Annual Assessment of Evidence of Learning ... -...

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Weber State University Annual Assessment of Evidence of Learning

Cover Page Department/Program: Health Information Management BS degree Academic Year of Report: 2014/15 Date Submitted: 12/16/2015 Report author: Pat Shaw, HIM Program Director Contact Information: Phone: 801-626-7979 Email: [email protected]

mailto:[email protected]

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A. Brief Introductory Statement:

Please review the Introductory Statement and contact information for your department displayed on the assessment site:

http://www.weber.edu/portfolio/departments.html - if this information is current, please place an ‘X’ below. No further information is

needed. We will indicate “Last Reviewed: [current date]” on the page.

_ _ Information is current; no changes required.

_X Information is not current; updates below.

Update:

Health Information Management is a program offered under Health Administrative Services.

The Utah State Board of Regents approved the development of a Health Information Management (HIM) program for the College of Health Professions in 1993 based upon evidence of a demonstrated need and strong support for the program by the Utah Hospital Association and the Utah Health Information Management Association. Health Information Management Practice Definition "Health information management represents a continuum of practice concerned with health-related information and the management of systems to collect, store, process, retrieve, analyze, disseminate, and communicate information related to the research, planning, provision, financing, and evaluation of healthcare services. Successful completion of the Health Information Management program leads to a Bachelor of Science degree in Health Administrative Services: Health Information Management emphasis. The HIM program is accredited by the Commission on Accreditation of Health Informatics and Information Management Education, allowing graduates to sit for the national registration exam. Students passing this national examination may use the professional designation of Registered Health Information Administrator (RHIA).

B. Mission Statement

Please review the Mission Statement for your department displayed on the assessment site: http://www.weber.edu/portfolio/departments.html - if

it is current, please indicate as much; we will mark the web page as “Last Reviewed [current date]”. No further information is needed.

If the information is not current, please provide an update: ___ Information is current; no changes required.

___X_ Information is not current; updates below.

HAS Department Mission Statement:

http://www.weber.edu/portfolio/departments.html


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Our mission is to develop exceptional professionals and leaders for health care organizations. The goals of the Health Information Management Program are: Faculty will demonstrate current knowledge, skills, qualifications, and professional development in the content areas they teach. Program graduates will demonstrate the HIM entry-level competencies. The HIM curriculum will include, at minimum, the required knowledge clusters with content and experiences to enable students to meet current entry-level competencies. The HIM program will demonstrate responsiveness to the needs of the community of interest. C. Student Learning Outcomes Please review the Student Learning Outcomes for your department displayed on the assessment site:

http://www.weber.edu/portfolio/departments.html - if they are current, please indicate as much; we will mark the web page as “Last Reviewed

[current date]”. No further information is needed.

If they are not current, please provide an update: ___ Information is current; no changes required.

_X Information is not current; updates below.

Measurable Learning Outcomes

At the end of their study at WSU, students in this program will:

Entry Level Competency Student Learning Outcomes

Bloom’s Level

Curricular Considerations

Domain I. Data Content, Structure & Standards (Information Governance)

DEFINITION: Academic content related to diagnostic and procedural classification and terminologies; health record documentation requirements; characteristics of the healthcare system; data accuracy and integrity; data integration and interoperability; respond to customer data needs; data management policies and procedures; information standards.

Subdomain I.A. Classification Systems

1. Evaluate, implement and manage electronic applications/systems for clinical classification and coding

5 Encoders, Computer Assisted Coding, Systems Development Life Cycle

2. Identify the functions and relationships between healthcare classification systems

3 Healthcare classification systems, and taxonomies o ICD, CPT, SNOMED-CT, DSM, RxNorm


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3. Map terminologies, vocabularies and classification systems 4 Mapping from a standard clinical terminology to a HIPAA code set

o LOINC to CPT or SNOMED-CT to ICD

Mapping from one code set to another code set o One revision of ICD to another

4. Evaluate the accuracy of diagnostic and procedural coding 5 Principles and applications of classification, taxonomies, nomenclatures, terminologies, clinical vocabularies, auditing

Subdomain I.B. Health Record Content and Documentation

1. Verify that documentation in the health record supports the diagnosis and reflects the patient’s progress, clinical findings, and discharge status

4 Health record components o General requirements for documentation for all record

types

2. Compile organization-wide health record documentation guidelines

6 Standards and regulations for documentation o The Joint Commission, CARF, CMS

Health record documentation policies and procedures

3. Interpret health information standards 5 Health information standards and regulations

Subdomain I.C. Data Governance

1. Format data to satisfy integration needs 4 Capture, structure, and use of health information

Interoperability

2. Construct and maintain the standardization of data dictionaries to meet the needs of the enterprise

6 Data dictionary composition

Data sources

3. Demonstrate compliance with internal and external data dictionary requirements

3 Accreditation standards o The Joint Commission, NCQA, CARF, CHAP, URAC

Data ,HL7, ASTM, HEDIS, ACS data standards

4. Advocate information operability and information exchange 5 Generally accepted recordkeeping principles

Subdomain I.D. Data Management

1. Analyze information needs of customers across the healthcare continuum

4 Capture, structure, and use of health information

2. Evaluate health information systems and data storage design 5 Storage media, disaster recovery, cloud computing

3. Manage clinical indices/databases/registries 5 Secondary data sources, registries, and indices

Healthcare data sets o HEDIS, UHDDS, OASIS

Indices and registry policies

4. Apply knowledge of database architecture and design to meet organizational needs

3 Database architecture and design

Data dictionary, data modeling, data warehousing

5. Evaluate data from varying sources to create meaningful presentations

5 Presentation software

Healthcare data

Indices and registries

Subdomain I.E. Secondary Data Sources

1. Validate data from secondary sources to include in the patient’s record, including personal health records

3 Data stewardship

Patient-centered health information technology

Secondary data sources, registries, and indices

Domain II. Information Protection: Access, Disclosure, Archival, Privacy & Security

