Last Updated 09 Jul 2021

Nightingale Community Hospital Jcaho Audit Preparation: Information Management

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Executive summary

Nightingale Community Hospital is preparing for a Joint Commission on Accreditation of Healthcare Organizations, or JCAHO, audit. In preparation of the coming audit, Nightingale has released JCAHO’s Priority Focus Areas for the hospital. The priority focus areas outlined are Information Management, Medication Management, Communication, and Infection Control. The area of focus for this assessment will be Information Management. Information management is one of the most important systems in health care.

Maintaining a complete and accurate record of the patient’s health care information. The patient’s health record includes all information about the patient, the health care the patient has received, and all practitioner’s notes pertaining to the patient’s care. Compliance in Information Management ensures that the hospital maintains a high quality of patient care. Information management, as outlined by JCAHO, includes three Joint Commission Standards in the audit. The first standard, IM. 02. 02. 01, which encompasses whether the hospital manages the collection of information effectively.

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The standard includes three Elements of Performance, or EPs. The three EPs include whether the hospital uses standardized and uniform data sets to collect information, whether the hospital uses standard, consistent terminology, abbreviations, symbols and whether the hospital follows a policy of prohibited abbreviations, symbols, and dose designations among other performance measures (The Joint Commission, 2012). Upon review of the rst EP as well as the reports and documentation provided by Nightingale Community Hospital, the Admission Orders form allows for consistent, pertinent patient information to be collected to ensure optimal ontinuum of care for patients. The form should be reviewed on a regular basis to ensure that critical data points are included in the collection process and to include updated requirements. One piece of critical information that should be included on all Admission Orders is the admitting diagnosis. The forms also include pre-checked consultations and orders which may not apply to every patient who is admitted; this check marks in the boxes will need to be removed. In accordance with the second EP, the hospital uses standard terminology, de? itions, abbreviations, acronyms, symbols, and dose designations on the forms that have been provided (The Joint Commission, 2012). The third EP, which addresses whether Nightingale Community Hospital follows a list of prohibited abbreviations, is not in compliance with the Joint Commission’s standards. The graph on page three of the National Patient Safety Goal Data: Information Management report, shows the incidence of using prohibited abbreviations was not within acceptable thresholds for January or December; the goal for compliance is 99. 6%.

To achieve compliance with the Joint Commission, the organization must not have more than 2 occurrences of non-compliance. The organization improved by eliminating the use of three abbreviations: qd, x3d, and sc. The organization’s graph shows that in January the abbreviation, u, was used 17% of the time and in December was used 63% which is an increase of 46%. To be in compliance with the hospital’s benchmark, the occurrences must be at or below the error threshold of 04%. To accomplish the task, the organization will need to implement a corrective action plan.

To begin, the organization will need to appoint an Information Management compliance team. The compliance team’s primary responsibilities should be limited to auditing the non-compliant records to determine trends in usage of prohibited abbreviations. When the audit is complete, the results will determine the source of the usage of prohibited abbreviations. The possibility of a specifc department or an individual within a department making the error will be reviewed. After identifying the cause of the increase in abbreviation errors, the team will make a recommendation for departmental compliance training or organization-wide compliance training. The departments leaders will be responsible for developing a compliance training plan, performing the designated training, then documenting who attended training as well as the training dates. Additional audits will be performed at three month intervals post-training to ensure Nightingale Community Hospital’s and The Joint Commission’s standards are met on a consistent basis. The next priority focus area is RC. 1. 01. 01 which ensures that the hospital maintains a separate, complete medical record for each patient. The EPs for this priority focus area include the medical record retention policy and the release of medical records policy (The Joint Commission, 2012). Nightingale Community Hospital appears to be compliant with the Joint Commission’s standards in this priority focus area. The final priority focus area, RC. 01. 04. 01, which ensures that the hospital audits their medical records, has three significantly more detailed EPs:

  1. The hospital conducts an ongoing review of medical records at the point of care, based on the following indicators: presence, timeliness, legibility (whether handwritten or printed), accuracy, authentication, and completeness of data and information.
  2. The hospital measures its medical record delinquency rate at regular intervals, but no less than every three months.
  3. The medical record delinquency rate averaged from the last four quarterly measurements is 50% or less of the average monthly discharge (AMD) rate. Each individual quarterly measurement is no greater than 50% of the AMD rate (The Joint Commission, 2012).

The organization appears to be compliant with all three of the EPs. However, the organization fails to provide documentation to reflect the interval in which audits are performed

The medical record delinquency rate also needs to be documented and graphed along with other measures of delinquency. The current graph outlining patient identification documentation errors shows data for two different years. Audit data needs to be consistent in all quality improvement graphs and reports.

The lack of adequate documentation on policy and procedure for the various measures makes it difficult to accurately assess whether Nightingale Community Hospital is in complete compliance with the Joint Commission’s standards. The suggestion for the team members responsible for ensuring accurate data is collected for the Joint Commission’s future audit, is to create a spreadsheet listing the Priority Focus Areas as well as the Elements of Performance. The spreadsheet should reflect which EPs require documentation and which require a Measure of Success as well as the Scoring Category of each.

The spreadsheet will help keep the data organized and the team members can quickly see what information is missing. Staying organized and thoroughly researching each performance measurement will help ensure a successful Joint Commission compliance audit.


  1. The Joint Commission. (2012). The Joint Commission Comprehensive Accreditation and Certification Manual. Retrieved from https://e-dition. jcrinc. com/MainContent. aspx.
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