Getting Started with IG—No Time to Sit and Relax

Keep up with the latest on information governance as this key strategy emerges for addressing a myriad of information management challenges in healthcare. This blog will highlight the trends and opportunities IG presents for ensuring information is treated as an organizational asset.


By Lesley Kadlec, MA, RHIA

Many healthcare organizations continue to struggle with implementing an information governance (IG) initiative. Oftentimes it can be a challenge to articulate exactly what IG is, and to find a simple way to get executive support to get started.

At session two of AHIMA’s pre-convention IG workshops, presenters demonstrated using a tool for getting executive support and getting started with IG called the “SBAR.” If you have never heard of this acronym before, it could be easy to think it stands for “sit back and relax.” But it’s quite the opposite!

“SBAR” is an acronym for an executive proposal tool that has gained popularity in healthcare, referring to a description of the following details:

  • Situation
  • Background
  • Assessment
  • Recommendation

 

Starting an organizational IG effort can seem daunting. It is advisable, therefore, to start small and establish a solid foundation for information governance. But how do you start? Look for an information problem that is a quick win, something easily achievable that will enable you to establish a cross-functional coordinated effort and obtain a positive outcome. Then use that same coordinated approach to grow the program.

The SBAR is an easy-to-use tool that can help define a starting point for information governance, as well as get buy-in and support from executive leadership for the work that needs to be done.

An SBAR begins first with a description of the situation. In this section you will identify the problem or concern and provide a brief description of it. The main goal is to communicate clearly about what is happening. One situation discussed at our workshop included the need for a coordinated effort around records retention and disposition.

The next section in the document is the background. The goal of the background section is to be able to identify the problem and provide the reasons that the problem has occurred. In the case of records retention and disposition that was identified in the workshop, the organization had a long-standing policy and procedure for records retention and destruction, but the policy had not been updated in quite some time and it was not being followed consistently or correctly.

After the background section is the assessment. In this section, the situation that is identified in the background section is reviewed and all relevant data is presented to assist leadership in determining the most appropriate course of action. In our example, some costs of storage and staffing for retrieval were included, along with a list of potential risks associated with having an outdated policy and keeping information that is no longer needed. Think about all of the possible solutions, and identify the work effort and costs, as well as any associated savings, in each of the options that will be presented in the recommendation section.

Finally, the recommendation section discusses a couple of possible solutions that could correct the problem identified. For example, one solution could be to continue to store the records as has been done historically, but to update the policy to reflect current practice. A second option could be to evaluate the current policy, then properly assign records for retention and destruction as the policy outlines. Or a third option may be to convert the historical records to electronic format via a scanning approach into the existing EHR.

You may think that your job is done at this point, but think again—once your SBAR is reviewed by leadership and one of the recommendations is ultimately accepted, it’s time to get your team pulled together and get started with the work. Regardless of the recommendation that you will be working on, you will likely require a wide variety of expertise from across the organization to complete the work. Get started by bringing together a cross-functional team to assist in achieving the recommended goal. Cross-functional team members can provide insight and suggestions; they will feel as if they “own” the outcome, which improves their level of commitment to success. Once this effort is complete, the team that you have formed can be expanded to tackle ongoing information governance issues by adding additional stakeholders depending on the issue to be solved.

We cannot continue to just “Sit Back And Relax” when it comes to healthcare IG. The time to get started with information governance is now. Using an SBAR is one way that you can bring attention to an existing information problem and get leadership support and a cross-functional team to assist in getting it resolved.

 

Lesley Kadlec (lesley.kadlec@ahima.org) is a direction of HIM practice excellence at AHIMA.

1 Comment

  1. In clinical medicine, there is a close analogy to SBAR. It is traditionally called the “SOAP note”: Subjective, Objective, Assessment, Plan. The SOAP note was invented in the 1960s by Dr. Larry Weed (http://www.modernhealthcare.com/article/20130126/MAGAZINE/301269953) and the basic format is still often used today although greatly modified in order to adjust to the 1995 or 1997 Medicare documentation guidelines.

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