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Definition: Understand healthcare law (theory of all healthcare law to exclude application of law covered in Domain V); develop privacy, security, and confidentiality policies, procedures and infrastructure; educate staff on health information protection methods; risk assessment; access and disclosure management.

Subdomain II.A. Health Law

1. Identify laws and regulations applicable to health care 3 Health information laws and regulations o HIPAA, The Joint Commission, State laws

Healthcare legal terminology

Centers for Medicare and Medicaid Services (CMS)

2. Analyze legal concepts and principles to the practice of HIM 4 Legal principles

Legal health records

Subdomain II.B. Data Privacy, Confidentiality & Security

1. Analyze privacy, security and confidentiality policies and procedures for internal and external use and exchange of health information

4 Patient verification and identity management policies

Privacy, confidentiality, security principles, policies and procedures, federal and state laws

E-Discovery

2. Recommend elements included in the design of audit trails and data quality monitoring programs

5 Data security o Audits, controls, data recovery e-security o Disaster recovery planning o Business continuity planning

3. Collaborate in the design and implementation of risk assessment, contingency planning, and data recovery procedures

4 Health information archival and retrieval systems

Data security protection methods o Authentication, encryption, decryption, firewalls

4. Analyze the security and privacy implications of mobile health technologies

4 Security threats of mobile device, healthcare delivery via mobile devices

5. Develop educational programs for employees in privacy, security, and confidentiality

6 Education and training principles

Privacy and security laws and regulations, adult education strategies, training methods

Subdomain II.C. Release of Information

1. Create policies and procedures to manage access and disclosure of personal health information

6 Principles for releasing PHI

Required elements of an authorization

2. Protect electronic health information through confidentiality and security measures, policies and procedures

3 Audit techniques and principles

Domain III. Informatics, Analytics and Data Use

Definition: Creation and use of Business health intelligence; select, implement, use and manage technology solutions; system and data architecture; interface considerations; information management planning; data modeling; system testing; technology benefit realization; analytics and decision support; data visualization techniques; trend analysis; administrative reports; descriptive, inferential and advanced statistical protocols and analysis; IRB; research; patient-centered health information technologies; health information exchange; data quality

Subdomain III.A. Health Information Technologies

1. Utilize technology for data collection, storage, analysis, and reporting of information

3 Health information archival and retrieval systems

Computer concepts

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o Hardware components, network systems architecture operating systems and languages, software packages and tools, Cloud computing applications

2. Assess systems capabilities to meet regulatory requirements 5 Electronic signatures, data correction, audit logs

3. Recommend device selection based on workflow, ergonomic and human factors

5 Human factors and user interface design o PDAs, screen size, mobile carts, bedside

terminals/point of care

4. Take part in the development of networks, including intranet and Internet applications

4 Communication technologies o Network-LANS, WANS, WLANS, VPNs

Internet technologies o Intranet, web-based systems, standards SGML, XML

5. Evaluate system architecture, database design, data warehousing

5 System testing

Interface management

Data relationships

6. Create the electronic structure of health data to meet a variety of end user needs

6 Data, information and file structures o Data administration, data definitions, data dictionary,

data modeling, data structures, data warehousing, database management systems

Subdomain III.B. Information Management Strategic Planning

1. Take part in the development of information management plans that support the organization’s current and future strategy and goals

4 Corporate strategic plan, operation improvement planning, information management plans

Disaster and recovery planning

2. Take part in the planning, design, selection, implementation, integration, testing, evaluation, and support of health information technologies

4 Systems development life cycle o Systems analysis, design, implementation,

evaluation, maintenance, EHRs, HIEs, RECs

Subdomain III.C. Analytics and Decision Support

1. Apply analytical results to facilitate decision-making 3 Data visualization, power point, dashboards

2. Apply data extraction methodologies 3 Data capture tools and technologies o Forms, computer screens, templates, other health

record documentation tools clinical, financial, administrative

Healthcare statistical formulas o LOS, death, birth, infection rates

3. Recommend organizational action based on knowledge obtained from data exploration and mining

5 Data exploration and mining

4. Analyze clinical data to identify trends that demonstrate quality, safety, and effectiveness of healthcare

4 Statistical analysis on healthcare data

Descriptive statistics o Mean, standard deviation, ranges, percentiles

Inferential statistics o T-tests, ANOVA, regression analysis, reliability,

validity

Epidemiological applications

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5. Apply knowledge of database querying and data exploration and mining techniques to facilitate information retrieval

