Agree or Object
Check Your Understanding 9.2
Breach Notification
Definition of Breach
Notification Requirements
Requirements Related to Commercial Uses: Marketing, Sale of Information, and Fundraising
HIPAA Privacy Rule Administrative Requirements
Designation of Privacy Officer
Standards for Policies and Procedures
Privacy Training
Enforcement of Federal Privacy Legislation and Rules
Penalties
Legal Action by State Attorneys General
Audits
Disclosure of Health Information
The Disclosure of Health Information Function
Disclosure of Health Information Quality Control
Authorizations
Valid Authorization
Who Can Authorize Release
Medical Identity Theft
Patient Verification
Fair and Accurate Credit Transactions Act (FACTA)
Patient Advocacy
Compliance
HIM Roles
Check Your Understanding 9.3
Real-World Case 9.1
Real-World Case 9.2
References
Chapter 10 Data Security
Megan R. Brickner, MSA, RHIA
Ensuring the Integrity of Data
Ensuring the Availability of Data
Data Security Threats
Threats Caused by People
Social Engineering
Threats Caused by Environmental and Hardware or Software Factors
Strategies for Minimizing Security Threats
Check Your Understanding 10.1
Components of a Security Program
Employee Awareness
Risk Management Program
Risk Analysis
Incident Detection
Incident Response Plan and Procedures
Access Safeguards
Identification
Authentication
Authorization
Physical Safeguards
Administrative Safeguards
Software Application Safeguards
Network Safeguards
Firewalls
Cryptographic Technologies
Web Security Protocols
Intrusion Detection Systems
Disaster Planning and Recovery
Risk Analysis
Disaster Planning
Disaster Recovery
Data Quality Control Processes
Check Your Understanding 10.2
Coordinated Security Program
HIPAA Security Provisions
General Rules
Administrative Safeguards
Physical Safeguards
Technical Safeguards
Organizational Requirements
Policies and Procedures and Documentation Requirements
American Recovery and Reinvestment Act of 2009 Provisions
Forensics
Check Your Understanding 10.3
HIM Roles
Real-World Case 10.1
Real-World Case 10.2
References
Part IV Informatics, Analytics, and Data Use
Chapter 11 Health Information Systems
Margret K. Amatayakul, MBA, RHIA, CHPS, CPEHR, FHIMSS
Health Information Systems
Current State of Health Information Systems
Scope of Health Information Systems
Source Systems
Administrative and Financial Applications
Clinical Departmental Applications
Specialty Clinical Systems
“Smart” Peripherals
Core Clinical EHR Systems
Results Management
Point of Care Documentation
Medication Management
Clinical Decision Support
Analytics and Reporting
Check Your Understanding 11.1
Supporting Infrastructure
Connectivity Systems
Telehealth and Newer Forms of Healthcare Delivery
Patient-Exchanged Health Information
Health Information Exchange
Check Your Understanding 11.2
Systems Development Life Cycle
Identify Needs
Specify Requirements
Design or Acquire
Develop and Implement
Maintain
Monitor Results
HIM Roles
Check Your Understanding 11.3
Real-World Case 11.1
Real-World Case 11.2
References
Chapter 12 Healthcare Information
Hertencia Bowe, EdD, MSA, RHIA, FAHIMA
Lynette M. Williamson, EdD, RHIA, CCS, CPC, FAHIMA
Role of Data Analytics in Healthcare Information
Introduction to Analytics
Analytics Tools
Data Visualization
Dashboard
Data Capture Tools
Data Mining
HIM Professionals and Analytics
Strategic Uses of Healthcare Information
Decision Support
Quality Measurement
Clinical Research
Check Your Understanding 12.1
Consumers and Healthcare Information
Introduction to Consumer Health Informatics
Health Literacy
Telehealth
Information Access and Navigational Tools
Mobile Devices
Patient Portals
Social Media
Personal Health Records
Information in Personal Health Records
Models of Personal Health Records
Patient Safety
Check Your Understanding 12.2
Health Information Exchange
Impact of HIE
Interoperability
Forms of Health Information Exchange
Benefits of Health Information Exchange
Users of Health Information Exchange
eHealth Exchange
Challenges with Sharing Healthcare Information
Patient Identity
Data Standards
Check Your Understanding 12.3
HIM Roles
Real-World Case 12.1
Real-World Case 12.2
References
Chapter 13 Research and Data Analysis
Lynette M. Williamson, EdD, RHIA, CCS, CPC, FAHIMA
Presentation of Statistical Data
Tables
Charts and Graphs
Bar Charts
Pareto Charts
Pie Charts
Line Graphs
Histograms
Frequency Polygons
