Perspectives on the role of health information management professionals in enhancing patient safety: A qualitative study

Perspectives on the role of health information management professionals in enhancing patient safety: A qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perspectives on the role of health information management professionals in enhancing patient safety: A qualitative study Trixie Kemp, Jennifer Ayton, Kerryn Butler-Henderson, Salma Arabi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6384767/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Health Information Management (HIM) professionals play an integral role in the healthcare system, supporting clinicians and healthcare service management by ensuring that data is trustworthy and reliable for informed decision-making. This study examined the key informant perspectives on whether HIM professionals contribute to patient safety in Australian acute hospitals and what this contribution entails. Methods This qualitative study involved semi-structured one-to-one interviews with HIM professionals and patient safety experts from across Australia, comprising eight from HIM and six from patient safety. The interviews were recorded, transcribed, and coded. Charmaz’s grounded theory informed the data analysis approach. Socio-technical system theory was used to examine the components of society (people and organisation) and technical (tasks and systems). Results All participants stated that HIM professionals contribute to patient safety, with 100% of patient safety experts indicating that the contribution is both direct and indirect. The opinions of the HIM experts were mixed. Participants provided various examples of how HIM professionals contribute to patient safety through data, documentation, education, and records management functions. Values, beliefs, and attitudes aligned with key elements of patient safety culture, including teamwork, communication, learning, leadership, and patient-centred care. Conclusions HIM professionals contribute to patient safety by applying their knowledge and skills in managing, interpreting, providing and reporting information. Measuring this impact against National Safety and Quality Healthcare Service (NSQHS) Standards would contribute to understanding the direct impact of HIM professional's role on clinical governance and quality indicators. Clinical coding data quality documentation health information management key informants patient safety quality records management socio-technical Figures Figure 1 Figure 2 Figure 3 BACKGROUND Health services collect and create vast amounts of information. In 1928, a need was identified for a dedicated workforce to manage information collection, storage, protection, analysis, and quality, which led to the formation of the health information management (HIM) profession (1). HIM professionals play a vital role in the healthcare system, supporting clinicians and health service management by ensuring that data is trustworthy and reliable for informed decision-making. Their skillset and knowledge cover records management, human resources, medical terminology, anatomy and physiology, clinical coding, classification and data management (2). However, their scope is not well-understood outside of the profession (3). HIM professionals have a unique perspective on the healthcare system, as they work with patient information at the individual, facility, and whole-service levels. Still, this profession is often overlooked in the context of patient safety. Health records are a key source of information for patient safety events and data (4). Literature confirms the connection between health records and patient safety (4–7) and between health records and HIM professionals (1, 8), with health records being the intersection point. A 2021 literature review by Kemp et al. identified non-empirical literature linking HIM functions to patient safety in information governance, corporate governance, data quality, and HIM skillset (6). The study identified a lack of empirical evidence examining how the HIM profession impacts patient safety (6). The World Health Organization (WHO) states that patient safety is a complex global public health concern due to the various settings, cultures, and resources (9). WHO defines patient safety as “the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum" (10). Patient safety can be described as being a mindset, not a task or specific intervention (11). Australia was an early leader in investigating quality and patient safety. The Quality in Australian Health Care Study (1995) reported that 16.6% of Australian inpatients had an adverse event, and 51% were preventable (12). In 2006, the Australian Commission on Safety and Quality in Healthcare (ACSQHC) was established to coordinate national quality and safety improvement by providing information and resources; developing national safety and quality standards, clinical care standards; and the accreditation scheme (12). The ACSQHC examines patient safety in health facilities by monitoring sentinel events, adverse events, hospital-acquired complications, and hospital-based indicators and undertaking accreditation assessments(12). Within Australia, health services are accredited against the National Safety and Quality Healthcare Service (NSQHS) Standards(7) to demonstrate an organisations' commitment to patient safety and quality. While improvements have occurred over the last 20 years, harm and adverse events still occur. Multiple data sources are used to monitor and report on the state of patient safety in the Australian healthcare system. These include coded data from health records, mortality indicators, a national list of hospital-acquired complications (HACs), patient surveys, and incident analysis (12). Reliable data is, therefore, essential for an accurate understanding of the Australian patient safety situation. This paper examines the perspectives of key informants on the contribution HIM professionals make to patient safety, whether the contribution is direct or indirect, and what the contribution is. Attitudes, values, and beliefs are also discussed to understand how they influence HIM professionals' behaviours and group practices regarding patient safety. Values are our principles or what individuals believe is of worth(13, 14), beliefs are ideas we accept without facts(15), and attitudes are the way an individual thinks or feels about something(13). When combined, they drive our behaviour (13, 16, 17). Therefore, understanding these characteristics will allow comparison to other health professions. METHODS This qualitative case study approach used one to one (phone or Zoom) interviews with Australian ‘experts’ in HIM and patient safety. Interviews are a well-established method in qualitative study to gain the perspectives and experience from experts in response to research questions (18). A socio-technical systems theory was used as a lens to examine the components of society (people and organisation), and technical (tasks and systems). STS originated from work at the Tavistock Institute for Human Relations in 1949 (13). STS examines the relationships between social and technical systems, aiming for joint optimisation to achieve tasks and outcomes. The social system considers people’s attributes, relationships, reward systems and governance and organisational structures. The technical system encompasses the processes, tasks, and technology required to produce outputs (15, 16). STS theory has been used to study other health professions and healthcare settings. Recruitment and selection Key informants were initially identified through the researchers’ network, based on the potential informant’s professional association or positions held, publication or research activities, or through recommendations from leaders in the fields of health information and patient safety. Once the interview commenced, informants were asked to suggest others to be interviewed on this topic. Once saturation had been reached, no further informants were recruited. Informants were grouped into the following categories: Past or present President of the Health Information Management Association of Australia (HIMAA) Leading practitioners or researchers in HIM or patient safety in Australia, and Patient safety experts based in patient safety governance roles. An invitation, participant information sheet and consent form were emailed to potential participants. Participation was indicated by returning a signed consent form to the primary investigator. Data collection The interviews concluded in January 2024 and were conducted via Microsoft Teams, Zoom or telephone. The interviews were semi-structured to support a conversational approach to gathering the data. An interview guide, developed specifically for this study, was used to ensure all participants were asked the questions for their expert group (15 open-ended questions for HIM experts and 13 for patient safety experts). Initial questions were informed by the literature review, investigators' experience in qualitative studies, and the research project aims. As the interviews progressed, the interview guide was adjusted to enhance the flow of questions and include additional prompts. The questions were designed to extract similar information from the experts, with an example of how the wording differed based on the informant's expertise as shown in Table 1 . Table 1 Expert group and interview questions Expert Group Questions HIM • “Do you think your role does or does not contribute to patient safety?” • “Thinking about the HIM profession in general, how are they directly or indirectly contributing to patient safety in acute hospitals?” • “Can you provide an example that demonstrates what we just discussed?” Patient Safety • “Considering this definition, do you think patient safety would be relevant to the HIM profession, and why? • “How do you think HIM professionals could contribute (directly or indirectly) to patient safety in acute hospitals?” • “Can you provide an example that demonstrates what we just discussed?” The interviews were audio recorded and transcribed verbatim. Participants were provided with the interview transcript to verify and identify the information they wished to redact. Once returned, the transcript was de-identified by removing any name and organisation identifiers and attributes assigned (distinguishing informant groups) and merged with transcripts from other participants. Data analysis A constructivist grounded theory (19) approach guided the data analysis. This approach involves coding, memo writing, and comparison (Fig. 1 ). Initial coding followed an inductive approach with multiple readings of the transcripts to assign a label that summarised and categorised the data fragment. These were provisional codes used to interpret participants' statements. Not all sentences were given a code. Focused coding followed, which involved examining the initial codes to identify frequent or significant entries in comparison to other transcripts for similarities and differences. Finally, a deductive approach was utilised using pre-defined codes related to the overall research project questions and theoretical framework. Researcher memos captured post-interview reflections, insights from data analysis, and emerging ideas (See supplementary file -data analysis protocol). RESULTS Fourteen (14) key informants were interviewed, including eight experts in the area of HIM, and six in patient safety (Table 2 ). The informants were categorised into three groups: past or present Presidents of HIMAA (n = 3), leading researchers in HIM or patient safety (n = 5), and working in patient safety governance roles (n = 6). One of the patient safety experts was a qualified health information manager. Informants were from across Australia, with most (85%), being from metropolitan areas and two (15%) being based in rural or remote locations. New South Wales (NSW) and Victoria (VIC) were the most represented Australian states, with five informants each, followed by Queensland (QLD), with two informants, and one each for the Australia Capital Territory (ACT) and Western Australia (WA). There were no informants from Tasmania or the Northern Territory. Four key functions performed by HIM professionals emerged through data analysis: data, documentation, education, and records management. In addition to the functions performed, informants discussed concerns for the profession and the professional association. All key informants (100%) stated that HIM professionals contributed to patient safety. The patient safety experts said the contribution was both direct and indirect, with four (50%) HIM experts agreeing. Two (25%) HIM experts stated the involvement was direct only, and another two (25%) expressed the contribution was only indirect. Overall, HIM experts described patient safety as the right care being provided without harm to patients. Some informants provided a deeper response, describing a patient safety culture that encompassed governance, policy, credentialing, communication, data, and information. Others recognised that patient safety is about the whole system, not just clinical care. The patient safety experts' understanding of HIM varied, with some focusing on coded data outputs, analysis, and reporting, while others understood the broader functions of managing information and privacy. All patient safety experts recognised that HIM professionals have an essential role in the health system to ensure information integrity, availability and trustworthiness for patient care decisions, funding, and performance measurement. Table 2 Key informant characteristics and responses – direct or indirect contribution Participant ID Expert Area Category Australian State HIMs contribute to patient safety? Contribution Direct Indirect Both KIP1 HIM 2 VIC Yes x KIP2 HIM 1 NSW Yes x KIP3 Patient Safety 3 NSW Yes x KIP4 Patient Safety 3 NSW Yes x KIP5 HIM 1 NSW Yes x KIP6 HIM 1 ACT Yes x KIP7 HIM 2 QLD Yes x KIP8 HIM 2 VIC Yes x KIP9 Patient Safety 3 VIC Yes x KIP10 HIM 2 NSW Yes x KIP11 Patient Safety 3 VIC Yes x KIP12 HIM 2 WA Yes x KIP13 Patient Safety 3 QLD Yes x KIP14 Patient Safety 3 VIC Yes x Key Functions: Function 1: Data Informants discussed the contribution of HIM professionals to patient safety as both direct and indirect, through the provision of data for patient care decisions, accreditation audits, benchmarking, costing, funding, modelling, planning, performance measurement, reflective practice, and safety indicators. KIP14 stated “ if we didn’t have you [HIM professionals] we wouldn’t have the information” and KIP5 stated “The recording of accurate data is a safety measure for all patients, and it is a very important part of the role of HIMs” , therefore showing the critical role of HIM professionals with providing data. This sentiment was reflected in the comments of many informants who advised