3 SQL, Data exploration and mining

Data presentation standards and tools

6. Evaluate administrative reports using appropriate software 5 SQL, Reporting tools

Subdomain III.D. Health Care Statistics

1. Interpret inferential statistics 5 Inferential statistics o T-tests, ANOVA, regression analysis, reliability,

validity

Computerized statistical packages o SPSS, SAS

2. Analyze statistical data for decision making 4 Statistical analysis on healthcare data

Descriptive statistics o Mean, standard deviation, ranges, percentiles

Data reporting and presentations techniques

Subdomain III.E. Research Methods

1. Apply principles of research and clinical literature evaluation to improve outcomes

3 Research design/methods o Quantitative, qualitative, evaluative, mixed, outcomes

Literature search and evaluation

Knowledge-based research techniques o Medline, CMS libraries, AHRQ, and other websites

2. Plan adherence to Institutional Review Board (IRB) processes and policies

3 National guidelines regarding human-subjects research

IRB process

Research protocol data management

Subdomain III.F. Consumer Informatics

1. Educate consumers on patient-centered health information technologies

3 Patient centered medical homes

Patient portals, patient safety, patient education

Personal Health Record

Subdomain III.G. Health Information Exchange

1. Collaborate in the development of operational policies and procedures for health information exchange

4 HIE’s, local, regional including providers, pharmacies, other health facilities

2. Conduct system testing to ensure data integrity and quality of health information exchange

6 Integration, interfaces, and data reliability

3. Differentiate between various models for health information exchange

5 RHIO, HIE

Subdomain III.H. Information Integrity and Data Quality

1. Discover threats to data integrity and validity 3 Intrusion detection systems, audit design and principle

2. Implement policies and procedures to ensure data integrity internal and external to the enterprise

3 Authentication, encryption, password management

3. Apply quality management tools 3 Control charts, Pareto charts, Fishbone diagrams and other Statistical Process Control techniques

4. Perform quality assessment including quality management, data quality, and identification of best practices for health information systems

4 Data quality assessment and integrity

Disease management process o Case management, critical paths, care coordination

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Outcomes measurement o Patient as patient, customer satisfaction, disease

specific

Patient and organization safety initiatives

5. Model policy initiatives that influence data integrity 3 Data quality Model

Characteristics of data integrity

Domain IV. Revenue Management

Definition: Healthcare reimbursement; revenue cycle; chargemaster; DOES NOT INCLUDE COMPLIANCE regulations and activities related to revenue management (coding compliance initiatives, fraud and abuse, etc.) AS THESE ARE COVERED IN DOMAIN V.

Subdomain IV.A. Revenue Cycle and Reimbursement

1. Manage the use of clinical data required by various payment and reimbursement systems

5 Clinical Data Management and reimbursement management

CaseMix Management

Payment systems o PPS, DRGs, RBRVS, RUGs, Value Based

Purchasing (VBP), MSDRGs, commercial , managed care, federal insurance plans

o Billing and reimbursement at hospital inpatient and outpatient, physician office and other delivery settings

2. Take part in selection and development of applications and processes for chargemaster and claims management

4 Chargemaster management

3. Apply principles of healthcare finance for revenue management

3 Cost reporting, budget variances, budget speculation

4. Implement processes for revenue cycle management and reporting

3 CCI-Electronic Billing X12N

Compliance strategies and reporting

Audit process o Compliance and reimbursement

Revenue cycle process

Utilization and resource management

Domain V. Compliance

Definition: COMPLIANCE activities and methods for all health information topics. For example, how to comply with HIPAA, Stark Laws, Fraud and Abuse, etc.; coding auditing; severity of illness; data analytics; fraud surveillance; clinical documentation improvement.

Subdomain V.A. Regulatory

1. Appraise current laws and standards related to health information initiatives

5 Compliance strategies and reporting

Regulatory and licensure requirements

Elements of compliance programs

Patient safety

2. Determine processes for compliance with current laws and standards related to health information initiatives and revenue cycle

5 Policies and procedures

Non retaliation policies

Auditing and monitoring

Subdomain V.B. Coding

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1. Construct and maintain processes, policies, and procedures to ensure the accuracy of coded data based on established guidelines

6 UHDDS, Federal compliance guidelines

Official coding guidelines from CMS, AMA, NCHVS, NCCI

2. Manage coding audits 5 Audit principles and reporting

3. Identify severity of illness and its impact on healthcare payment systems

3 Casemix

Computer assisted coding systems

Payment Systems o PPS, DRG, RBRVS, RUG, VBP, MSDRG,

commercial, managed care, federal plans

Subdomain V.C. Fraud Surveillance

1. Determine policies and procedures to monitor abuse or fraudulent trends

5 Fraud detection

Subdomain V.D. Clinical Documentation Improvement

1. Implement provider querying techniques to resolve coding discrepancies

3 Query process, written, verbal and template queries, timeliness and interpretation, query retention

2. Create methods to manage Present on Admission, hospital acquired conditions, and other CDI components

6 CDI concurrent, retrospective, post-bill review

CDI metrics and reporting process

Domain VI. Leadership

Definition: Leadership models, theories, and skills; critical thinking; change management; workflow analysis, design, tools and techniques; human resource management; training and development theory and process; strategic planning; financial management; ethics and project management

Subdomain VI.A Leadership Roles

1. Take part in effective negotiating and use influencing skills 4 Negotiation techniques

2. Discover personal leadership style using contemporary leadership theory and principles

3 Professional development for self

Role of HIM in the C-Suite

3. Take part in effective communication through project reports, business reports and professional communications

4 Process re-engineering and work redesign

4. Apply personnel management skills 3 Communication and interpersonal skills

Emotional intelligence

People developer/staffing mentor

Negotiation

Leadership and governance

5. Take part in enterprise-wide committees

4 Facilitation, networking, consensus building

Meetings with executive boards and other high level organization groups, interdisciplinary committees

