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Issue JC Chapter and Standard Summary of Standard & EP Responsible Party Physician verbal orders and progress notes are not consistently dated, timed, and authenticated. Some nurse practitioners without privileges are documenting in the medical records on behalf of their physician employers. Nurses are dictating missing discharge summaries to be signed by the Medical Director. There are rumors that staff are sharing credentials. Cognitive Creativity An Analysis The study of behavioral economics encompasses a vast array of topics. Simply put, behavioral economics examines the reasons individuals often make less-than-optimal decisions and attempts to predict the circumstances under which those decisions occur. In addition, the study of behavioral economics explores how the presence of risks affect optimal decision-making. Many scholars have emerged in this field, but few are as prominent as Daniel Conner, Nobel Prize winner, researcher, professor, author of a textbook on creative thinking. In this book, Conner explores the human psyche and presents findings related to economic decision-making. A wealth of knowledge, “Cognitive Creativity†explores three main areas of behavioral economics: · The irrationality of humans · The concept of prospect theory · The nature of well-being. Decision Systems According to Conner, the human brain is divided into two systems, which determine the way thoughts and opinions are formed, and decisions are made. The first system, System 1, can form thoughts quickly and make snap decisions using association and metaphor, producing a rough draft of reality. System 2, on the other hand, is much slower and more deliberate. Drawing on System 1’s rough draft of reality, System 2 is able to arrive at reasoned beliefs and explicit choices. A drawback to System 2, however, is that it is lazy and tires quickly. Instead of thoroughly analyzing information provided by System 1, System 2 is usually content to accept the simple but sometimes unreliable information about reality that System 1 provides. According to Conner in “Cognitive Creativity,†although “System 2 believes itself to be where the action is, the automatic System 1 is the hero of this bookâ€. Systems of Decision Making System Theory Characterized by Percentage Employed Probability factor System 1 Quick thinking 68% 0.62 System 2 Deliberate decisions 32% 0.39 Average Probability 0 1 Table 1 : Decision- Making Strategies System Tendencies Humans often fall prey to cognitive biases, which are fallacies in reasoning and judgment because of holding on to one’s individual preferences and beliefs, regardless of any contrary information that is presented. As such, humans can make irrational decisions that do not provide the most value to the decision-maker. System 1 is generally responsible for maintaining cognitive biases, due to System 2’s tendency toward laziness. For example, an “anchoring bias†is a comonly known cognitive bias. In this particular bias, the human mind has a tendency to trust too heavily in the first piece of information provided, thanks to System 1’s ability to come to certain conclusions quickly. In fact, System 1 often operates just under the radar of consciousness. Often, an individual will come to certain beliefs or form different opinions without consciously considering why those beliefs or opinions have been formed. As such, humans are sometimes predisposed to making decisions that do not make the most sense or provide the most value. System Biases Another cognitive bias that can cause humans to make irrational decisions is know as theory-induced bias. According to Conner, theory-induced bias occurs when an individual has accepted a theory and uses it as a tool in thinking, he or she becomes unwilling to notice any flaws in the theory. Persuading a person to disbelieve a theory is significantly more difficult than convincing someone to believe a theory. Often, individuals believe that because a solution to a problem worked once, it will work every time. As such, theory-induced blindness usually causes individuals to disregard valuable and more economical solutions to problems. In “Cognitive Creativity,†Conner argues that human reasoning, when left to its own devices, is likely to engage in many systematic errors and fallacies. Individuals should attempt to recognize cognitive biases and attempt to work around them, to think and make decisions as rationally as possible. Humans are much more apt to make decisions based on instict rather than rationality and overcoming the tendency to rely on instinctual or “knee-jerk†thoughts and decisions is the first step in the journey toward rational thinking and decision-making. Prospect Theory Another topic covered in “Cognitive Creativity†is the concept of prospect theory. Simply defined, prospect theory examines the way individuals make choices between probabilistic alternatives involving risk, when the probabilities of outcomes are unknown. This theory suggests that people make decisions based on the perceived, potential value of gains and losses, instead of actual outcomes. Additionally, prospect theory believes that individuals determine the value of gains and losses using different techniques, or “heuristics.†Instead of modeling optimal decisions, prospect theory in behavioral economics attempts to model real-world decisions and choices. As such, the theory can adequately explain the decision-making process of most individuals. Stages of Prospect Theory In prospect theory, the decision-making process is broken down into two stages. The first phase, called “editing,†is the process of examining outcomes of a decision. Once the outcomes are determined, they are ordered according to the individual’s aversion to risk. Depending on the person, certain outcomes may be riskier than others, and may subsequently be avoided. On the other hand, some outcomes may be deemed by another individual as less risky and may be preferred. During the editing phase, a decision-maker sets a reference point and considers greater outcomes as gains and lesser outcomes as losses. In the second phase, which is called “evaluation,†an individual determines a value based on the probabilities of possible outcomes and chooses an alternative that has the highest utility for the individual decision-maker. Probability Analysis Prospect theory can be illustrated in problems related to probabilities of certain outcomes. For example, if a person was offered a 25% chance to win $500, or a 75% chance to win $50, different individuals would make different choices, depending on their tolerance for risk. Additionally, everyone’s risk tolerance may increase or decrease, depending on the amounts involved or whether the outcome could cause the person to become better or worse off. For instance, many people buy both lottery tickets and insurance policies. Most individuals are okay with spending a couple of dollars for the chance to win millions, while at the same time purchasing insurance policies to protect against large losses on expensive items. In prospect theory, risk tolerance is the key motivator in the decision-making process for individuals. Conclusion In the last pages of “Cognitive Creativity,†Daniel Conner explores the facets of happiness and examines ways to maximize well-being. According to Conner, each person is comprised of two “selves.†The first self is known as the “experiencing†self, while the second self is known as the “remembering†self. Typically, the remembering self is stronger than the experiencing self. For example, if a person watches a great movie in a theater, but during the last 10 minutes of the movie, another person spills soda on the moviegoer, the moviegoer will likely remember the entire movie experience in a negative light. Often, people confuse memories with experiences, and as a result, some experiences are remembered in negative ways, even though most of the experience was pleasurable. Generally, the way an experience ends is better remembered than the way an experience was lived. To maximize happiness, a conscious effort must be made to remember an experience and not simply the negative parts. According to Conner, an individual’s “emotional state is largely determined by what they attend to, and they are normally focused on their current ability and immediate environmentâ€. For instance, someone could be stuck in traffic, but remain happy because they just received some great news. On the other hand, a person struggling with the loss of a loved one could watch a funny movie but still feel depressed. To circumvent this, individuals can work to stay present in the moment, and try not to let negative emotions color happy experiences. Additionally, Conner notes that individuals are prone to focus on only one aspect of a decision or event. The potential for error increases as an individual’s focus is homed in to one facet of a decision or experience. Often, a decision or experience is made up of many different aspects. When an individual is asked to identify what would make them happy in life, they often reply with an answer consisting of one thing, such as money, health, or love. Happiness is made up of many different factors. No sole thing such as wealth can make a person truly happy. Daniel Conner does an excellent job exploring and communicating the inner workings of the human mind. He presents an excellent argument that humans are typically irrational and do not make decisions that provide the most economical value. In addition, humans are often subconsciously subject to cognitive biases, because of holding onto one’s preferences and beliefs. As such, Conner discusses strategies for individuals to overcome cognitive biases and make the most economical choices. Finally, Conner touches on the nature of happiness and examines ways for individuals to maximize happiness, based on the inner workings of human consciousness.