that data contributes directly to patient safety when used in real time and indirectly when used retrospectively. Data for monitoring quality and safety featured heavily in the comments for the capture, trending and reporting on hospital-acquired complications (HACs). Informants discussed how HIM professionals help to understand what is happening in the health system through their data as they collate and report information from various sources, identify discrepancies and quality issues, and can articulate the impacts of poor-quality data or assumptions about data on decisions. KIP03 and KIP04 spoke of the data collected by HIM professionals being is used to monitor patient safety through clinical indicators, benchmarking, HACs, and accreditation activities. Informants also discussed the clinical coding process with abstracting data to tell the patient journey through codes, and then how this coded data is used for funding. KIP02 stated if the documentation does not describe the complexity of care provided, this is not captured in the coded data, and this becomes a patient safety issue as hospitals do not receive the right funding for the level of care provided. The patient safety experts identified opportunities for the HIM profession with data and information, particularly with data analytics. KIP09 stated “… as we get much more mature in our understanding of data then it’s all going to be about the interpretation and presentation back in, and how does that impact”. Informants spoke of HIM professionals' understanding of the data lifecycle from capture to disposal, and that the profession understands how data is used in patient care and its secondary applications in safety monitoring, quality improvement, benchmarking, service planning, disease surveillance, research and funding. Function 2: Documentation Informants discussed how HIM professionals guide the design of clinical forms (paper and electronic) to support workflows and accurate capture of information as an indirect contribution to patient safety. KIP13 stated “ Documentation is key to quality and safety ”. Other informants supported this by highlighting that clinical documentation integrity and improvement activities, which include educating clinicians on enhancing written documentation, directly contribute to patient safety. Written communication is a crucial element of clinical handover. Informants also reflected on the shift in focus from quality to reimbursement with the introduction of activity-based funding under the National Health Reform Agreement in 2012. Other documentation activities that informants stated have a direct contribution included reviewing information for completeness and accuracy, and maintaining accurate records in systems that impact patient flow. Function 3: Education The theme of education includes providing training and advice. Informants stated that when HIM professionals provide education to clinicians on documentation, records management, privacy, and data collection, individuals apply this knowledge to their work, which contributes to patient safety. Informants indicated that providing education is an indirect contribution, but once this knowledge is applied, it becomes a direct contribution to patient safety. KIP05 stated: “One of our roles .... was to talk to nurses and doctors about recording issues in medical records, particularly in recording issues relating to patient safety. We emphasised the need to record clear and precise information in the medical record”. Privacy was another function that informants indicated had a direct and indirect contribution to patient safety. One participant described responding to a confidentiality complaint as being direct, whereas auditing and surveillance activities for inappropriate system access were indirect. Function 4: Record Management Functions A key function HIM professionals perform is providing health information at the point of care. Seven (7) informants described this activity as directly impacting patient safety, given the implications for patient care if the information is unavailable. For instance, “HIMS in a clinical facility though, are responsible for making sure that the right information is available at the right time to the right providers so they can deliver the best possible care” [KIP07]. HIM experts further expanded upon this by discussing the management of duplicate health records, impact of incorrectly merged records, patient identification, and ensuring a single source of truth for clinicians to reference. Informants also discussed how HIM professionals influence the capture of demographic data and educate on interviewing techniques to ensure accurate data collection, therefore holding services accountable for the quality of the data they enter. When discussing records management functions that indirectly impact patient safety, informants described how HIM professionals safeguard confidential information from inappropriate access by conducting audits and investigating patient concerns or complaints about privacy breaches. One participant described the impact of confidentiality breaches on the patient, hospital and community, including a lack of trust in the health service and reluctance to disclose information. Further indirect examples provided by informants included HIM professionals involvement with electronic health records (EHRs) implementations and HIM professionals managing systems, records and record content so that it is accessible, accurate and available for patient care. Informants spoke of the changes and perceptions that arose with the introduction of EHRs. The HIM experts spoke of how they were heavily involved in the governance and management of health records in a paper format, but once information became electronic, their level of involvement decreased or changed. HIM experts expressed feeling forgotten about and undervalued for their knowledge in EHRs, as HIM professionals are educated on managing information regardless of the format in which it is captured. As a result, the HIM informants were concerned the HIM profession may be substituted, replaced, or made obsolete in the future and what the impact would be on patient safety. Concerns for the HIM Profession In addition to the concerns raised in response to the introduction of EHRs, informants also discussed other concerns for the profession and the professional association. These included the impact of course closures rather than transforming the future profession, and how the professional association supports HIM professionals. Some linked these concerns to the functions performed, whereas others voiced concerns when asked generic questions about key messages or to share additional thoughts they had on the topic. Informants offered suggestions on where the profession can refocus or reskill. HIM informants spoke of the work, or lack thereof, from the national peak body for the HIM profession. KIP05 expressed that the national association needs to be more visible to promote the profession's role in the healthcare system, while KIP12 spoke of the association needing to broaden its horizons to attract members to enable the sharing of knowledge and skills from related fields. KIP02 raised several areas that the national association needs to address, including instilling the value of supporting patient care so HIM professionals understand why they do the work they do, how the association has lost its passion for improving the profession, and the association’s leadership needing to understand patient outcomes, patient safety and quality, not just revenue. Furthermore, KIP02 stated that professional competencies do not link to quality and safety in healthcare. KIP01 also spoke of the Australian competencies for HIM professionals, and how they are preparing the graduates for today, not tomorrow. KIP01 spoke of the focus within the competencies on clinical coding and how the national body’s accreditation process requires this competency be taught, even though a large proportion of graduates will never work in a clinical coding role. KIP01 stressed that the national association needs to update the competencies to be reflective of the future workforce needs; otherwise, university graduates will not be work-ready. In discussing where the HIM profession can add value in the future, KIP11 stated: … you know some of that again might be around re-branding the profession because management of information is important but it's the use piece that is where the rubber really hits the road and so you know, maybe that's again a time to rethink that profession and think what, where will it head? what are the key strategic areas for the future? and how can the HIM professional to be able to support what's going to be required in the future? KIP11 further queried who will hospitals turn to for data expertise, HIM professionals or someone else, and KIP09 shared that HIM professionals need to take ownership of data science and data analytics. Clinical documentation integrity (CDI) was identified as an area for growth for HIM professionals. KIP08 stated “Getting better systems in place for CDI will actually help us re-engage more on a patient safety” , while KIP02 spoke as clinical documentation integrity being part of the clinical coding process and how HIM professionals can raise awareness of what good quality documentation looks. KIP05 stated “Clinical documentation improvement is not new. It is an area HIMs have been involved with for many years but it was not called CDI”. Furthermore, KIP05 linked documentation integrity to patient safety: “ The work that we should do is helping to ensure that the medical record or health record tells the story of the patient’s treatment and care while in hospital. The recording of accurate data is a safety measure for all patients and it is a very important part of the role of HIMs”. The concerns raised by informants for professional association to consider covered the role of the professional association in promoting the HIM professional part in patient safety; the need to focus on instilling the value of supporting patient care as foundational to HIM professionals; raising the profile of the HIM workforce role in healthcare; and highlighting the HIMS professionals is essential. Informants noted that immediate action is necessary to ensure the HIM profession has a future. Informants discussed challenges facing the HIM profession. They believe that workforce role substitution and hiring of unqualified HIM professionals is a risk to patient safety. Informants discussed that people unqualified in HIM might know what to do through workplace experience but may not understand why something is important. Informants further expressed that qualified people understand that the focus should not be on finance but on accurately capturing the patient journey and safeguarding information. Furthermore, the experts raised that resource shortages cause challenging workplace circumstances with insufficient staff to complete work. They described that this results in reduced quality activities and errors, lack of access to or understanding of information, and incorrect data for decision making, ultimately putting patient safety at risk. Values, Beliefs and Attitudes Informants were asked about values, beliefs, and attitudes as they influence behaviours, which is critical for an organisation’s patient safety culture and minimising harm. Words such as caring, empathy, ethical, honest, integrity, and person-centred were the most frequently mentioned by informants when providing examples of values, beliefs, and attitudes centred (Fig. 2 ). Informant responses indicated that HIM professionals work in roles or organisations that improve Australians' health or welfare as they believe that HIM professionals want to help patients. Respondents used words and phrases such as helping, giving back, respectful, valuing people, and helping staff help patients. One participant stated “ I think there is the belief that they’re [HIMS professionals] they’re for the good of the patient and the health service, and to do the best they can” [KIP6]. Another participant stated “ I do 100 million extra things on top of what I do because I believe that our profession is important, it has an important role to play in the whole healthcare ecosystem” [KIP07] and “Your belief system should be around caring. Being a caring individual. That you believe that the health service you work for is doing the right thing by its staff, its patients, and everybody who comes in contact with the health service. That's my belief” [KIP02]. Finally, KIP10 stated “ I’ve actually helped them [the clinician] and hopefully in that small way that helps the patient and contributes to safe care and all that sort of stuff and no harm”. Both the HIM and patient safety experts discussed the ‘do no harm’ belief. One participant discussed harm-free healthcare as something to aspire to, while others mentioned that ‘do not harm’ applies to all who work in healthcare. One HIM Informant linked patient safety and quality, stating, “ There’s a lot of quality behind the safety, and I believe we do have a direct impact ” [KIP12] whilst another linked these topics when discussing both patient safety and quality concepts being taught in university as they complement each other. KIP01 spoke of the current focus of university courses is geared towards patient safety, rather than quality, as harm still occurs in healthcare. There was also a belief that the data collected, stored, managed, analysed, and reported by HIM professionals significantly impacts the systems supporting patient safety and minimising harm. The value of caring and patient-centred care was evident in the informant responses as they spoke of the people behind the data, information, codes, and records, and that they deserve safe and quality care. Participants described what happens when a HIM professional does not care, which they believe could result in data quality errors, duplicate records created, and misfiled information. The concept of caring was described in other ways, including empathy and authenticity, as a means of building trust. Other participants spoke of having a ‘want to help’ attitude as a way of caring, treating people how they wanted to be treated, and not making assumptions or judgements. Multiple informants emphasised the value of integrity and how HIM professionals apply it in their work by adhering to ethical practices throughout the clinical coding process, assigning codes, and only accessing information appropriate to performing their duties. Integrity was linked with accountability, in that HIM professionals are responsible for their productivity, decisions and commitment. Advocacy was discussed by participants, such as “ the role HIM can play, is advocacy for good information, because information saves lives” [KIP07] and “ working with clinicians is you know advocating for them