6. Build effective teams 6 Team/consensus building

Subdomain VI.B. Change Management

1. Interpret concepts of change management theories, techniques and leadership

5 Change Management

Mergers

Risk exposure

Organizational design

EHR implementation

Subdomain VI.C. Work Design and Process Improvement

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1. Analyze workflow processes and responsibilities to meet organizational needs

4 Workflow reengineering, workflow design techniques

2. Construct performance management measures 6 Benchmarking techniques o Productivity standards, report cards, dashboards

3. Demonstrate workflow concepts 3 Swimlane diagrams

Use cases

Top down diagrams

Subdomain VI.D. Human Resources Management

1. Manage human resources to facilitate staff recruitment, retention, and supervision

5 Principles of human resources management o Recruitment, supervision, retention, counseling,

disciplinary action

2. Ensure compliance with employment laws 5 Employment laws, labor laws o Federal and state

3. Create and implement staff orientation and training programs 6 Workforce education and training

4. Benchmark staff performance data incorporating labor analytics

4 Labor trends, market analysis

5. Evaluate staffing levels and productivity, and provide feedback to staff regarding performance

5 Performance standards

Professional development in self and others

Subdomain VI.E. Training and Development

1. Evaluate initial and on-going training programs 5 Information systems, clinical documentation improvement, compliance, prospective payment system changes

PPS, CDI, EHRs

Subdomain VI.F. Strategic and Organizational Management

1. Identify departmental and organizational survey readiness for accreditation, licensing and/or certification processes

3 Accreditation standards o The Joint Commission, NCQA, CARF, CHAP, URAC o Provider credentialing requirements o CMS Conditions of Participation

2. Implement a departmental strategic plan 3 Strategic planning, critical thinking, benchmarking

3. Apply general principles of management in the administration of health information services

3 Organizational structures and theory

4. Evaluate how healthcare policy-making both directly and indirectly impacts the national and global healthcare delivery systems

5 Healthy People 2020

IOM reports

CDC

State, local and federal policies

PCORI

5. Identify the different types of organizations, services, and personnel and their interrelationships across the health care delivery system

3 Managed care organizations

ACOs

Payers/providers, all delivery settings

Payers’ impact to each delivery setting

Biotech

Medical devices

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6. Collaborate in the development and implementation of information governance initiatives

4 Inter/intra-organizational team-building and leadership

Project management

7. Facilitate the use of enterprise-wide information assets to support organizational strategies and objectives

4 Information management planning

Enterprise information management

Master data/information management

Subdomain VI.G. Financial Management

1. Evaluate capital, operating and/or project budgets using basic accounting principles

5 Budget process o Capital and operating o Staffing budgeting

2. Perform cost-benefit analysis for resource planning and allocation

4 Accounting

Cost/benefit analysis o Outsourcing, acquisition

3. Evaluate the stages of the procurement process 5 Content of and answers to a request for proposal, request for information and request for quotation

Subdomain VI.H. Ethics

1. Comply with ethical standards of practice 5 Professional ethics issues

Ethical decision making process

AHIMA Code of Ethics

Patient rights

Patient safety

2. Evaluate the culture of a department 5 Cultural Diversity

3. Assess how cultural issues affect health, healthcare quality, cost, and HIM

5 Cultural competence

Healthcare professionals self-assessment of cultural diversity

Self-awareness of own culture

Assumptions, Biases, stereotypes

4. Create programs and policies that support a culture of diversity

6 Diversity awareness training programs: age, race, sexual orientation, education, work experience, geographic location, disability

Regulations such as ADA, EEOC

Subdomain VI.I. Project Management

1. Take part in system selection processes 4 RFI and RFP

2. Recommend clinical, administrative, and specialty service applications

5 RFP vendor selection, electronic record, clinical coding

3. Apply project management techniques to ensure efficient workflow and appropriate outcomes

3 GANTT Charts, benchmarking, risk analysis, team structure

4. Facilitate project management by integrating work efforts 4 Issue tracking, facilitation techniques, opportunity costs

Project management

Subdomain VI.J. Vendor/Contract Management

1. Evaluate vendor contracts 5 System acquisition and evaluation

Contract management

2. Develop negotiation skills in the process of system selection 6 System acquisition and evaluation

Subdomain VI.K. Enterprise Information Management

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1. Manage information as a key strategic resource and mission tool

5 Information Management Plan, information as an asset

Supporting Body of Knowledge (Pre-requisite or Evidence of Knowledge)

Pathophysiology and Pharmacology

Anatomy and Physiology

Medical Terminology

Computer Concepts and Applications

Statistics

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D. Curriculum

Please review the Curriculum Grid for your department displayed on the assessment site: http://www.weber.edu/portfolio/departments.html - if it

is current, please indicate as much; we will mark the web page as “Last Reviewed: [current data]”. No further information is needed.