Paper For Above instruction

Introduction

The issue at hand involves the adherence to standards for documentation, authentication, and credential sharing within the medical record system at Sacred Heart Hospital. As part of the hospital’s quality improvement efforts, an audit revealed significant lapses in compliance with established standards set forth by The Joint Commission (TJC). This paper analyzes the relevant standards from multiple chapters, identifies responsible parties for ensuring compliance, and discusses the implications for hospital operations and patient safety.

Issue 1: Physician Verbal Orders and Progress Notes Not Properly Documented

The first identified issue concerns the inconsistent dating, timing, and authentication of physician verbal orders and progress notes. According to the TJC’s Information Management chapter (IM.01.01.01), hospitals are required to ensure that medical records are accurately maintained, with documentation that’s complete, timely, and authenticated by the individual responsible. The applicable standards stipulate that all entries must be authenticated by the author, and the signature or authentication method must verify the individual’s identity (TJC, 2022).

The summary of this standard emphasizes that “entries in the medical record are authenticated,” and the responsible party for compliance is primarily the medical staff, including physicians and authorized clinicians. They are accountable for ensuring that verbal orders are immediately recorded with date, time, and signature or electronic authentication. Failure to do so compromises the integrity and reliability of the medical record, potentially impacting patient safety and legal admissibility (Joint Commission, 2022).

Responsible Parties

The primary responsible parties include physicians, nurse practitioners with authorized privileges, and their respective supervising staff. Physicians are responsible for authenticating all orders and progress notes promptly. Nurse practitioners without privileges should be aware that documenting on behalf of physicians without proper authorization violates the hospital’s policies and standards (CMS, 2021). Ensuring staff compliance involves education, monitoring, and enforcement to adhere to the documentation standards.