to come to HIM and talked to us about what data we can help them with to inform their data collections, or what they're doing. Uhm, so that informs patient safety in that they have better information available to make decisions or plan for their unit” [KIP08]. The responses of participants described how HIM professionals collaborate with clinicians and how patients are affected by decisions made based on data. Advocacy was described as both a value and behaviour of HIM professionals. Informants stated that HIM professionals recognise that behind each piece of data or information is a person, and that person deserves respect and confidentiality. Linking the values of respect and patient-centred was demonstrated through one informants statement: “ I think the values is the respect for people's privacy and I find the HIM's and very good, you know that is uh, sometimes in the privacy officer role, whether it's delegated or done by the HIMs, that's a really important value, there is the respect of the individual, the patients and that that you know that's really precious information” [KIP03]. Workforce-related beliefs were prominent in the informants' responses. Participants stated that individuals with HIM qualifications understand the relationship between their role and patient safety, and they ensure a focus on patient safety and quality rather than finances. Informants also discussed that the role of HIM professionals with patient safety has evolved over time: “maybe 20 years ago there was a broader health information, had a health information managers had a bigger role and a broader role in impacting on patient safety. But with the increased focus on the funding aspect, it's like made them focus in on looking at documentation that just impacts funding” [KIP08]. Negative workforce-related beliefs and attitudes were mentioned by informants. Informant responses indicated HIM professionals believe workforce shortages and high workloads are barriers to HIM professionals collaborating or participating in patient safety initiatives. Some informants discussed that HIM professionals feel undervalued as they do not feel they can contribute or speak up, with some stating HIM professionals have lost sight of the big picture of why they are in the workplace. Informants also expressed that if their beliefs and values do not align with their workplace and colleagues, this can impact an individual’s attitude towards work, which can impact behaviours. Behaviours and Group Practices Behaviours are the way individuals act in response to different situations or stimuli; these can be individual behaviours or group practices. Informants discussed the behaviours of HIM professionals towards patient safety through their actions or work. As shown in Fig. 2 , they covered facilitation behaviours and team dynamics. For instance, HIM professionals advocate for privacy, confidentiality, and quality documentation to ensure accurate patient stories and reliable information: “ I don't think often enough privacy is recognised as a patient safety issue, but it is. It is a huge impact on patient safety. because you know, safety isn't just physical harm, it's also mental harm, psychological harm, financial harm ”[KIP01]. HIM professionals also audit and educate on clinical documentation, therefore supporting the integrity and quality of clinical documentation. For example, one informant stated that “ over 80% of safety events is some breakdown in communication and that's essentially what you're [HIM professionals] doing is that you're providing the formal structured communication around that patient” [KIP14]. Sharing ideas, and exploring issues and problems are additional examples of communication and collaboration behaviours raised by informants. However, some informants mentioned of a lack of proactive behaviour in relation to not speaking up about patient safety concerns: “ our behaviours as HIMs has to change to be able to feel that we can do that, and that we can speak out. Because I've seen dangerous surgeons who have got a higher complication rate then a surgeon who is doing exactly the same procedure …... But I personally think our behaviour should change so that we have got the ability to approach somebody and say look, I do have concerns. I mean, clinical indicators will show it. But you've got to be able to report it properly and have the evidence” [KIP02]. Participants also described that HIM professionals are the experts in health records: “they should be prepared to speak up, listened to and heard. They have to go to a meeting well prepared, knowing they have the knowledge, to discuss these issues and give advice” [KIP05]. Informants discussed how the team culture is influenced by leadership and individuals feeling valued, which impacts team dynamics and the confidence to share their ideas and opinions. Informants also spoke of collaboration being both a behaviour, group practice and a value, particularly when HIM professionals translate clinical information into data for others to use or from a patient perspective, considering health literacy in designing clinical forms. Informants spoke of HIM professionals considering their communities when undertaking their duties, recognising that people, staff and patients, take their experience from the health facility back into the community, both good and bad. Overall, participants described HIM professionals as behaving in a helpful and welcoming manner. Alignment of informant responses to the Socio-Technical Systems Theory Overlaying the STS framework with the informants' feedback on HIM professionals and patient safety (Fig. 3 ), relationships between social and technical elements can be identified. For instance, within the people element, a behaviour of quality focus has direct relationship with physical systems and tasks. Informants spoke of HIM professionals having attention to detail (behaviour) as the coded data (task) is used for decision-making for patient care and service planning (organisation). For data to be of high quality, HIM professionals follow standards (physical system). Therefore, all quadrants of the framework were described by the key informants. Examining the social and technical systems that apply to HIM professionals in the patient safety context will aid in understanding dependencies and optimisation opportunities. DISCUSSION The key informant interview responses clearly demonstrate a link between HIM professionals and patient safety. This was shown through examples of functions performed, behaviours and cultural characteristics. From the informant's professional perspective, patient safety is both a mindset and actions, and is applied through how HIM professionals manage and care for the information about patients in the health system, ensuring this information is available and trustworthy for patient care, and improving patients' health. Kemp et al (6) identified that the HIM professionals' link to patient safety is likely through their functions in information governance, corporate governance, data quality and applying the health information management skillset. The key informants supported this view, as demonstrated by their examples related to data, documentation, education, and records management. HIM professionals engage at various points in the patient care journey, mainly through data capture. Informants conveyed that their work is significant, reflecting this in both their beliefs and behaviours. The core value of integrity means keeping your commitments, treating others well, and respecting others' opinions while also expressing your own views and feelings (16). The results above show how the HIM professional's values of integrity are associated with their behaviours towards advocacy, collaboration, respect, and caring. This finding was observed in other health professions, such as integrity as a crucial part of nursing leadership (16). The value-based and caring interactions of nurses build a positive culture and relationships that permeate through to patient care (20). Compassion and leadership were identified by Ahmed et al.(21) as two of the leading human factors that impact patient safety. They state that leadership that emphasises compassion will enhance organisational culture, patient experience, and overall healthcare. Values in healthcare extend through to documentation behaviours in how information is written in the health record (22). Stigmatising language may influence clinicians' attitudes, conscious or unconscious, and, therefore, decisions. Saha and Beach discuss the impact of language in clinical handovers on empathy and respect for patients, as well as its effect on patient safety. There is an opportunity for HIM professionals to leverage their values of integrity and respect, which align with those of clinicians, to influence their documentation practices and, ultimately, patient care. Informants from both HIM and patient safety backgrounds raised the belief of ‘do no harm’ in healthcare. Primum non nocere or ‘first, do no harm’ is associated with clinicians, such as the Physician’s pledge (oath or declaration) with their commitment to their profession and patients, and not typically associated with the non-clinical health roles. A core principle in patient safety is that no one is harmed in healthcare (10), which includes the function of the non-clinician, yet informants indicated that this belief applies to all who work in healthcare. This view aligns with the NSQHS Standards, to protect the public from harm and improve the quality of health service provision (7). These standards apply to the organisation, not individual professions; therefore, they imply that do no harm applies to all in healthcare. Understanding the patient safety culture of an organisation aids in addressing problems and improving patient safety (23). Informants’ responses identified behaviours related to patient safety culture, such as not speaking up (a potential risk) and collaboration (a strength). Seven subcultures of patient safety have been identified in the literature by Sammer et al(24): leadership, teamwork, learning, evidence-based, communication, just, and patient-centred. The Institute for Healthcare Improvement and Safe & Reliable Healthcare developed a framework covering strategic, operational, and clinical ideas for achieving safe, reliable, and effective healthcare. The Framework for Safe, Reliable, and Effective Care (25) outlines nine components under two domains, with the patient and family at the centre. The culture domain components are psychological safety, accountability, teamwork and communication, negotiation, and aligning, and the learning elements are transparency, reliability, improvement and measurement, and continuous learning (25). The final element, leadership, aligns with both culture and learning (25). Responses from the HIM and PS informants were compared to two patient safety culture frameworks (Table 3 ), with a focus on communication, leadership, learning, and patient-centred care, consistent with these frameworks. Table 3 Patient safety culture comparison Elements Sammer et al (2010) Frankel (2017) Key Informants Accountability X X Communication X X X Evidence-based X Improvement and measurement X X Just X Leadership X X X Learning X X X Negotiation X Patient-centred X X X Psychological safety X Reliability X X Teamwork X X X Transparency X Informants discussed how it feels to help others and their desire always to do better. The sentiment of ‘we are to help, and we care’ was present in all HIM experts' responses. This attitude is related to patient safety as informants stated that HIM professionals are accountable, willing to learn, pay attention to detail, and have a positive mindset. These items impact the workplace culture of HIM professionals. Informants also expressed that values-based roles and working in an organisation that aligns with personal values were important to HIM professionals. A positive workplace safety culture means individuals can comfortably raise issues, concerns or hazards without fear of repercussions (26). Wachter (26) discusses authority gradients, or hierarchies, and the divide between workers and a superior. While these gradients are expected, they can become unsafe when a person lower on the gradient is reluctant to question someone higher in the hierarchy for fear of being wrong or angering them (26). Speaking up is an individual's behaviour and not a group practice. Based on Wachter's description, HIM professionals not voicing concerns could be related to a perceived position in an organisation's hierarchy. Therefore, when they do not speak up when noticing a patient safety issue, such as a high surgical error rate, higher frequency of HACs in a particular area, or errors in documentation, this is cause for concern due to the potential for harm to future patient care and impact of safety culture. The informant responses indicate patient safety culture as an area for improvement. HIM professionals need to have confidence in their knowledge, be equipped and educated on how to raise issues and receive support from leaders to apply this skill set. Otherwise, this mindset will not change. Informants raised concerns for the HIM profession, professional identity and the professional association. Appointing unqualified individuals to professional positions in HIM is an example of role substitution. Informants discussed how a lack of understanding of the ‘why’ behind activities carried out in a particular way, which is taught as part of qualifications, can lead to incorrect practices or processes related to information governance, data management, and privacy. The profession needs to adapt and transform to survive (27), and role substitution introduces ethical, confidentiality and medico-legal concerns (28), and lack of access to education and course closures will impact the ability to fill vacancies in the future (28). Research indicates the ageing workforce and a lack of graduates from HIM courses will impact on having a sustainable professional workforce to meet future healthcare demands (27, 28). While these challenges will impact available qualified HIM workers, Butler-Henderson(27) highlighted retention rates of HIM professionals in the workplace and the increasing demand for health services will continue to provide employment opportunities. With the changing health landscape, Butler-Henderson also provides insights into functions the HIM profession should be moving towards, such as information governance and data science (27). Informants also described the HIM profession as needing to target these areas. Until there is sufficient workforce supply, role and task substitution will continue to be a solution to ensure duties are completed. Adeleke et al. (29) discuss role substitution from the viewpoint of lesser-trained individuals completing tasks without supervision or they are not qualified for, which can