If the curriculum grid is not current, please provide an update:

___ Information is current; no changes required.

_X Information is not current; updates below Baccalaureate HIM Level Curricular Competencies

Courses HIM 2000

HIM 2250

HIM 2300

HIM 2320

HIM 2330

HIM 2410

HIM 2500

HIM 2861

HIM 2862

HIM 2863

HIM 3000

HIM 3300

HIM 3200

HIM 3400

HIM 3450

HIM 3500

HIM 4100

HIM 4990

HAS 3000

HAS 3230

HAS 3240

HAS 3260

HAS 3750

IST 2010

IST 3110

ACTG 2010

Entry Level Competency

Domain I: Data Content, Structure & Standards (Information Governance)

Subdomain I.A Classification Systems A A U A I A U

Subdomain I.B Health Record Content & Documentation A U A U A

Subdomain I.C Data Governance I A U U A

Subdomain I.D Data Management E U U U A U U

Subdomain I.E Secondary Data Sources E A

Domain II: Information Protection: Access, Disclosure, Archival, Privacy & Security

Subdomain II.A Health Law I A

Subdomain II.B Data Privacy, Confidentiality & Security E A A

Subdomain II.C Release of Information A

Domain III: Informatics, Analytics and Data Use


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Subdomain III.A Health Information Technologies E U A E A A

Subdomain III.B Information Management Strategic Planning A A

Subdomain III.C Analytics and Decision Support I E A A

Subdomain III.D Health Care Statistics E A

Subdomain III.E Research Methods A A

Subdomain III.F Consumer Informatics A

Subdomain III.G Health Information Exchange A E

Subdomain III.H Information Integrity & Data Quality E U A U

Domain IV: Revenue Management

Subdomain IV.A Revenue Cycle and Reimbursement U A E A

Domain V: Compliance

Subdomain V.A Regulatory U U U U A

Subdomain V.B Coding U A U U U

Subdomain V.C Fraud Surveillance U U A

Subdomain V.D Clinical Documentation Improvement A

Domain VI: Leadership

Subdomain VI.A Leadership Roles U U E U A

Subdomain VI.B Change Management E U A

Subdomain VI.C Work Design & Process Improvement U A U U

Subdomain VI.D Human Resource Management E E U A

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Subdomain VI.E Training & Development A A

Subdomain VI.F Strategic & Organizational Management I U U U U A I A

Subdomain VI.G Financial Management U A U

Subdomain VI.H Ethics U U U A U U

Subdomain VI.I Project Management U U A I

Subdomain VI.J Vendor/Contract Management U A

Subdomain VI.K Enterprise Information Management U E

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E. Assessment Plan Please review the Assessment Plan for your department displayed on the assessment site: http://www.weber.edu/portfolio/departments.html - if the

plan current, please indicate as much; we will mark the web page as “Last Reviewed [current date]”. No further information is needed.

The site should contain an up-to-date assessment plan with planning going out a minimum of three years beyond the current year. Please review the

plan displayed for your department at the above site. The plan should include a list of courses from which data will be gathered and the schedule, as

well as an overview of the assessment strategy the department is using (for example, portfolios, or a combination of Chi assessment data and student

survey information, or industry certification exams, etc.).

Please be sure to include your planned assessment of any general education courses taught within your department. This information will be used to

update the General Education Improvement and Assessment Committee’s planning documentation.

Health Information Management – BS Degree Department of Health Administrative Services

Program Evaluation Plan

Goals Standards/Outcomes Evaluation Methods

1. Program graduates will demonstrate the HIM entry-level competencies.

A. 80% of all HIM graduates taking the RHIA certification examination will pass on the first writing.

Annual review of the RHIA certification examination results to analyze student performance in each knowledge area in comparison with overall performance.

B. 80% or more of program graduates will rate the program as providing adequate preparation for the HIM profession.

Graduate surveys are administered by the Office of Institutional Effectiveness and results shared with the program of our graduates.

C. Employers will express adequate to excellent competence regarding technical skills expected of entry-level health information technicians by domain level.

Employer surveys are completed by the HIM Program Director annually and the results are shared with the Program Advisory Committee.

2. The HIM curriculum will include, at minimum, the required

Detailed assessment will occur at the subdomain level using the AHIMA

AHIMA Domains, subdomains, and knowledge cluster


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knowledge clusters with content and experiences to enable students to meet current entry-level competencies.

Baccalaureate Degree Entry Level curricular competencies. See assessment by course as noted above. Each measure will be collected annually by the defined academic year.

content assessment are reviewed annually by the HIM faculty and Program Advisory Committee.

11/1/16

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F. Report of assessment results for the most previous academic year:

There are a variety of ways in which departments can choose to show evidence of learning. This is one example. The critical pieces to include are 1) what learning outcome is being assessed, 2) what method of measurement was used, 3) what the threshold for ‘acceptable performance’ is for that measurement, 4) what the actual results of the assessment were, 5) how those findings are interpreted, and 6) what is the course of action to be taken based upon the interpretation.

A. Evidence of Learning: Courses within the Major Program Goal #1 Program graduates will demonstrate the HIM entry-level competencies. Standard/Outcome A. 80% of all HIM graduates taking the RHIA certification examination will pass on the first writing. Evaluation Method 1. Annual review of the RHIA certification examination will pass on the first writing. Follow-up from 14-15 report:

Exam score were all at or above the national average in all exam content areas, so not follow-up needed. Program director will continue to monitor exam scores.

Results:

14 of 15 first-time students sat for and passed the RHIA certification examination, or 93%.

Students scores are trending at or above the national average in all exam content areas.