Scatter Charts
Bubble Charts
Stem and Leaf Plots
Box-and-Whisker Plots
Statistical Packages and Presentation Software
Check Your Understanding 13.1
Descriptive Statistics
Frequency and Percentile
Measures of Central Tendency
Mean
Median
Mode
Measures of Variability
Range
Variance
Standard Deviation
Check Your Understanding 13.2
Normal Distribution
Inferential Statistics
t-tests
Chi-square Tests
Regression Equations
Analysis of Variance
Check Your Understanding 13.3
How to Analyze Information
Quality, Safety, and Effectiveness of Healthcare
Structure and Use of Health Information and Healthcare Outcomes
Individual Data
Comparative Data
Aggregate Data
Check Your Understanding 13.4
Research Methodologies
Quantitative Studies
Descriptive Studies
Correlational Studies
Retrospective Studies
Prospective Studies
Experimental Studies
Quasi-Experimental Studies
Qualitative Research
Grounded Theory
Ethnography
Mixed-Methods Approach
Randomization
Check Your Understanding 13.5
Institutional Review Board
Healthcare Research Organizations
Centers for Disease Control and Prevention
World Health Organization
Agency for Healthcare Research and Quality
Ethics in Research
HIM Roles
Check Your Understanding 13.6
Real-World Case 13.1
Real-World Case 13.2
References
Chapter 14 Healthcare Statistics
Marjorie H. McNeill, PhD, RHIA, CCS, FAHIMA
Discrete versus Continuous Data
Check Your Understanding 14.1
Common Statistical Measures Used in Healthcare
Three Common Examples of Ratio-Level Data: Ratios, Proportions, and Rates
Ratio
Proportion
Rate
Check Your Understanding 14.2
Acute-Care Statistical Data
Administrative Statistical Data
Inpatient Census Data
Check Your Understanding 14.3
Inpatient Bed Occupancy Rate
Bed Turnover Rate
Check Your Understanding 14.4
Length of Stay Data
Check Your Understanding 14.5
Patient Care and Clinical Statistical Data
Hospital Death (Mortality) Rates
Gross Death Rate
Net Death Rate
Newborn Death Rate
Fetal Death Rate
Maternal Death Rate
Check Your Understanding 14.6
Autopsy Rates
Gross Autopsy Rates
Net Autopsy Rates
Hospital Autopsy Rates
Newborn Autopsy Rates
Fetal Autopsy Rates
Check Your Understanding 14.7
Healthcare-Associated Infection Rates
Healthcare-Associated Infection Rates
Postoperative Infection Rates
Consultation Rates
Check Your Understanding 14.8
Case-Mix Statistical Data
Check Your Understanding 14.9
Ambulatory Care Statistical Data
Check Your Understanding 14.10
Public Health Statistics and Epidemiological Information
National Vital Statistics System
Population-Based Statistics
Birth Rates and Measures of Infant Mortality
Other Death (Mortality) Rates
Measures of Morbidity
Check Your Understanding 14.11
National Notifiable Diseases Surveillance System
HIM Roles
Check Your Understanding 14.12
Real-World Case 14.1
Real-World Case 14.2
References
Part V Revenue Cycle Management and Compliance
Chapter 15 Revenue Management and Reimbursement
Morley L. Gordon, RHIT
Healthcare Insurance
Revenue Cycle Management
Patient Registration
Documentation, Coding, and Charge Capture
Healthcare Claims Processing
Working the Accounts Receivable
Check Your Understanding 15.1
Healthcare Insurers
Commercial Insurance
Private Healthcare Insurance
Employer-Based Coverage
Employer-Based Self-Insurance Plans
Not-for-Profit and For-Profit Healthcare Plans
Managed Care
Health Maintenance Organizations
Preferred Provider Organizations
Point-of-Service Plans
Exclusive Provider Organizations
Government-Sponsored Healthcare Plans
Medicare
Medicaid
The Medicare–Medicaid Relationship
TRICARE
Veterans Health Administration
Civilian Health and Medical Program of the Department of Veterans Affairs
Indian Health Services
Workers’ Compensation
Check Your Understanding 15.2
New Trends
Health Insurance Marketplace or Exchange
Consumer-Directed Health Plans
Hospital-Acquired Conditions and Present on Admission Indicator Reporting
Medicare Access and CHIP Reauthorization Act
Patient Protection and the Affordable Care Act
Utilization Management
Case Management
Healthcare Reimbursement Methodologies
Fee-for-Service Reimbursement
Value-Based Purchasing
Traditional Fee-for-Service Reimbursement
Managed Fee-for-Service Reimbursement
Episode-of-Care Reimbursement Methodologies
Capitation
Global Payment
Prospective Payment
Medicare Acute Inpatient Prospective Payment System
Medicare Severity Diagnosis-Related Groups
Resource-Based Relative Value Scale System