result in a risk to the healthcare system in the management and ethical use of health data (29). Workforce shortages are a challenge in other health roles. Nursing workforce shortages can be attributed to ineffective policy and planning, training and enrolment barriers, workforce turnover, workload, burnout and job dissatisfaction (30). The Australian Institute of Health and Welfare (AIHW) reports an increase in demand for healthcare professionals, with the 2023 Skills Priority List indicating shortages in four out of five professional occupations (31). AIHW advises global competition may impact the recruitment of health professionals to Australia. Global workforce shortages also affect HIM, and the impact will be on standards, data quality management, records and information management, and information governance(32). These elements contribute to trustworthy, quality, and available information that is needed for patient care and running the healthcare system. There are opportunities, a strong sense of professional identity and a recognition of the importance of the profession (33), that has always adapted and responded to the political, social and technological influences on data and information (34). For instance, informants voiced that the recent increase in clinical documentation integrity programs has shifted the focus from revenue to high-quality documentation that reflects the complexity of care provided. Informants acknowledged clinical documentation integrity as a growing area for HIM professionals, along with ongoing roles in data. KIP 3 (patient safety expert) discussed how data is used in algorithms and artificial intelligence (AI), stating, “with the growing nature of Algorithms and AI and those kinds of intelligent decision support, that all relies on the coded data, that that relies on the next patient in front of you, that relies on the last 100 patients that you've treated, and that, that sort of builds a picture of your population, your treatments, the effectiveness there of. So it starts to then give you the tools to provide better care now into the future hopefully as well”. This comment highlights how the past influences the present and the future, and reflects a growing interest in utilising AI and natural language processing to support clinical coding. In addition to clinical coding, Stanfill and Marc (35) identified the future use of AI as impacting data management, privacy and confidentiality, governance, and education. A key role of HIM professionals is to identify nuances in the data that require a deeper dive and collaborate with clinicians to review documentation and information. Reducing administrative burden is one of the benefits of AI (36), and workflows are a potential where AI would benefit HIMS professionals. Informants expressed that the increase in the adoption and implementation of digital health technologies presents both opportunities and threats to the HIM profession. HIM professionals possess a wealth of knowledge that is highly beneficial for digital health, particularly in the context of electronic health records; however, they need to be actively engaged. The threat is that they will not be involved, opening the door for other professions to replace them. Role substitution has been identified as an issue requiring action to evolve the HIM profession (27). The International Federation of Health Information Management Associations (IFHIMA) recognises the need to elevate the HIM profession due to its pivotal role in data and information, which is integral to the delivery of healthcare(32). IFHIMA identified information governance, including data standards, access, and security); embracing technology; HIM education and curriculum; specialisation and diversification; increased visibility of profession; and championing the HIM skillset as priorities(32). HIM professionals build awareness and expectations of privacy and security of health information through the education they deliver. HIM professionals serve as spokespersons for confidentiality and privacy and, therefore, information governance. CONCLUSION The findings from this study highlight the altruistic nature of HIM professionals, who believe their work significantly supports clinicians and has a positive impact on patients and healthcare organisations. Their values, beliefs, and attitudes closely align with those of clinicians and the principles of patient safety culture, particularly in areas such as accountability, communication, leadership, learning, teamwork, and patient-centred care. While the “do no harm” philosophy has traditionally been associated with clinicians, HIM professionals embody this belief through their daily actions. These actions include advocating for patient privacy, ensuring the capture of high-quality information, providing education on these topics, and translating data into actionable and comprehensible information. Collectively, their behaviours foster a dynamic environment that promotes collaboration, communication, and cohesiveness, leading and guiding processes and discussions on various HIM topics and issues. Informants identified several concerns for the HIM profession, including a lack of recognition for their expertise, which they believed hindered their full utilisation in areas such as patient safety. Issues such as role substitution, unqualified individuals in HIM roles, and workforce challenges were also noted as potential impacts to patient safety. These insights provide an opportunity for the professional association to reflect on and guide the profession into the future. All experts interviewed affirmed that HIM professionals contribute to patient safety both directly and indirectly. This contribution encompasses information and data governance, documentation integrity practices, education, and the management of both paper and digital records. HIM professionals can leverage their shared values, beliefs, and attitudes with clinicians to foster positive working relationships and influence clinician behaviours in areas such as privacy, documentation, and data management. These findings will be further validated by HIM professionals working in acute hospitals during the next research stage. Further research could also be conducted to measure the impact of HIM professionals on the NSQHS Standards, thereby understanding their role in clinical governance and quality indicators. Abbreviations ACSQHC Australian Commission on Safety and Quality in Healthcare AI Artificial Intelligence EHRs Electronic health records HAC hospital-acquired complication HIM health information management HIMAA Health Information Management Association of Australia IFHIMA International Federation of Health Information Management Associations NQSHS National Safety and Quality Healthcare Service WHO World Health Organization Declarations Ethics approval and consent to participate: The RMIT University Human Research Ethics Committee (HREC 24904) approved the study design, methodology, literature review, document analysis, and key informant interviews for a PhD study. Informed consent was obtained from all individual participants. The study is in accordance with the Declaration of Helsinki. Consent for publication: Written consent was obtained from participants for this study, including publication of de-identified findings. Availability of data and materials: Not applicable Competing interests: This research is part of a PhD study for the lead author Trixie Kemp. The other authors declare that they have no competing interests. Funding: No funding was received for conducting this study Authors’ contributions: Authors Trixie Kemp, Kerryn Butler-Henderson and Jennifer Ayton contributed to the study's conception and design. Trixie Kemp performed material preparation, data collection, and analysis. Trixie Kemp wrote the manuscript's first draft, and all authors commented on previous versions. All authors read and approved the final manuscript. Acknowledgements: Not applicable. References Abdelhak M, Hanken MA. Health information: management of a strategic resource. St Louis, Missouri, USA: Elsevier/Saunders; 2016. HIMAA. Definition of the Profession Web: Health Information Management Association of Australia; 2021 [Available from: https://himaa.org.au/the-professions/ Butler-Henderson K, Gray K. A Glimpse at the Australian Health Information Workforce: Findings from the First Australian Census: IOS Press; 2019. Institute of Medicine Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. Kemp TE, Butler-Henderson K, Allen P, Ayton J. Evolution of the Health Record as a Communication Tool to Support Patient Safety. In: Chisita C, Enakrire R, Durodolu O, Tsabedze V, Ngoaketsi J, editors. Handbook of Research on Records and Information Management Strategies for Enhanced Knowledge Coordination. Advances in Library and Information Science. Hershey, PA, USA: IGI Global; 2021. p. 127 − 55. Kemp TE, Butler-Henderson K, Allen P, Ayton J. The impact of health information management professionals on patient safety: A systematic review. Health information and libraries journal. 2021;38(4):248 − 58. ACSQHC. National Safety and Quality Health Service Standards Australia 2nd edition. Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2021. Butler-Henderson K. Health information management 2025: 'What is required to create a sustainable profession in the face of digital transformation?'. Launceston: University of Tasmania; 2017. Contract No.: ISBN 978-1-82695-88-3. World Health Organization. Patient safety research: a guide for developing training programmes: World Health Organization; 2012. World Health Organization. Patient Safety Factsheet 2023 [updated 11/09/2023. Available from: https://www.who.int/news-room/fact-sheets/detail/patient-safety. Woodward S. Rethinking Patient Safety. 1st ed. ed. Portland: Productivity Press; 2017. Australian Commission on Safety and Quality in Health Care. The state of patient safety and quality in Australian hospitals 2019. Sydney: ACSQHC; 2019. Krasny ME. Values, Beliefs, and Attitudes. Ithaca, NY: Cornell University Press; 2020. p. 101 − 16. Schwartz SH, Vecchione M, Fischer R, Ramos A, Demirutku K, Dirilen-Gumus O, et al. Refining the Theory of Basic Individual Values. Journal of Personality & Social Psychology. 2012;103(4):663 − 88. Shealy CN, Acheson K. Making sense of beliefs and values : theory, research, and practice. 1st ed. New York, New York: Springer Publishing Company; 2016. Poirier D. Achieve lasting change through a values-driven workforce: Guiding employees’ attitudes, beliefs can lead to sustainable results. ISE: Industrial & Systems Engineering at Work. 2020;52(5):42. Ajzen I. The theory of planned behavior. Organizational behavior and human decision processes : a journal of fundamental research and theory in applied psychology. 1991;50(2):179–211. Creswell JW, Creswell JD. Research design : qualitative, quantitative & mixed methods approaches: Sage Publishing; 2018. Charmaz K. Constructing grounded theory. 2nd ed. ed: SAGE; 2013. Hemberg J, Salmela S. Integrity and Efficiency in Nursing Leadership: An Integrative Review. International journal of caring sciences. 2021;14(2):1496 − 513. Ahmed Z, Ellahham S, Soomro M, Shams S, Latif K. Exploring the impact of compassion and leadership on patient safety and quality in healthcare systems: a narrative review. BMJ Open Quality. 2024;13(Suppl 2):e002651. Saha S, Beach MC. Building a Culture of Quality and Safety in Health Care-The Importance of Respect for Patients. JAMA network open. 2024;7(12):e2450134. Bartonickova D, Kalankova D, Ziakova K. How to Measure Patient Safety Culture? a Literature Review of Instruments. Acta Medica Martiniana. 2021;21(2):69–79. Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. What is patient safety culture? A review of the literature. J Nurs Scholarsh. 2010;42(2):156 − 65. Frankel A, Haraden C, Federico F, J. L-E. A Framework for Safe, Reliable, and Effective Care. White Paper.. Cambridge, MA, USA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017. Wachter RM, Gupta K. Understanding patient safety. Third edition. ed. New York: McGraw-Hill Education; 2018. Butler-Henderson K. Health information management 2025: 'What is required to create a sustainable profession in the face of digital transformation? Launceston: University of Tasmania; 2017. Report No.: 978-1-86295-888-3 Contract No.: ISBN 978-1-82695-88-3. HIMAA. Health Information Workforce Summit Report 2015. Sydney, Australia: Health Information Management Association of Australia; 2016. Adeleke IT, Suleiman-Abdul QB, Aliyu A, Ishaq IA, Adio RA. Deploying unqualified personnel in health records practice: Role substitution or quackery? Implications for health services delivery in Nigeria. Health Information Management Journal. 2019;48(3):152-6. Tamata AT, Mohammadnezhad M. A systematic review study on the factors affecting shortage of nursing workforce in the hospitals. Nursing open. 2023;10(3):1247-57. AIHW. Health Workforce Web: Australian Institute of Health and Welfware; 2024 [Available from: https://www.aihw.gov.au/reports/workforce/health-workforce. IFHIMA. Examining Today's HIM Workforce with Recommendations for Elevating the Profession. Internet: International Federation of Health Information Management Associations; 2022. Nexhip A, Riley M, Robinson K. Professional identity and workplace motivation: A case study of health information managers. Health Information Management Journal. 2024;53(2):76–84. Wissmann S, Henderson J, Robinson K. The health information management workforce: Looking to the future. Health Information Management Journal. 2024;0(0):18333583241303635. Stanfill MH, Marc DT. Health Information Management: Implications of Artificial Intelligence on Healthcare Data and Information Management. Yearb Med Inform. 2019;28(1):056–64. Schulman KA, Nielsen JPK, Patel K. AI Alone Will Not Reduce the Administrative Burden of Health Care. JAMA : the journal of the American Medical Association. 2023;330(22):2159-60. Additional Declarations No competing interests reported. Supplementary Files InterviewGuideKeyInformantInterviewsv1.0.