Scores by Domain for the first three quarters of 2015-2016:

Domain Oct 1 through Dec 31, 2015 – 4/5 students passed

Jan 1 through March 31 2016 – 3/3 students passed

Apr 1 through June 30 2016 – 7/7 students passed

WSU National WSU National WSU National

1 23.60 22.33 24.33 21.80 24.14 21.73

2 27.40 26.83 31.33 29.20 29.14 28.30

3 21.60 20.83 24.67 22.00 23.14 20.65

4 16.20 15.00 19.00 16.60 17.86 15.88

5 15.00 14.67 19.00 17.60 18.43 17.38

Total 103.80 99.67 118.33 107.20 112.71 103.94

Responsive/Corrective Action: Will add the fourth quarter data into this measure as soon as it becomes available and take action at that time if necessary. If scores continue on this trend no action is needed at this time. Scores are above average

B. 80% or more of the subject areas of the graduate surveys will show adequate instruction.

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1. Detailed graduate surveys are conducted annually and the results are analyzed and shared with the Program Advisory Committee. Follow-up from 14-15 report:

We are still having problems getting graduate surveys returned, in an effort to minimize the number of surveys sent to our graduates from the University, the program will utilize the data captured by the Office of Institutional Effectiveness graduate surveys going forward. We are hoping that this will provide the program more responses.

Results: 8/31 responses were received; surveys were sent to students using graduate survey process by the Office of Institutional Effectiveness.

These surveys are sent to graduates immediately after their degree posts. One-hundred percent of students responded extremely satisfied with their

chosen major, and 100% extremely satisfied with their academic department.

Responsive/Corrective Action:

We need to improve the response rate for this survey, but it appears that we are meeting our program graduates needs.

C. Employers will express adequate to excellent competence or unimportant regarding HIM skills expected of entry-level health information technicians. Evaluation Method 1. Employee surveys are administered to area employers by HIM Program Director annually and the results are shared with the Program Advisory Committee.

Results: The results of employer surveys show that the employers of our graduates are satisfied to extremely satisfied with the entry-level student performance on the HIM competencies. Responsive/Corrective Action:

No response needed at this time, as employers are satisfied with program graduates.

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B. Evidence of Learning: High Impact or Service Learning If you provide students with high impact or service learning opportunities briefly describe those opportunities and explain how you assess their impact on student learning. This excerpt from George D. Kuh provides a brief overview of high-impact practices.

WSU Health Information Management BS Degree Program

Goal 2: The HIM curriculum will include, at minimum, the required knowledge clusters with content and experiences to enable students to meet current entry-level competencies.

Domain/Subdomain Measures 2015-2016 Results Action Plan

Domain I: Data Content, Structure & Standards (Information Governance)

Subdomain I.A Classification Systems

HIM 2000 midterm exam - At least 80% of students will earn 75% or higher(HIM 2000)

87% received 80% or higher on exam 2, exceeding the threshold.

No curricular changes needed at this time

HIM 2863 SDS Coding and INP Coding: At least 80% of students will earn 83% or higher

88% of students received 80% or higher on the assignments, exceeding the threshold.


Subdomain I.B Health Record Content & Documentation

Midterm Exam - At least 80% of students will earn 75% or higher (HIM 2000)

87% received 80% or higher on exam 2, exceeding the threshold.


Mock Survey Assignment in HIM 4100 - At least 80% of students will earn 83% or higher.

75% of HIM 4100 students earned 83% or higher on the Mock Survey Assignment, not meeting the threshold.

The program will monitor this measure to see if this trend continues and make adjustments to the course content and delivery if necessary. If this does not improve next year, changes will be implemented.

Subdomain I.C Data Governance

HIM 3450 Data Dictionary Assignment - At least 80% of students will earn 83% or higher

100% of HIM 3450 students earned 83% or higher on the Data Dictionary Assignment, exceeding the threshold.


http://apps.weber.edu/wsuimages/oie/Support%20Documents/Kuh_HighImpactActivities.pdf

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Subdomain I.D Data Management

Disaster Planning Assignment in HIM 4100 - At least 80% of students will earn 83% or higher.

80% of HIM 4100 students earned 83% or higher on the Disasater Planning assignment, meeting the threshold.


Data Presentation Assignment - At least 80% of studetns will earn >= 83% (HIM2500)

96% of HIM 2500 students earned >= 83% on the Data Presentation Assignment exceeding the threshold

Although we are meeting the outcome measure in this subdomain, these assignments are not at the level that CAHIIM requires. To address this deficit, the program added a new course HIM 3550 Healthcare Data Analytics in 2016-2017 to bring these outcomes to a hire taxonomical level.

Subdomain I.E Secondary Data Sources

HIM 2500 Health Datasets Assignment - At least 80% of students will earn >= 83%

92% of HIM 2500 students earned >= 83% on the Health Datasets assignment, exceeding the threshold.


Domain II: Information Protection: Access, Disclosure, Archival, Privacy & Security

Subdomain II.A Health Law Midterm-At least 80% of students will earn 80% or higher (HIM 2250)

92% of students scored 80% or higher on midterm, exceeding the threshold

No curricular changes needed at this time.

Subdomain II.B Data Privacy, Confidentiality & Security

80% of class will get 83% or higher on security audit (HIM 3000)

94% of all HIM 3300 students scored 83% or higher exceeding the threshold.


HIPAA Training Plan Assignment in HIM 4100 - At least 90% of students will earn 83% or higher.

