Performance Improvement Initiative
Increasing Credentialed Staff Numbers
Willow View Medical Center
Health Information Management Department
Problem Statement
Willow View Medical Center has a low percentage of credentialed HIM coding staff. Despite meeting productivity standards, many experienced coders lack formal credentials, creating compliance, reimbursement, and workforce sustainability risks (AHIMA, n.d.).
Who, When, and Where
Who: HIM coders, department leadership, and organizational stakeholders
When: During performance reviews, audits, and hiring processes
Where: HIM Department at Willow View Medical Center
Why This Is an Issue
Credentialing supports coding accuracy, regulatory compliance, and data integrity. Lack of credentials increases organizational risk and limits workforce advancement (AHIMA, 2023; CDC, 2023).
PI Methodology: PDSA
Plan: Assess credentialing gaps and barriers
Do: Provide education, exam prep, and financial support
Study: Monitor credentialing progress
Act: Adjust strategies to improve outcomes
PI Visual Tools
• Gantt Chart: 12-month credentialing timeline
• Fishbone Diagram: Root cause analysis
• Bar Chart: Credentialed vs. non-credentialed staff baseline
Expected Outcomes
• Increased number of credentialed HIM staff
• Improved compliance and coding accuracy
• Stronger workforce readiness and retention
References
American Health Information Management Association (AHIMA)
Centers for Disease Control and Prevention (CDC)
See accompanying PI document for full APA references
Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!
Writing a performance improvement (PI) initiative paper can feel complicated, but breaking it into clear steps helps you organize and write effectively. Follow this step-by-step guide to structure your paper based on the Willow View Medical Center HIM department initiative.
Step 1: Understand the Assignment Content
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Identify key elements – Focus on the problem statement, stakeholders, timeline, PI methodology, visual tools, and expected outcomes.
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Note supporting references – AHIMA and CDC are essential for evidence-based rationale and credibility.
Step 2: Conduct Additional Research
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Search for recent, credible sources related to:
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Credentialing and workforce development in health information management
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Regulatory compliance in coding
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PDSA methodology in healthcare settings
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Recommended resources:
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Peer-reviewed journals via PubMed
Step 3: Outline Your Paper
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Introduction
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Briefly describe Willow View Medical Center and the HIM department.
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State the purpose of the PI initiative and its relevance to coding accuracy, compliance, and workforce readiness.
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Problem Statement
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Explain the lack of credentialed HIM staff and associated risks (compliance, reimbursement, sustainability).
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Methodology (PDSA)
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Plan: Assess gaps and barriers to credentialing.
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Do: Describe education, exam preparation, and financial support interventions.
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Study: Explain how progress will be monitored and measured.
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Act: Describe adjustments based on results.
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Who, When, and Where
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Identify stakeholders (coders, leadership), timing (reviews, audits), and location (HIM Department).
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PI Visual Tools
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Include Gantt chart, fishbone diagram, and bar chart. Explain what each tool demonstrates.
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Expected Outcomes
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Increased credentialed staff
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Improved compliance and coding accuracy
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Stronger workforce readiness and retention
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Conclusion
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Summarize the importance of credentialing and how the PI initiative supports organizational goals.
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Step 4: Draft Your Paper
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Write clearly, using professional language.
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Integrate evidence from AHIMA, CDC, and scholarly articles to support your statements.
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Include visual tools where appropriate to illustrate findings.
Step 5: Revise and Proofread
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Ensure alignment with the rubric and assignment requirements.
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Check grammar, spelling, and APA formatting.
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Verify that all sections of the PDSA cycle are addressed and evidence is cited.
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