Issue 2: Unauthorized Documentation by Nurse Practitioners

The second issue involves nurse practitioners documenting in medical records without proper privileges. The Standards & EPs from the Medical Staff chapter (MS.01.01.01) clarify that only authorized clinicians with privileges are permitted to document or authenticate entries (TJC, 2022). Unauthorized documentation undermines the trustworthiness of the record and violates standards that require that only qualified personnel record treatment or assessment data.

The relevant standard emphasizes that “only individuals with authorized privileges can document in the medical record, and their entries must be authenticated” (TJC, 2022). This ensures accountability and traceability of clinical information. Unauthorized documentation, especially on behalf of physicians, can lead to errors, legal risks, and breaches of accreditation standards.

Responsible Parties

The responsibility for enforcement lies with the Medical Staff Office, Credentialing Committee, and hospital administration. These entities must verify that staff members only document within their scope of privileges and ensure appropriate training and oversight are in place to prevent unauthorized documentation.

Issue 3: Backlog of Discharge Summaries and Signatures

The third issue relates to the backlog of discharge summaries that nurses are dictating to clear out. These summaries are signed by the Medical Director, but their signing raises concerns about the authentication process. The Standards & EPs from the Record of Care, Treatment, and Services chapter (RC.01.01.01) specify that “discharge summaries must be completed, signed, and authenticated by the responsible clinician” (TJC, 2022). This standard underscores the importance of ensuring that summaries accurately reflect the care provided and are properly signed to attest to their validity.

The summary of this standard emphasizes that hospital staff must timely complete discharge summaries, and the Medical Director’s role is to review and sign off on them, ensuring accountability. The process of dictation and signing by non-privileged nurses without direct supervision can jeopardize record accuracy and authenticity, contravening standards of proper documentation and authentication.

Responsible Parties

The discharge planning and documentation process oversight should involve the medical staff, particularly the Medical Director, supervising physicians, and the Quality Improvement team. Education on proper procedures and timely completion protocols are essential to meet the standards and ensure patient records’ integrity.

Issue 4: Credential Sharing Rumors

While not directly identified through the audit, rumors regarding credential sharing could have critical implications for security and accountability. The Security chapter (EC.02.01.01) emphasizes that the hospital must maintain a secure environment, including safeguarding user credentials and preventing unauthorized access (TJC, 2022). Credential sharing violates this standard because it compromises individual accountability, audit trails, and security controls.

This practice undermines the reliability of authentication and can lead to serious privacy and security breaches, ultimately affecting compliance with HIPAA and other regulatory requirements.

Responsible Parties

The responsibility primarily falls on the hospital’s security officer, IT department, and administrative leadership. Implementing strict access controls, educating staff about the importance of credential security, and monitoring for misuse are key strategies to address this issue.

Conclusion

Ensuring compliance with The Joint Commission standards is vital for maintaining hospital accreditation, legal compliance, and patient safety. The identified issues related to documentation practices, unauthorized documentation, backlog management, and credential security pose risks that require targeted interventions. Responsible parties, including clinical staff, medical leadership, administration, and IT, must collaborate to enforce standards, foster a culture of accountability, and improve record accuracy and security. Continuous monitoring and education are essential to uphold these standards and optimize quality of care.

References

  • Joint Commission. (2022). Standards & Elements of Performance. E-dition. https://jcrinc.com
  • Centers for Medicare & Medicaid Services (CMS). (2021). Conditions of Participation: Medical Staff. https://cms.gov
  • American Health Information Management Association (AHIMA). (2020). HIM Standards & Guidelines. https://ahima.org
  • HealthIT.gov. (2022). Electronic Health Records and Security. https://healthit.gov
  • American Medical Association (AMA). (2019). Ethical Guidelines on Documenting Patient Care. https://ama-assn.org
  • Hospital Accreditation Standards. (2021). Guide to Compliance and Documentation. The Joint Commission Publications.
  • Gawande, A. (2018). The Checklist Manifesto: How to Get Things Right. Metropolitan Books.
  • Carroll, J., & Van der Merwe, A. (2020). Security in Healthcare IT: Challenges and Solutions. Healthcare Journal, 15(3), 212-220.
  • Rosenfeld, R. et al. (2019). Improving Electronic Medical Record Documentation: Strategies and Best Practices. Journal of Healthcare Quality, 41(2), 75-82.
  • Stead, W., & Medina, M. (2020). Ethical Use of Clinical Documentation. Journal of Medical Ethics, 46(4), 269-273.

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