JC Delinquent Charts Directions
Scenario: You are the HIM Director at a hospital recently surveyed by the Joint Commission. Your department is using hybrid records. The following areas of noncompliance were reported:
· Operative reports are delinquent
· H&Ps are delinquent
In response, the Performance Improvement Committee has established a performance indicator threshold of 98.5% for monitoring ongoing compliance with meeting the operative report and H&P JC standards (measured against the average monthly operations and average monthly discharges, respectively).
You have run a report of delinquencies for the past year and now must prepare the data for presentation to the PI committee.
Directions
1. Download the 2023 Delinquent Data Report Download 2023 Delinquent Data Report (Excel file). You will input your answers on the spreadsheet and submit the completed Excel file.
2. Calculate the average monthly discharges for the year and enter in cell B15 (highlighted in yellow).
3. Calculate the average monthly operations for the year and enter in cell B16 (highlighted in red).
4. Calculate the allowable number of delinquent records based on a 50% requirement (hint: multiply the average monthly discharges by 50% – this is the number of records allowed to be delinquent). Enter in cell B17 (highlighted in blue).
5. Compare the figure from #4 to each month’s total delinquent records to determine which months are out of compliance. Add a column to the spreadsheet to capture this data.
6. Calculate the allowable number of delinquent H&Ps based on the requirement of 98.5% completion. Compare this figure to each month’s delinquent H&Ps to determine which months are out of compliance. Add a column to the spreadsheet to capture this data.
· Hint: This means only 1.5% of records may be delinquent. Use the average monthly discharges in your calculations.
7. Calculate the allowable number of delinquent operative reports based on the requirement of 98.5% completion. Compare this figure to each month’s delinquent op reports to determine which months are out of compliance. Add a column to the spreadsheet to capture this data.
· Hint: This means only 1.5% of records may be delinquent. Use the average monthly operations in your calculations.
8. Format the data (add title/headings, remove highlighting, change column sizes to accommodate text, text formatting, etc.). It should be professional, easy to understand, and ready for committee presentation.
9. Extra credit: Use the built-in Excel formula functions for your calculations. +2 points for each correct use of formula.