94.7% of HIM 4100 students earned 83% or higher on the HIPAA training plan assignment, meeting the threshold.


Subdomain II.C Release of Information

80% of class will earn 70% or higher on ROI assignment (HIM 2250)

90% of students received 70% or higher on Ch 12 quiz, exceeding the threshold


Domain III: Informatics, Analytics and Data Use

Subdomain III.A Health Information Technologies

HIM 3400 Module 13 Assignment- At least 80% of students will earn 83% or higher

82.6% of HIM 3400 students earned 83% or higher on the Module 13 Assignment, meeting this threshold.


Subdomain III.B Information Management Strategic Planning

HIM 4100 HIM Dept Mgmt Case - At least 80% of students will earn 83% or higher

78.9% of HIM 4100 students earned 83% or higher on the HIM Dept Mgmt Case, not meeting the threshold.

The program will monitor this measure to see if this trend continues and make adjustments to the course content and

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delivery if necessary. If this does not improve next year, changes will be implemented.

Subdomain III.C Analytics and Decision Support

80% of class will earn 80% or higher on policy and procedure writing assignment (HIM 2250)

93% of students scored 80% or higher on policy and procedure writing assignment, exceeding the threshold


HIM 3200 SPSS Assignment #2 - 80% of students will earn 80% or higher

79.6% of the HIM 3200 students earned 80% or higher on the SPSS Assignment #2, just below the threshold.


Subdomain III.D Health Care Statistics

HIM 3200 SPSS Assignment #2 - 80% of students will earn 80% or higher

79.6% of the HIM 3200 students earned 80% or higher on the SPSS Assignment #2, just below the threshold.


Subdomain III.E Research Methods

HIM 3500 Research Paper Outline - 80% of students will earn 83% or higher

73.9% of student in HIM 3500 earned 83% or higher on the Research Paper Outline, not meeting the threshold.

The content and delivery of this material will be evaluated for improvement.

Subdomain III.F Consumer Informatics

80% of students will earn 80% or higher on mobile device policy assignment (HIM 3000)

97% of students earned 80% or higher on mobile device policy, exceeding the threshold


Subdomain III.G Health Information Exchange

80% of students will earn 80% or higher on HIE assignment

96% of students scored 80% or higher on HIE assignment, exceeding the threshold Note: rigor was increased in spring 2016

Subdomain III.H Information Integrity & Data Quality

PI Project - At least 80% of students will earn > or = 83% (HIM 3300)



Domain IV: Revenue Management

Subdomain IV.A Revenue Cycle and Reimbursement

HAS 3750 Exam 2 & 3: At least 90% of students will earn a 73 or higher.

72.2% of the HAS 3750 students earned 73% or higher on exams 2 and 3, slightly below the threshold.

The faculty has changed the text, added additional support matierals, study guides, and practice problems to assist students to be successful on these exams and in the course content.

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HIM 2330 Midterm/Final: At least 80% of the students will earn 83% or higher

66% of all HIM 2330 students scored 83% or higher on midterm/final grades. Not meeting our threshold.

We changed these exams midyear 2015-2016, and this improved the scores in spring semester to 75.5%. Item analysis will be conducted on each of the questions in these exams and changes made as necessary.

HIM 2330 Bill Case: At least 80% of students will earn 83% or higher This is a new assignment for 2016-2017

Domain V: Compliance

Subdomain V.A Regulatory

HIM 4100 Mock Survey Case - At least 80% of students will earn 83% or higher.

68.4% of HIM 4100 students earned 83% or higher on the Mock Survey Assignment, not meeting the threshold.

The content and delivery of this material will be evaluated for improvement.

Subdomain V.B Coding

80% of students will earn 83% or higher on the coding guideline assessment 2 in HIM 2863.

97.6% of all HIM 2863 students scored 83% or higher, exceeding the threshold


80% of student will earn 83% or higher on the coding audit assignment in HIM 2320.

54.7% of students in HIM 2320 scored 83% or higher on the coding audit assignment in HIM 2320, not meeting the threshold.

Subdomain V.C Fraud Surveillance

80% of HIM 4100 students will earn 83% or higher on the Medical Identify Reflective Essay.

80% of HIM 4100 students earned 83% or higher on the Medical Identity Reflective Essay, meeting this threshold.

Although meeting this outcome threshold, the program will develop a better assignment/measure for this subdomain. Possibly using Neehr Perfect software program for audit trail assessment.

80% of HIM 3000 students will earn 83% or higher on the Security Audit assignment.

94.4% of HIM 3000 students earned 83% or higher on the Security Audit assignment, exceeding the threshold.


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Subdomain V.D Clinical Documentation Improvement

80% of class will earn 80% or higher on clinical documentation analysis (HIM 2000)

87% of class scored 80% or higher on assignment, meeting the threshold

Although meeting the threhold, several students struggled with documentation on paper records. Starting Fall,16 this assignment has moved to EHR and will now be tested on Neehr Perfect: Introduction to Chart deficiencies

HIM 2863 Detailed Query Assignment- At least 80% of students will earn 80% or higher.

82.7% of students scored 80% or higher, exceeding the threshold.

There were a few students that opted not to take the quiz, bringing the overall average score down because it was only worth 10 points. The point value has been increased to motivate students all students to take the quiz.

Domain VI: Leadership

Subdomain VI.A Leadership Roles

HAS 3260 Final Paper: At least 90% of students will earn a 73% or higher.