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 01 Apr, 2026 Reviewers agreed at journal 31 Mar, 2026 Reviewers agreed at journal 25 Mar, 2026 Reviewers agreed at journal 10 Dec, 2025 Reviewers invited by journal 12 Apr, 2025 Editor assigned by journal 11 Apr, 2025 Submission checks completed at journal 10 Apr, 2025 First submitted to journal 10 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6384767","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":446351521,"identity":"65e3e0a6-09a0-4db1-80d5-31a535fea82e","order_by":0,"name":"Trixie Kemp","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYFACNhBhA2HzEKOBB6IljXQth0nQYi99LPHRzR3n5eVnJDA+eNvGIG9wgJAtfGmHjXPP3DbccCOB2XBuG4PhBoJaeNjbpHPbbicYSCSwSfO2MTASo6X9d27buQSgw9h/A7XYE6GF7RhzbtuBBIYbCWzMQC2JhLWcYUuWzj2TbLjhzMNmyTnnJJJnEtLC3sNm+Dl3h528fHvywQ9vymxs+whpAQPGBjgpQYx6uJZRMApGwSgYBTgAAC16PD8F3ccJAAAAAElFTkSuQmCC","orcid":"","institution":"Charles Sturt University","correspondingAuthor":true,"prefix":"","firstName":"Trixie","middleName":"","lastName":"Kemp","suffix":""},{"id":446351522,"identity":"f5fe2b03-5435-4b3e-98b7-f46dc7598ca1","order_by":1,"name":"Jennifer Ayton","email":"","orcid":"","institution":"University of Tasmania","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Ayton","suffix":""},{"id":446351523,"identity":"a6b800c3-ba8d-464e-92c9-f83935bcc6eb","order_by":2,"name":"Kerryn Butler-Henderson","email":"","orcid":"","institution":"Charles Sturt University","correspondingAuthor":false,"prefix":"","firstName":"Kerryn","middleName":"","lastName":"Butler-Henderson","suffix":""},{"id":446351524,"identity":"85869f1b-fd5d-4d73-b8cf-7a467a784223","order_by":3,"name":"Salma Arabi","email":"","orcid":"","institution":"Charles Sturt University","correspondingAuthor":false,"prefix":"","firstName":"Salma","middleName":"","lastName":"Arabi","suffix":""}],"badges":[],"createdAt":"2025-04-06 04:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6384767/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6384767/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82143986,"identity":"fbb4161f-5339-4bd9-800e-37c475ed1121","added_by":"auto","created_at":"2025-05-07 06:44:17","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":240148,"visible":true,"origin":"","legend":"\u003cp\u003eData analysis approach\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6384767/v1/e499a0c2bc842f7fb7b7dd3e.jpeg"},{"id":82143988,"identity":"7ec8a9e1-b498-4fa6-b8a0-6efeb91fac1d","added_by":"auto","created_at":"2025-05-07 06:44:17","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":73157,"visible":true,"origin":"","legend":"\u003cp\u003eValues, beliefs, attitudes, behaviours and group practices of HIM professionals in relation to patient safety\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6384767/v1/d243e3428249451f16eb5b3c.jpg"},{"id":82143992,"identity":"e4b7b158-73f3-47cc-8750-408a001590df","added_by":"auto","created_at":"2025-05-07 06:44:17","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":95578,"visible":true,"origin":"","legend":"\u003cp\u003eHIM professionals and patient safety through socio-technical systems lens\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6384767/v1/7ca600876073d53881d8f99c.jpg"},{"id":82147235,"identity":"8d3ebd85-4dc5-4d9a-b8da-17dec02bace9","added_by":"auto","created_at":"2025-05-07 07:00:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1230455,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6384767/v1/64d8cbec-1669-4310-ba7d-84005ecd94e3.pdf"},{"id":82143991,"identity":"bacaa65a-b641-4a83-bba6-334b1fc29ceb","added_by":"auto","created_at":"2025-05-07 06:44:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":153880,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewGuideKeyInformantInterviewsv1.0.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6384767/v1/f011c05e0feaad8936d6d1dc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perspectives on the role of health information management professionals in enhancing patient safety: A qualitative study","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eHealth services collect and create vast amounts of information. In 1928, a need was identified for a dedicated workforce to manage information collection, storage, protection, analysis, and quality, which led to the formation of the health information management (HIM) profession (1). HIM professionals play a vital role in the healthcare system, supporting clinicians and health service management by ensuring that data is trustworthy and reliable for informed decision-making. Their skillset and knowledge cover records management, human resources, medical terminology, anatomy and physiology, clinical coding, classification and data management (2). However, their scope is not well-understood outside of the profession (3).\u003c/p\u003e \u003cp\u003eHIM professionals have a unique perspective on the healthcare system, as they work with patient information at the individual, facility, and whole-service levels. Still, this profession is often overlooked in the context of patient safety. Health records are a key source of information for patient safety events and data (4). Literature confirms the connection between health records and patient safety (4\u0026ndash;7) and between health records and HIM professionals (1, 8), with health records being the intersection point. A 2021 literature review by Kemp et al. identified non-empirical literature linking HIM functions to patient safety in information governance, corporate governance, data quality, and HIM skillset (6). The study identified a lack of empirical evidence examining how the HIM profession impacts patient safety (6).\u003c/p\u003e \u003cp\u003eThe World Health Organization (WHO) states that patient safety is a complex global public health concern due to the various settings, cultures, and resources (9). WHO defines patient safety as \u0026ldquo;the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum\" (10). Patient safety can be described as being a mindset, not a task or specific intervention (11). Australia was an early leader in investigating quality and patient safety. The Quality in Australian Health Care Study (1995) reported that 16.6% of Australian inpatients had an adverse event, and 51% were preventable (12). In 2006, the Australian Commission on Safety and Quality in Healthcare (ACSQHC) was established to coordinate national quality and safety improvement by providing information and resources; developing national safety and quality standards, clinical care standards; and the accreditation scheme (12). The ACSQHC examines patient safety in health facilities by monitoring sentinel events, adverse events, hospital-acquired complications, and hospital-based indicators and undertaking accreditation assessments(12).\u003c/p\u003e \u003cp\u003eWithin Australia, health services are accredited against the National Safety and Quality Healthcare Service (NSQHS) Standards(7) to demonstrate an organisations' commitment to patient safety and quality. While improvements have occurred over the last 20 years, harm and adverse events still occur. Multiple data sources are used to monitor and report on the state of patient safety in the Australian healthcare system. These include coded data from health records, mortality indicators, a national list of hospital-acquired complications (HACs), patient surveys, and incident analysis (12). Reliable data is, therefore, essential for an accurate understanding of the Australian patient safety situation.\u003c/p\u003e \u003cp\u003eThis paper examines the perspectives of key informants on the contribution HIM professionals make to patient safety, whether the contribution is direct or indirect, and what the contribution is. Attitudes, values, and beliefs are also discussed to understand how they influence HIM professionals' behaviours and group practices regarding patient safety. Values are our principles or what individuals believe is of worth(13, 14), beliefs are ideas we accept without facts(15), and attitudes are the way an individual thinks or feels about something(13). When combined, they drive our behaviour (13, 16, 17). Therefore, understanding these characteristics will allow comparison to other health professions.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis qualitative case study approach used one to one (phone or Zoom) interviews with Australian \u0026lsquo;experts\u0026rsquo; in HIM and patient safety. Interviews are a well-established method in qualitative study to gain the perspectives and experience from experts in response to research questions (18). A socio-technical systems theory was used as a lens to examine the components of society (people and organisation), and technical (tasks and systems). STS originated from work at the Tavistock Institute for Human Relations in 1949 (13). STS examines the relationships between social and technical systems, aiming for joint optimisation to achieve tasks and outcomes. The social system considers people\u0026rsquo;s attributes, relationships, reward systems and governance and organisational structures. The technical system encompasses the processes, tasks, and technology required to produce outputs (15, 16). STS theory has been used to study other health professions and healthcare settings.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment and selection\u003c/h2\u003e \u003cp\u003eKey informants were initially identified through the researchers\u0026rsquo; network, based on the potential informant\u0026rsquo;s professional association or positions held, publication or research activities, or through recommendations from leaders in the fields of health information and patient safety. Once the interview commenced, informants were asked to suggest others to be interviewed on this topic. Once saturation had been reached, no further informants were recruited.\u003c/p\u003e \u003cp\u003eInformants were grouped into the following categories:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePast or present President of the Health Information Management Association of Australia (HIMAA)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLeading practitioners or researchers in HIM or patient safety in Australia, and\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatient safety experts based in patient safety governance roles.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e An invitation, participant information sheet and consent form were emailed to potential participants. Participation was indicated by returning a signed consent form to the primary investigator.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe interviews concluded in January 2024 and were conducted via Microsoft Teams, Zoom or telephone. The interviews were semi-structured to support a conversational approach to gathering the data. An interview guide, developed specifically for this study, was used to ensure all participants were asked the questions for their expert group (15 open-ended questions for HIM experts and 13 for patient safety experts). Initial questions were informed by the literature review, investigators' experience in qualitative studies, and the research project aims. As the interviews progressed, the interview guide was adjusted to enhance the flow of questions and include additional prompts. The questions were designed to extract similar information from the experts, with an example of how the wording differed based on the informant's expertise as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExpert group and interview questions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpert Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuestions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Do you think your role does or does not contribute to patient safety?\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Thinking about the HIM profession in general, how are they directly or indirectly contributing to patient safety in acute hospitals?\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Can you provide an example that demonstrates what we just discussed?\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Considering this definition, do you think patient safety would be relevant to the HIM profession, and why?\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;How do you think HIM professionals could contribute (directly or indirectly) to patient safety in acute hospitals?\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Can you provide an example that demonstrates what we just discussed?\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe interviews were audio recorded and transcribed verbatim. Participants were provided with the interview transcript to verify and identify the information they wished to redact. Once returned, the transcript was de-identified by removing any name and organisation identifiers and attributes assigned (distinguishing informant groups) and merged with transcripts from other participants.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA constructivist grounded theory (19) approach guided the data analysis. This approach involves coding, memo writing, and comparison (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Initial coding followed an inductive approach with multiple readings of the transcripts to assign a label that summarised and categorised the data fragment. These were provisional codes used to interpret participants' statements. Not all sentences were given a code. Focused coding followed, which involved examining the initial codes to identify frequent or significant entries in comparison to other transcripts for similarities and differences. Finally, a deductive approach was utilised using pre-defined codes related to the overall research project questions and theoretical framework. Researcher memos captured post-interview reflections, insights from data analysis, and emerging ideas (See supplementary file -data analysis protocol).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eFourteen (14) key informants were interviewed, including eight experts in the area of HIM, and six in patient safety (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The informants were categorised into three groups: past or present Presidents of HIMAA (n\u0026thinsp;=\u0026thinsp;3), leading researchers in HIM or patient safety (n\u0026thinsp;=\u0026thinsp;5), and working in patient safety governance roles (n\u0026thinsp;=\u0026thinsp;6). One of the patient safety experts was a qualified health information manager. Informants were from across Australia, with most (85%), being from metropolitan areas and two (15%) being based in rural or remote locations. New South Wales (NSW) and Victoria (VIC) were the most represented Australian states, with five informants each, followed by Queensland (QLD), with two informants, and one each for the Australia Capital Territory (ACT) and Western Australia (WA). There were no informants from Tasmania or the Northern Territory.\u003c/p\u003e \u003cp\u003eFour key functions performed by HIM professionals emerged through data analysis: data, documentation, education, and records management. In addition to the functions performed, informants discussed concerns for the profession and the professional association. All key informants (100%) stated that HIM professionals contributed to patient safety. The patient safety experts said the contribution was both direct and indirect, with four (50%) HIM experts agreeing. Two (25%) HIM experts stated the involvement was direct only, and another two (25%) expressed the contribution was only indirect. Overall, HIM experts described patient safety as the right care being provided without harm to patients. Some informants provided a deeper response, describing a patient safety culture that encompassed governance, policy, credentialing, communication, data, and information. Others recognised that patient safety is about the whole system, not just clinical care. The patient safety experts' understanding of HIM varied, with some focusing on coded data outputs, analysis, and reporting, while others understood the broader functions of managing information and privacy. All patient safety experts recognised that HIM professionals have an essential role in the health system to ensure information integrity, availability and trustworthiness for patient care decisions, funding, and performance measurement.