Skilled Nursing Facility Prospective Payment System
Outpatient Prospective Payment System
Ambulatory Surgery Center Prospective Payment System
Home Health Prospective Payment System
Ambulance Fee Schedule
HIM Roles
Check Your Understanding 15.3
Real-World Case 15.1
Real-World Case 15.2
References
Chapter 16 Fraud and Abuse Compliance
Darline A. Foltz, RHIA, CHPS, CPC
Karen M. Lankisch, PhD, MHI, RHIA, CHDA, CPC, CPPM
Federal Regulations and Initiatives
Office of the Inspector General
False Claims Act
Whistleblower Protection Act
Anti-Kickback Statute
The Stark Law
Balanced Budget Act of 1997 and the Exclusions Program
Health Insurance Portability and Accountability Act
Health Care Fraud Prevention and Enforcement Action Team
Recovery Audit Contractor
Quality Improvement Organization
Merit-Based Incentive Payment System
Check Your Understanding 16.1
Compliance Program
Fraud and Abuse Prevention Strategies
Audits
Types of Audits
Preparing for and Conducting Audits
External Audits
Denials and Appeals
Coding and Fraud and Abuse
Coding Compliance
Queries
Computer-Assisted Coding
Check Your Understanding 16.2
Clinical Documentation Integrity
Information Systems and CDI
Clinical Documentation Integrity Monitoring and Metrics
HIM Roles
Real-World Case 16.1
Real-World Case 16.2
References
Part VI Leadership
Chapter 17 Management
Leslie L. Gordon, MS, RHIA, FAHIMA
Management
Organizational Behavior
Organizational Structure
Management Levels
Organizational Tools
Organizational Chart
Mission, Vision, and Values Statements
Policies and Procedures
Check Your Understanding 17.1
Strategic and Operational Planning
Developing Strategic and Operational Plans
Information Management Strategic Plan
Strategic Information Systems Planning
Work Analysis, Change Management, and Project Management
Work Analysis and Design
Change Management
Project Management
Project Management Life Cycle
Project Management Tools
Project Management Professional
Check Your Understanding 17.2
Financial Management
Accounting
Budgets
Supply management
Staffing
Management of Resources and Allocation
Management of Vendors and Contracts
Enterprise Information Management
Management of Mergers
Management of Corporate Compliance and Patient Safety
Risk Management and Risk Analysis
Customer Satisfaction
HIM Roles
Check Your Understanding 17.3
Real-World Case 17.1
Real-World Case 17.2
References
Chapter 18 Performance Improvement
Darcy Carter, DHSc, MHA, RHIA
Miland N. Palmer, MPH, RHIA
Performance Measurement and Quality Improvement
Traditional Performance Improvement Process
Sentinel Events
Quality Dimensions of Performance Improvement
Contemporary Approach to Process Improvement
Check Your Understanding 18.1
Fundamental Principles of Continuous Performance Improvement
The Problem Is Usually the System
Variation Is Constant
Data Must Support Performance Improvement Activities and Decisions
Support Must Come from the Top Down
The Organization Must Have a Shared Vision
Staff and Management Must Be Involved in the Process
Setting Goals Is Critical
Effective Communication Is Important
Success Should Be Celebrated
Formal Performance Improvement Activities
Checksheets
Data Abstracts
Time Ladders
Statistics-Based Modeling Techniques
Check Your Understanding 18.2
Team-Based Performance Improvement
Identifying Customers and Their Requirements
Documenting Current Processes and Identifying Barriers
Benchmarking
Collecting Current Process Data
Flow Chart Current Process
Brainstorm Problem Areas
Cause-and-Effect Diagram
Force-Field Analysis
Analyzing Process Data
Process Redesign
Recommendations for Process Change
Check Your Understanding 18.3
Managing Quality and Performance Improvement
Organizational Components of PI
Standards of Organizational Quality in Healthcare
Clinical Practice Guidelines and Protocols
Accreditation Standards
Government Regulations and Licensure Requirements
Check Your Understanding 18.4
Utilization Management
Risk Management
Risk Identification and Analysis
Loss Prevention and Reduction
Claims Management
Patient Advocacy
Accreditation Requirements for Risk Management in Acute-Care Hospitals
Clinical Quality Management Initiatives
Accountable Care Organizations
Robust Process Improvement Methodologies
Lean
Six Sigma
Lean Six Sigma
High Reliability Organizations
ISO 9001 Certification
Medication Reconciliation
HIM Roles
Check Your Understanding 18.5
Real-World Case 18.1