97.1% of HAS 3260 students completed the final paper with a grade of 73% or better, exceeding the threshold.


Subdomain VI.B Change Management

HAS 3260 Managing Change Assignment: At least 90% of students will earn a 73% or higher

97.1% of HAS 3260 students completed the assignment with a grade of 73% or better, exceeding the threshold.


Subdomain VI.C Work Design & Process Improvement

PI Project - At least 80% of students will earn > or = 83% (HIM 3300)



Subdomain VI.D Human Resource Management

HAS 3240 composite score of all assignments: At least 90% of students will complete the assignments with an average grade of 73% or better.

98.7% of HAS 3240 students earned a composite score on all assignments higher than 73%, exceeding the threshold.


HAS 3240 composite score on Quizzes: At least 90% of students will average a grade of 73% or better on all course quizzes.

88% of HAS 3240 students earned a composite score on all quizzes higher than 73%, slightly below the threshold.


HAS 3240 composite score on exams: At least 90% of students will complete the final exam with a grade of 73% or better.

97% of HAS 3240 students earned a composite score on all exams higher than 73%, exceeding the threshold.


Subdomain VI.E Training & Development

HAS 3240 Assignment 4: At least 90% of students will complete the

100% of HAS 3240 students earned a scored of 73% or higher on assignment 4, exceeding the threshold.


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assignment with a grade of 73% or better

HIM 4100 HIM Dept Employee HIPAA Training Plan Assignment - 80% of students will earn 83% or higher

94.7% of HIM 4100 students earned 83% or higher on the HIPAA training plan assignment, meeting the threshold.


Subdomain VI.F Strategic & Organizational Management

Mock Survey Assignment in HIM 4100 - At least 80% of students will earn 83% or higher.

75% of HIM 4100 students earned 83% or higher on the Mock Survey Assignment, not meeting the threshold.


Subdomain VI.G Financial Management

HAS 3750 Exam 2 & 3: At least 90% of students will earn a 73 or higher.

72.2% of the HAS 3750 students earned 73% or higher on exams 2 and 3, slightly below the threshold.

The faculty has changed the text, added additional support matierals, study guides, and practice problems to assist students to be successful on these exams and in the course content.

HAS 3750 Exam 2: At least 90% of students will earn a 73% or higher.

75.9% of the HAS 3750 students earned 73% or higher on exam 2, meeting the threshold.


HAS 3750 Final project: At least 90% of students will earn a 83% or higher.

96.8% of the HAS 3750 students earned 83% or higher on the final project, meeting the threshold.


Subdomain VI.H Ethics

HAS 3230 SWOT Analysis Assignment: At least 90% of students will complete the assignment with a grade of 73% or better

97.8% of HAS 3230 students completed the assignment with a grade of 73% or better, exceeding the threshold.


HAS 3230 Final project: At least 90% of students will complete the assignment with a grade of 73% or better

97.4% of HAS 3230 students completed the final project with a grade of 73% or better, exceeding the threshold.


Subdomain VI.I Project Management

HIM 3450 System Selection Assignment - 80% of students will earn 83% or higher

88.2% of HIM 3450 students earned 83% or higher on the System Selection Assignment, meeting the threshold.


Subdomain VI.J Vendor/Contract Management

HIM 4100 Contract Evaluation Assignment - 80% of students will earn 83% or higher

89.4% of HIM 4100 students earned 83% or higher on the Contract Evaluation assignment, meeting the threshold.


Subdomain VI.K Enterprise Information Management

Measure to be added 2016-2017: HIM 2500 Data Governance Plan and Presentation

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Appendix A Additional narrative:

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Appendix B Please provide the following information about the full-time and adjunct faculty contracted by your department during the last academic year (summer through spring). Gathering this information each year will help with the headcount reporting that must be done for the final Five Year Program Review document that is shared with the State Board of Regents.

Faculty Headcount With Doctoral Degrees (Including MFA and other terminal degrees, as specified by the institution)

Full-time Tenured 1 Full-time Non-Tenured (includes tenure-track) 2 Part-time 0 With Master’s Degrees Full-time Tenured Full-time Non-Tenured 1 Part-time 3 With Bachelor’s Degrees Full-time Tenured Full-time Non-tenured Part-time Other Full-time Tenured Full-time Non-tenured 1 Part-time 1 Total Headcount Faculty Full-time Tenured 1 Full-time Non-tenured 4 Part-time 4

Faculty are shared with the HAS/LTC programs, but the HIM programs have 3 full-time permanent positions, and 1 full-time grant funded position at this time. Two of these faculty completed Doctorate degrees this year, and the other two are enrolled in doctoral programs.

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Please respond to the following questions.

1) Based on your program’s assessment findings, what subsequent action will your program take?

Program faculty has adopted the recommend action for each of the courses assessed. Implementation of the recommendations will occur over for the next semester that the course is taught. In addition, productive conversation has evolved around overall course improvement and adaptation to the increased demands of the online environment. Increase collaboration is occurring regarding the curriculum within the program. Also, faculty “leads” will be assigned to coordinate each course.

2) Are there assessment strategies within your department or program that you feel are particularly effective and/or innovative? If so, what are those strategies and what do you learn about your students by using them? We believe that the results of the RHIA certification examination are the most effective measure of our program outcomes. This past year we had 93% of our program graduates pass this certification examination. In addition, these graduates scored at or above the national average in all domain areas.

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