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey informant characteristics and responses \u0026ndash; direct or indirect contribution\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eParticipant ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eExpert Area\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAustralian State\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHIMs contribute to patient safety?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eContribution\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDirect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIndirect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNSW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient Safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNSW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient Safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNSW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNSW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eACT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQLD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient Safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNSW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient Safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient Safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQLD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKIP14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient Safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eKey Functions:\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFunction 1: Data\u003c/h2\u003e \u003cp\u003eInformants discussed the contribution of HIM professionals to patient safety as both direct and indirect, through the provision of data for patient care decisions, accreditation audits, benchmarking, costing, funding, modelling, planning, performance measurement, reflective practice, and safety indicators. KIP14 stated \u0026ldquo;\u003cem\u003eif we didn\u0026rsquo;t have you [HIM professionals] we wouldn\u0026rsquo;t have the information\u0026rdquo;\u003c/em\u003e and KIP5 stated \u003cem\u003e\u0026ldquo;The recording of accurate data is a safety measure for all patients, and it is a very important part of the role of HIMs\u0026rdquo;\u003c/em\u003e, therefore showing the critical role of HIM professionals with providing data. This sentiment was reflected in the comments of many informants who advised that data contributes directly to patient safety when used in real time and indirectly when used retrospectively. Data for monitoring quality and safety featured heavily in the comments for the capture, trending and reporting on hospital-acquired complications (HACs).\u003c/p\u003e \u003cp\u003eInformants discussed how HIM professionals help to understand what is happening in the health system through their data as they collate and report information from various sources, identify discrepancies and quality issues, and can articulate the impacts of poor-quality data or assumptions about data on decisions. KIP03 and KIP04 spoke of the data collected by HIM professionals being is used to monitor patient safety through clinical indicators, benchmarking, HACs, and accreditation activities. Informants also discussed the clinical coding process with abstracting data to tell the patient journey through codes, and then how this coded data is used for funding. KIP02 stated if the documentation does not describe the complexity of care provided, this is not captured in the coded data, and this becomes a patient safety issue as hospitals do not receive the right funding for the level of care provided.\u003c/p\u003e \u003cp\u003eThe patient safety experts identified opportunities for the HIM profession with data and information, particularly with data analytics. KIP09 stated \u0026ldquo;\u0026hellip;\u003cem\u003eas we get much more mature in our understanding of data then it\u0026rsquo;s all going to be about the interpretation and presentation back in, and how does that impact\u0026rdquo;.\u003c/em\u003e Informants spoke of HIM professionals' understanding of the data lifecycle from capture to disposal, and that the profession understands how data is used in patient care and its secondary applications in safety monitoring, quality improvement, benchmarking, service planning, disease surveillance, research and funding.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFunction 2: Documentation\u003c/h3\u003e\n\u003cp\u003eInformants discussed how HIM professionals guide the design of clinical forms (paper and electronic) to support workflows and accurate capture of information as an indirect contribution to patient safety. KIP13 stated \u0026ldquo;\u003cem\u003eDocumentation is key to quality and safety\u003c/em\u003e\u0026rdquo;. Other informants supported this by highlighting that clinical documentation integrity and improvement activities, which include educating clinicians on enhancing written documentation, directly contribute to patient safety. Written communication is a crucial element of clinical handover. Informants also reflected on the shift in focus from quality to reimbursement with the introduction of activity-based funding under the National Health Reform Agreement in 2012. Other documentation activities that informants stated have a direct contribution included reviewing information for completeness and accuracy, and maintaining accurate records in systems that impact patient flow.\u003c/p\u003e\n\u003ch3\u003eFunction 3: Education\u003c/h3\u003e\n\u003cp\u003eThe theme of education includes providing training and advice. Informants stated that when HIM professionals provide education to clinicians on documentation, records management, privacy, and data collection, individuals apply this knowledge to their work, which contributes to patient safety. Informants indicated that providing education is an indirect contribution, but once this knowledge is applied, it becomes a direct contribution to patient safety. KIP05 stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;One of our roles .... was to talk to nurses and doctors about recording issues in medical records, particularly in recording issues relating to patient safety. We emphasised the need to record clear and precise information in the medical record\u0026rdquo;.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePrivacy was another function that informants indicated had a direct and indirect contribution to patient safety. One participant described responding to a confidentiality complaint as being direct, whereas auditing and surveillance activities for inappropriate system access were indirect.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFunction 4: Record Management Functions\u003c/h2\u003e \u003cp\u003eA key function HIM professionals perform is providing health information at the point of care. Seven (7) informants described this activity as directly impacting patient safety, given the implications for patient care if the information is unavailable. For instance, \u003cem\u003e\u0026ldquo;HIMS in a clinical facility though, are responsible for making sure that the right information is available at the right time to the right providers so they can deliver the best possible care\u0026rdquo;\u003c/em\u003e [KIP07]. HIM experts further expanded upon this by discussing the management of duplicate health records, impact of incorrectly merged records, patient identification, and ensuring a single source of truth for clinicians to reference.\u003c/p\u003e \u003cp\u003eInformants also discussed how HIM professionals influence the capture of demographic data and educate on interviewing techniques to ensure accurate data collection, therefore holding services accountable for the quality of the data they enter. When discussing records management functions that indirectly impact patient safety, informants described how HIM professionals safeguard confidential information from inappropriate access by conducting audits and investigating patient concerns or complaints about privacy breaches. One participant described the impact of confidentiality breaches on the patient, hospital and community, including a lack of trust in the health service and reluctance to disclose information.\u003c/p\u003e \u003cp\u003eFurther indirect examples provided by informants included HIM professionals involvement with electronic health records (EHRs) implementations and HIM professionals managing systems, records and record content so that it is accessible, accurate and available for patient care. Informants spoke of the changes and perceptions that arose with the introduction of EHRs. The HIM experts spoke of how they were heavily involved in the governance and management of health records in a paper format, but once information became electronic, their level of involvement decreased or changed. HIM experts expressed feeling forgotten about and undervalued for their knowledge in EHRs, as HIM professionals are educated on managing information regardless of the format in which it is captured. As a result, the HIM informants were concerned the HIM profession may be substituted, replaced, or made obsolete in the future and what the impact would be on patient safety.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eConcerns for the HIM Profession\u003c/h2\u003e \u003cp\u003eIn addition to the concerns raised in response to the introduction of EHRs, informants also discussed other concerns for the profession and the professional association. These included the impact of course closures rather than transforming the future profession, and how the professional association supports HIM professionals. Some linked these concerns to the functions performed, whereas others voiced concerns when asked generic questions about key messages or to share additional thoughts they had on the topic. Informants offered suggestions on where the profession can refocus or reskill.\u003c/p\u003e \u003cp\u003eHIM informants spoke of the work, or lack thereof, from the national peak body for the HIM profession. KIP05 expressed that the national association needs to be more visible to promote the profession's role in the healthcare system, while KIP12 spoke of the association needing to broaden its horizons to attract members to enable the sharing of knowledge and skills from related fields. KIP02 raised several areas that the national association needs to address, including instilling the value of supporting patient care so HIM professionals understand why they do the work they do, how the association has lost its passion for improving the profession, and the association\u0026rsquo;s leadership needing to understand patient outcomes, patient safety and quality, not just revenue. Furthermore, KIP02 stated that professional competencies do not link to quality and safety in healthcare. KIP01 also spoke of the Australian competencies for HIM professionals, and how they are preparing the graduates for today, not tomorrow. KIP01 spoke of the focus within the competencies on clinical coding and how the national body\u0026rsquo;s accreditation process requires this competency be taught, even though a large proportion of graduates will never work in a clinical coding role. KIP01 stressed that the national association needs to update the competencies to be reflective of the future workforce needs; otherwise, university graduates will not be work-ready.\u003c/p\u003e \u003cp\u003eIn discussing where the HIM profession can add value in the future, KIP11 stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip; you know some of that again might be around re-branding the profession because management of information is important but it's the use piece that is where the rubber really hits the road and so you know, maybe that's again a time to rethink that profession and think what, where will it head? what are the key strategic areas for the future? and how can the HIM professional to be able to support what's going to be required in the future?\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eKIP11 further queried who will hospitals turn to for data expertise, HIM professionals or someone else, and KIP09 shared that HIM professionals need to take ownership of data science and data analytics.\u003c/p\u003e \u003cp\u003eClinical documentation integrity (CDI) was identified as an area for growth for HIM professionals. KIP08 stated \u003cem\u003e\u0026ldquo;Getting better systems in place for CDI will actually help us re-engage more on a patient safety\u0026rdquo;\u003c/em\u003e, while KIP02 spoke as clinical documentation integrity being part of the clinical coding process and how HIM professionals can raise awareness of what good quality documentation looks. KIP05 stated \u003cem\u003e\u0026ldquo;Clinical documentation improvement is not new. It is an area HIMs have been involved with for many years but it was not called CDI\u0026rdquo;.\u003c/em\u003e Furthermore, KIP05 linked documentation integrity to patient safety:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe work that we should do is helping to ensure that the medical record or health record tells the story of the patient\u0026rsquo;s treatment and care while in hospital. The recording of accurate data is a safety measure for all patients and it is a very important part of the role of HIMs\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe concerns raised by informants for professional association to consider covered the role of the professional association in promoting the HIM professional part in patient safety; the need to focus on instilling the value of supporting patient care as foundational to HIM professionals; raising the profile of the HIM workforce role in healthcare; and highlighting the HIMS professionals is essential. Informants noted that immediate action is necessary to ensure the HIM profession has a future.