Real-World Case 18.2
References
Chapter 19 Leadership
Leslie L. Gordon, MS, RHIA, FAHIMA
Leadership Theories
Trait Theory
Behavior Theory
Contingency Theory
Power and Influence Theory
Leadership Styles
Patterns of Leadership
Transformational and Transactional Leadership
Check Your Understanding 19.1
Change Management
Methods of Change Management
Kotter’s Eight-Step Method to Leading Change
Lewin’s Change Management Model
Bridge’s Transitional Model of Change
Mergers
Electronic Record Systems
Leadership
Leadership Competencies
Emotional Intelligence
Leading Others
Critical-Thinking Skills
C-Suite
Chief Executive Officer
Chief Information Officer
Chief Financial Officer
Check Your Understanding 19.2
Team Leadership
Team Charter
Team Purpose
Team Selection
Team and Member Participation
Team Norms
Team Meetings
Scheduling of Meetings
Conducting Effective Meetings
Consensus Building
Communication
Check Your Understanding 19.3
Business-Related Partnerships
Internal Business Partnerships
External Business Partnerships
Leadership Roles
HIM Roles
Real-World Case 19.1
Real-World Case 19.2
References
Chapter 20 Human Resources Management
Valerie S. Prater, MBA, RHIT, FAHIMA
Human Resources Management
Roles and Responsibilities
Employment Law and Ethics
Ethical Principles
Fair Labor Standards Act of 1938
Equal Pay Act of 1963
Title VII of the Civil Rights Act of 1964
Harassment
Pregnancy Discrimination Act of 1978
Age Discrimination in Employment Act of 1967
Occupational Safety and Health Act of 1970
Americans with Disabilities Act of 1990
Civil Rights Act of 1991
Family and Medical Leave Act of 1993
Genetic Nondiscrimination Act of 2008
Major Labor Laws
Check Your Understanding 20.1
Workforce Planning and Job Analysis
Workforce Planning
Job Analysis
Job Description and Job Specifications
Recruitment and Selection
Recruitment
Selection
Testing
Interviewing
Check Your Understanding 20.2
Staffing
Organizing Work
Scheduling Work
Measuring and Improving Performance
Performance Management
Performance Measurement
Developing Standards
Measuring Performance
Performance Appraisal
Performance Appraisal Methods
Check Your Understanding 20.3
Employee Engagement and Retention
Employee Engagement
Reducing Turnover
Employee Relations and Fair Treatment
Communication Strategies
Conflict Management
Disciplinary Action
Handling Grievances
Dismissal
Labor Relations
Union Organization
Supervising in a Union Environment
Check Your Understanding 20.4
Training and Development
New Employee Orientation
Employee Training and Development
Planning and Implementation
Delivery Methods
Career Development
Employer Role
Employee Role
Return on Investment: Training and Development
Check Your Understanding 20.5
HIM Roles
Real-World Case 20.1
Real-World Case 20.2
References
Chapter 21 Ethical Issues in Health Information Management
Misty Hamilton, MBA, RHIT
Moral Values and Ethical Principles
Cultural Competence in the Healthcare Environment
Cultural Disparities in US Healthcare
Healthcare Professionals and Cultural Competence
Healthcare Organization Cultural Competence Awareness
Training Programs
Regulations for Cultural Awareness
Check Your Understanding 21.1
Ethical Foundations of Health Information Management
Professional Code of Ethics for the Health Information Management Professional
Professional Values and Obligations
Ethical Issues Related to Medical Identity Theft
Ethical Decision Making
Breach of Healthcare Ethics
Important Health Information Ethical Problems
Ethical Issues Related to Documentation and Privacy
Ethical Issues Related to Disclosure of Health Information
Ethical Issues Related to Coding
Ethical Issues Related to Quality Management, Decision Support, and Public Health
Ethical Issues Related to Managed Care
Ethical Issues Related to Sensitive Health Information
Ethical Issues Related to Research
Ethical Issues Related to Electronic Health Record Systems
Check Your Understanding 21.2
HIM Roles
Real-World Case 21.1
Real-World Case 21.2
References
Appendix A Check Your Understanding Answer Key
Appendix B Glossary
Index

Nanette B. Sayles, EdD, RHIA, CCS, CHDA, CHPS, CPHIMS, FAHIMA, is a　professor in the health information management program at East Central College in Union, Missouri.

Leslie L. Gordon, MS, RHIA, FAHIMA, is the director of performance improvement for the Southeast Alaska Regional Health Consortium.

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