- Calhoun Community College
- Mid-South Community College
-
South Arkansas Community College
- Kern Community College District (KCCD)
- Los Rios Community College District
- Mt. San Antonio Community College District
- San Diego State University Research Foundation
- San Jose State University Research Foundation
- San Bernardino Community College District
-
Youth Policy Institute
- Spanish Speaking Unity Council
- Otero Junior College
- National Council of La Raza
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Providence Health Foundation of Providence Hospital
DeKalb Technical College (DTC)
Governors State University
Indianapolis Private Industry Council, Inc.
Ivy Tech Community College of Indiana
Iowa Workforce Development
Maysville Community and Technical College
Louisiana Technical College, Greater Acadiana Region 4
Southern University at ShreveportMaine Department of Labor
The Community College of Baltimore County (CCBC)
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Macomb Community College
Northland Community and Technical College
MN State Colleges & Universities DBA Pine Technical College
South Central College
The Montgomery Institute
Full Employment Council
Crowder College
Maryville University - St. Louis
American Indian Opportunities Industrialization Center
University of New Hampshire
Passaic County Community College
Fulton Montgomery Community College (FMCC)
Hudson Valley Community College (HVCC)
University Behavioral Associates, Inc.
Workforce Investment Board of Herkimer, Madison, and Oneida Counties
Goodwill Industries, Inc., Serving E. Neb and SW Iowa
Nevada Cancer Institute
Berea Children's Home
Total
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BioOhio
Cincinnati State Technical and Community College
Columbus State Community College
Enterprise for Employment and Education
Trident Technical College
Florence-Darlington Technical College (FDTC)
The University of South Dakota
Centerstone of Tennessee, Inc.
North Central Texas College
San Jacinto Community College District
The University of Texas Medical Branch at Galveston (UTMB)
Shenandoah Valley Workforce Investment Board, Inc. (SVWIB)
Workforce Training and Education Coordinating Board |
Standard
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Elements of Performance
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Standard IM.2.10 "Information privacy and confidentiality are maintained." JCAHO defines privacy as "an individual's right to limit the disclosure of personal information" and confidentiality as "the safekeeping of data/information so as to restrict access to individuals who have need, reason, and permission for such access." |
Developed written processes based on and consistent with applicable laws addressing privacy and confidentiality
Policies have been effectively communicated to staff
Effective processes for enforcing policy
Monitor compliance with the policy
Use monitoring results for improving privacy and confidentiality
Patients are aware of uses and disclosures that may or will be made
Removal of identifiers encouraged
PHI is used for purposes identified to patients or as required by law and not further disclosed without patient authorization
Hospital preserves confidentiality of information and “requires extraordinary means to preserve patient privacy”
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IM.2.20 ensures that “Information security, including data integrity, is maintained.”
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There are 7 Elements of Performance including:
Developed written process based on and consistent with applicable law that addresses information security, including data integrity
Effective communication of policy, and any changes, to applicable staff
Effective process for enforcing the policy
Monitors compliance with policy
Monitoring results and technology developments used to improve information security, including data integrity
Develops and implements controls to safeguard data and information, including the clinical record, against loss, destruction, and tampering
Policies and procedures, including plans for implementation and for electronic information systems, address: data integrity, authentication, non-repudiation, encryption as warranted, and auditability, as appropriate to the system and types of information, e.g., patient information and billing information.
JCAHO specifies the following controls for safeguarding data and information:
Developing and implementing policies when removal of records is permitted
Protecting data and information against unauthorized intrusion, corruption or damage
reventing falsification of data and information
Developing and implementing guidelines to prevent the destruction of records
Developing and implementing guidelines for destroying copies of records
Protecting records in a manner that minimizes the possibility of damage from fire and water.
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JCAHO IM.2.30, which requires “The hospital has a process for maintaining continuity of information.”
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Business continuity/disaster recovery plan
Periodic testing to ensure business interruption backup techniques are effective
Electronic systems – business continuity/disaster recovery plan addresses the following:
- • Plans for scheduled/unscheduled interruptions, including end user training
- • Contingency procedures
- • Plans for minimal interruptions during scheduled downtime
- • Emergency service plan
- • Back up system
- • Data retrieval – including from storage and information presently in active systems
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IM 3.0 requires that the hospital has processes in place to effectively manage information, including the capturing, reporting, processing, storing, retrieving, disseminating, and displaying of clinical/service and non-clinical data and information.
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Uniform data definitions and data capture methods
- • Minimum data sets, terminology definitions, classifications, vocabulary, and standardized nomenclature
- • Industry standards are used when possible
Abbreviations, acronyms, and symbols are standardized throughout the hospital and there is a “don't use” list
Quality control systems are used to monitor data content and collection activities
- • Method used assures timely and economical data collection with the degree of accuracy, completeness, and discrimination necessary for their intended use
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(Source: wikimedia.org)
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Executive Director of Information Services:
30 employees
budget of approximately $3.2 million for operating and capital projects
undergraduate degree in business administration, computer science, health administration or other technical field, and a graduate degree preferred
eight years experience, with three to five of those years in progressive management experience
recent experience in the health care field
understanding of project management and change management
reports to the Chief Operating Officer |
Director of Health Information Management
three managers with 40 full-time direct reports
Registered Health Information Administratorm certification
10 years of experience in health records, some management experience
reports to the Chief Operating Officer
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Chief Security Officer The Vice President of Marketing and Business Development serves is responsible for security of information.
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