\u003c/p\u003e \u003cp\u003eInformants discussed challenges facing the HIM profession. They believe that workforce role substitution and hiring of unqualified HIM professionals is a risk to patient safety. Informants discussed that people unqualified in HIM might know what to do through workplace experience but may not understand why something is important. Informants further expressed that qualified people understand that the focus should not be on finance but on accurately capturing the patient journey and safeguarding information. Furthermore, the experts raised that resource shortages cause challenging workplace circumstances with insufficient staff to complete work. They described that this results in reduced quality activities and errors, lack of access to or understanding of information, and incorrect data for decision making, ultimately putting patient safety at risk.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eValues, Beliefs and Attitudes\u003c/h2\u003e \u003cp\u003eInformants were asked about values, beliefs, and attitudes as they influence behaviours, which is critical for an organisation\u0026rsquo;s patient safety culture and minimising harm. Words such as caring, empathy, ethical, honest, integrity, and person-centred were the most frequently mentioned by informants when providing examples of values, beliefs, and attitudes centred (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Informant responses indicated that HIM professionals work in roles or organisations that improve Australians' health or welfare as they believe that HIM professionals want to help patients. Respondents used words and phrases such as helping, giving back, respectful, valuing people, and helping staff help patients.\u003c/p\u003e \u003cp\u003eOne participant stated \u0026ldquo;\u003cem\u003eI think there is the belief that they\u0026rsquo;re [HIMS professionals] they\u0026rsquo;re for the good of the patient and the health service, and to do the best they can\u0026rdquo; [KIP6].\u003c/em\u003e Another participant stated \u0026ldquo;\u003cem\u003eI do 100\u0026nbsp;million extra things on top of what I do because I believe that our profession is important, it has an important role to play in the whole healthcare ecosystem\u0026rdquo;\u003c/em\u003e[KIP07] and \u003cem\u003e\u0026ldquo;Your belief system should be around caring. Being a caring individual. That you believe that the health service you work for is doing the right thing by its staff, its patients, and everybody who comes in contact with the health service. That's my belief\u0026rdquo;\u003c/em\u003e[KIP02]. Finally, KIP10 stated \u0026ldquo;\u003cem\u003eI\u0026rsquo;ve actually helped them [the clinician] and hopefully in that small way that helps the patient and contributes to safe care and all that sort of stuff and no harm\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBoth the HIM and patient safety experts discussed the \u0026lsquo;do no harm\u0026rsquo; belief. One participant discussed harm-free healthcare as something to aspire to, while others mentioned that \u0026lsquo;do not harm\u0026rsquo; applies to all who work in healthcare. One HIM Informant linked patient safety and quality, stating, \u0026ldquo;\u003cem\u003eThere\u0026rsquo;s a lot of quality behind the safety, and I believe we do have a direct impact\u003c/em\u003e\u0026rdquo; [KIP12] whilst another linked these topics when discussing both patient safety and quality concepts being taught in university as they complement each other. KIP01 spoke of the current focus of university courses is geared towards patient safety, rather than quality, as harm still occurs in healthcare. There was also a belief that the data collected, stored, managed, analysed, and reported by HIM professionals significantly impacts the systems supporting patient safety and minimising harm.\u003c/p\u003e \u003cp\u003eThe value of caring and patient-centred care was evident in the informant responses as they spoke of the people behind the data, information, codes, and records, and that they deserve safe and quality care. Participants described what happens when a HIM professional does not care, which they believe could result in data quality errors, duplicate records created, and misfiled information. The concept of caring was described in other ways, including empathy and authenticity, as a means of building trust. Other participants spoke of having a \u0026lsquo;want to help\u0026rsquo; attitude as a way of caring, treating people how they wanted to be treated, and not making assumptions or judgements.\u003c/p\u003e \u003cp\u003eMultiple informants emphasised the value of integrity and how HIM professionals apply it in their work by adhering to ethical practices throughout the clinical coding process, assigning codes, and only accessing information appropriate to performing their duties. Integrity was linked with accountability, in that HIM professionals are responsible for their productivity, decisions and commitment.\u003c/p\u003e \u003cp\u003eAdvocacy was discussed by participants, such as \u0026ldquo;\u003cem\u003ethe role HIM can play, is advocacy for good information, because information saves lives\u0026rdquo;\u003c/em\u003e [KIP07] and\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eworking with clinicians is you know advocating for them to come to HIM and talked to us about what data we can help them with to inform their data collections, or what they're doing. Uhm, so that informs patient safety in that they have better information available to make decisions or plan for their unit\u0026rdquo;\u003c/em\u003e [KIP08].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe responses of participants described how HIM professionals collaborate with clinicians and how patients are affected by decisions made based on data. Advocacy was described as both a value and behaviour of HIM professionals.\u003c/p\u003e \u003cp\u003eInformants stated that HIM professionals recognise that behind each piece of data or information is a person, and that person deserves respect and confidentiality. Linking the values of respect and patient-centred was demonstrated through one informants statement:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI think the values is the respect for people's privacy and I find the HIM's and very good, you know that is uh, sometimes in the privacy officer role, whether it's delegated or done by the HIMs, that's a really important value, there is the respect of the individual, the patients and that that you know that's really precious information\u0026rdquo;\u003c/em\u003e [KIP03].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWorkforce-related beliefs were prominent in the informants' responses. Participants stated that individuals with HIM qualifications understand the relationship between their role and patient safety, and they ensure a focus on patient safety and quality rather than finances. Informants also discussed that the role of HIM professionals with patient safety has evolved over time:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;maybe 20 years ago there was a broader health information, had a health information managers had a bigger role and a broader role in impacting on patient safety. But with the increased focus on the funding aspect, it's like made them focus in on looking at documentation that just impacts funding\u0026rdquo;\u003c/em\u003e [KIP08].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNegative workforce-related beliefs and attitudes were mentioned by informants. Informant responses indicated HIM professionals believe workforce shortages and high workloads are barriers to HIM professionals collaborating or participating in patient safety initiatives. Some informants discussed that HIM professionals feel undervalued as they do not feel they can contribute or speak up, with some stating HIM professionals have lost sight of the big picture of why they are in the workplace. Informants also expressed that if their beliefs and values do not align with their workplace and colleagues, this can impact an individual\u0026rsquo;s attitude towards work, which can impact behaviours.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eBehaviours and Group Practices\u003c/h2\u003e \u003cp\u003eBehaviours are the way individuals act in response to different situations or stimuli; these can be individual behaviours or group practices. Informants discussed the behaviours of HIM professionals towards patient safety through their actions or work. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, they covered facilitation behaviours and team dynamics. For instance, HIM professionals advocate for privacy, confidentiality, and quality documentation to ensure accurate patient stories and reliable information: \u0026ldquo;\u003cem\u003eI don't think often enough privacy is recognised as a patient safety issue, but it is. It is a huge impact on patient safety. because you know, safety isn't just physical harm, it's also mental harm, psychological harm, financial harm\u003c/em\u003e\u0026rdquo;[KIP01].\u003c/p\u003e \u003cp\u003eHIM professionals also audit and educate on clinical documentation, therefore supporting the integrity and quality of clinical documentation. For example, one informant stated that \u0026ldquo;\u003cem\u003eover 80% of safety events is some breakdown in communication and that's essentially what you're\u003c/em\u003e [HIM professionals] \u003cem\u003edoing is that you're providing the formal structured communication around that patient\u0026rdquo;\u003c/em\u003e [KIP14]. Sharing ideas, and exploring issues and problems are additional examples of communication and collaboration behaviours raised by informants. However, some informants mentioned of a lack of proactive behaviour in relation to not speaking up about patient safety concerns:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo; \u003cem\u003eour behaviours as HIMs has to change to be able to feel that we can do that, and that we can speak out. Because I've seen dangerous surgeons who have got a higher complication rate then a surgeon who is doing exactly the same procedure \u0026hellip;... But I personally think our behaviour should change so that we have got the ability to approach somebody and say look, I do have concerns. I mean, clinical indicators will show it. But you've got to be able to report it properly and have the evidence\u0026rdquo;\u003c/em\u003e[KIP02].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants also described that HIM professionals are the experts in health records: \u003cem\u003e\u0026ldquo;they should be prepared to speak up, listened to and heard. They have to go to a meeting well prepared, knowing they have the knowledge, to discuss these issues and give advice\u0026rdquo;\u003c/em\u003e [KIP05].\u003c/p\u003e \u003cp\u003eInformants discussed how the team culture is influenced by leadership and individuals feeling valued, which impacts team dynamics and the confidence to share their ideas and opinions. Informants also spoke of collaboration being both a behaviour, group practice and a value, particularly when HIM professionals translate clinical information into data for others to use or from a patient perspective, considering health literacy in designing clinical forms. Informants spoke of HIM professionals considering their communities when undertaking their duties, recognising that people, staff and patients, take their experience from the health facility back into the community, both good and bad. Overall, participants described HIM professionals as behaving in a helpful and welcoming manner.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAlignment of informant responses to the Socio-Technical Systems Theory\u003c/h2\u003e \u003cp\u003eOverlaying the STS framework with the informants' feedback on HIM professionals and patient safety (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), relationships between social and technical elements can be identified. For instance, within the people element, a behaviour of quality focus has direct relationship with physical systems and tasks. Informants spoke of HIM professionals having attention to detail (behaviour) as the coded data (task) is used for decision-making for patient care and service planning (organisation). For data to be of high quality, HIM professionals follow standards (physical system). Therefore, all quadrants of the framework were described by the key informants. Examining the social and technical systems that apply to HIM professionals in the patient safety context will aid in understanding dependencies and optimisation opportunities.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe key informant interview responses clearly demonstrate a link between HIM professionals and patient safety. This was shown through examples of functions performed, behaviours and cultural characteristics. From the informant's professional perspective, patient safety is both a mindset and actions, and is applied through how HIM professionals manage and care for the information about patients in the health system, ensuring this information is available and trustworthy for patient care, and improving patients' health. Kemp et al (6) identified that the HIM professionals' link to patient safety is likely through their functions in information governance, corporate governance, data quality and applying the health information management skillset. The key informants supported this view, as demonstrated by their examples related to data, documentation, education, and records management. HIM professionals engage at various points in the patient care journey, mainly through data capture. Informants conveyed that their work is significant, reflecting this in both their beliefs and behaviours.\u003c/p\u003e \u003cp\u003eThe core value of integrity means keeping your commitments, treating others well, and respecting others' opinions while also expressing your own views and feelings (16). The results above show how the HIM professional's values of integrity are associated with their behaviours towards advocacy, collaboration, respect, and caring. This finding was observed in other health professions, such as integrity as a crucial part of nursing leadership (16). The value-based and caring interactions of nurses build a positive culture and relationships that permeate through to patient care (20). Compassion and leadership were identified by Ahmed et al.(21) as two of the leading human factors that impact patient safety. They state that leadership that emphasises compassion will enhance organisational culture, patient experience, and overall healthcare. Values in healthcare extend through to documentation behaviours in how information is written in the health record (22). Stigmatising language may influence clinicians' attitudes, conscious or unconscious, and, therefore, decisions. Saha and Beach discuss the impact of language in clinical handovers on empathy and respect for patients, as well as its effect on patient safety. There is an opportunity for HIM professionals to leverage their values of integrity and respect, which align with those of clinicians, to influence their documentation practices and, ultimately, patient care.\u003c/p\u003e \u003cp\u003eInformants from both HIM and patient safety backgrounds raised the belief of \u0026lsquo;do no harm\u0026rsquo; in healthcare. \u003cem\u003ePrimum non nocere\u003c/em\u003e or \u0026lsquo;first, do no harm\u0026rsquo; is associated with clinicians, such as the Physician\u0026rsquo;s pledge (oath or declaration) with their commitment to their profession and patients, and not typically associated with the non-clinical health roles. A core principle in patient safety is that no one is harmed in healthcare (10), which includes the function of the non-clinician, yet informants indicated that this belief applies to all who work in healthcare. This view aligns with the NSQHS Standards, to protect the public from harm and improve the quality of health service provision (7). These standards apply to the organisation, not individual professions; therefore, they imply that do no harm applies to all in healthcare.\u003c/p\u003e \u003cp\u003eUnderstanding the patient safety culture of an organisation aids in addressing problems and improving patient safety (23). Informants\u0026rsquo; responses identified behaviours related to patient safety culture, such as not speaking up (a potential risk) and collaboration (a strength). Seven subcultures of patient safety have been identified in the literature by Sammer et al(24): leadership, teamwork, learning, evidence-based, communication, just, and patient-centred. The Institute for Healthcare Improvement and Safe \u0026amp; Reliable Healthcare developed a framework covering strategic, operational, and clinical ideas for achieving safe, reliable, and effective healthcare. The Framework for Safe, Reliable, and Effective Care (25) outlines nine components under two domains, with the patient and family at the centre. The culture domain components are psychological safety, accountability, teamwork and communication, negotiation, and aligning, and the learning elements are transparency, reliability, improvement and measurement, and continuous learning (25). The final element, leadership, aligns with both culture and learning (25). Responses from the HIM and PS informants were compared to two patient safety culture frameworks (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), with a focus on communication, leadership, learning, and patient-centred care, consistent with these frameworks.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient safety culture comparison\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElements\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSammer et al (2010)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrankel (2017)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKey Informants\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccountability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvidence-based\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprovement and measurement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJust\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLearning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegotiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient-centred\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychological safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReliability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeamwork\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransparency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInformants discussed how it feels to help others and their desire always to do better. The sentiment of \u0026lsquo;we are to help, and we care\u0026rsquo; was present in all HIM experts' responses. This attitude is related to patient safety as informants stated that HIM professionals are accountable, willing to learn, pay attention to detail, and have a positive mindset. These items impact the workplace culture of HIM professionals. Informants also expressed that values-based roles and working in an organisation that aligns with personal values were important to HIM professionals. A positive workplace safety culture means individuals can comfortably raise issues, concerns or hazards without fear of repercussions (26). Wachter (26) discusses authority gradients, or hierarchies, and the divide between workers and a superior. While these gradients are expected, they can become unsafe when a person lower on the gradient is reluctant to question someone higher in the hierarchy for fear of being wrong or angering them (26). Speaking up is an individual's behaviour and not a group practice. Based on Wachter's description, HIM professionals not voicing concerns could be related to a perceived position in an organisation's hierarchy. Therefore, when they do not speak up when noticing a patient safety issue, such as a high surgical error rate, higher frequency of HACs in a particular area, or errors in documentation, this is cause for concern due to the potential for harm to future patient care and impact of safety culture. The informant responses indicate patient safety culture as an area for improvement. HIM professionals need to have confidence in their knowledge, be equipped and educated on how to raise issues and receive support from leaders to apply this skill set. Otherwise, this mindset will not change.\u003c/p\u003e \u003cp\u003eInformants raised concerns for the HIM profession, professional identity and the professional association. Appointing unqualified individuals to professional positions in HIM is an example of role substitution. Informants discussed how a lack of understanding of the \u0026lsquo;why\u0026rsquo; behind activities carried out in a particular way, which is taught as part of qualifications, can lead to incorrect practices or processes related to information governance, data management, and privacy. The profession needs to adapt and transform to survive (27), and role substitution introduces ethical, confidentiality and medico-legal concerns (28), and lack of access to education and course closures will impact the ability to fill vacancies in the future (28). Research indicates the ageing workforce and a lack of graduates from HIM courses will impact on having a sustainable professional workforce to meet future healthcare demands (27, 28). While these challenges will impact available qualified HIM workers, Butler-Henderson(27) highlighted retention rates of HIM professionals in the workplace and the increasing demand for health services will continue to provide employment opportunities. With the changing health landscape, Butler-Henderson also provides insights into functions the HIM profession should be moving towards, such as information governance and data science (27). Informants also described the HIM profession as needing to target these areas. Until there is sufficient workforce supply, role and task substitution will continue to be a solution to ensure duties are completed. Adeleke et al. (29) discuss role substitution from the viewpoint of lesser-trained individuals completing tasks without supervision or they are not qualified for, which can result in a risk to the healthcare system in the management and ethical use of health data (29). Workforce shortages are a challenge in other health roles. Nursing workforce shortages can be attributed to ineffective policy and planning, training and enrolment barriers, workforce turnover, workload, burnout and job dissatisfaction (30). The Australian Institute of Health and Welfare (AIHW) reports an increase in demand for healthcare professionals, with the 2023 Skills Priority List indicating shortages in four out of five professional occupations (31). AIHW advises global competition may impact the recruitment of health professionals to Australia. Global workforce shortages also affect HIM, and the impact will be on standards, data quality management, records and information management, and information governance(32). These elements contribute to trustworthy, quality, and available information that is needed for patient care and running the healthcare system.\u003c/p\u003e \u003cp\u003eThere are opportunities, a strong sense of professional identity and a recognition of the importance of the profession (33), that has always adapted and responded to the political, social and technological influences on data and information (34). For instance, informants voiced that the recent increase in clinical documentation integrity programs has shifted the focus from revenue to high-quality documentation that reflects the complexity of care provided. Informants acknowledged clinical documentation integrity as a growing area for HIM professionals, along with ongoing roles in data. KIP 3 (patient safety expert) discussed how data is used in algorithms and artificial intelligence (AI), stating, \u003cem\u003e\u0026ldquo;with the growing nature of Algorithms and AI and those kinds of intelligent decision support, that all relies on the coded data, that that relies on the next patient in front of you, that relies on the last 100 patients that you've treated, and that, that sort of builds a picture of your population, your treatments, the effectiveness there of. So it starts to then give you the tools to provide better care now into the future hopefully as well\u0026rdquo;.\u003c/em\u003e This comment highlights how the past influences the present and the future, and reflects a growing interest in utilising AI and natural language processing to support clinical coding. In addition to clinical coding, Stanfill and Marc (35) identified the future use of AI as impacting data management, privacy and confidentiality, governance, and education. A key role of HIM professionals is to identify nuances in the data that require a deeper dive and collaborate with clinicians to review documentation and information. Reducing administrative burden is one of the benefits of AI (36), and workflows are a potential where AI would benefit HIMS professionals.\u003c/p\u003e \u003cp\u003eInformants expressed that the increase in the adoption and implementation of digital health technologies presents both opportunities and threats to the HIM profession. HIM professionals possess a wealth of knowledge that is highly beneficial for digital health, particularly in the context of electronic health records; however, they need to be actively engaged. The threat is that they will not be involved, opening the door for other professions to replace them. Role substitution has been identified as an issue requiring action to evolve the HIM profession (27). The International Federation of Health Information Management Associations (IFHIMA) recognises the need to elevate the HIM profession due to its pivotal role in data and information, which is integral to the delivery of healthcare(32). IFHIMA identified information governance, including data standards, access, and security); embracing technology; HIM education and curriculum; specialisation and diversification; increased visibility of profession; and championing the HIM skillset as priorities(32). HIM professionals build awareness and expectations of privacy and security of health information through the education they deliver. HIM professionals serve as spokespersons for confidentiality and privacy and, therefore, information governance.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe findings from this study highlight the altruistic nature of HIM professionals, who believe their work significantly supports clinicians and has a positive impact on patients and healthcare organisations. Their values, beliefs, and attitudes closely align with those of clinicians and the principles of patient safety culture, particularly in areas such as accountability, communication, leadership, learning, teamwork, and patient-centred care. While the \u0026ldquo;do no harm\u0026rdquo; philosophy has traditionally been associated with clinicians, HIM professionals embody this belief through their daily actions. These actions include advocating for patient privacy, ensuring the capture of high-quality information, providing education on these topics, and translating data into actionable and comprehensible information. Collectively, their behaviours foster a dynamic environment that promotes collaboration, communication, and cohesiveness, leading and guiding processes and discussions on various HIM topics and issues.\u003c/p\u003e \u003cp\u003eInformants identified several concerns for the HIM profession, including a lack of recognition for their expertise, which they believed hindered their full utilisation in areas such as patient safety. Issues such as role substitution, unqualified individuals in HIM roles, and workforce challenges were also noted as potential impacts to patient safety. These insights provide an opportunity for the professional association to reflect on and guide the profession into the future.\u003c/p\u003e \u003cp\u003eAll experts interviewed affirmed that HIM professionals contribute to patient safety both directly and indirectly. This contribution encompasses information and data governance, documentation integrity practices, education, and the management of both paper and digital records. HIM professionals can leverage their shared values, beliefs, and attitudes with clinicians to foster positive working relationships and influence clinician behaviours in areas such as privacy, documentation, and data management. These findings will be further validated by HIM professionals working in acute hospitals during the next research stage. Further research could also be conducted to measure the impact of HIM professionals on the NSQHS Standards, thereby understanding their role in clinical governance and quality indicators.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACSQHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAustralian Commission on Safety and Quality in Healthcare\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eArtificial Intelligence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEHRs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eElectronic health records\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHAC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehospital-acquired complication\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHIM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehealth information management\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHIMAA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Information Management Association of Australia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIFHIMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Federation of Health Information Management Associations\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNQSHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Safety and Quality Healthcare Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e The RMIT University Human Research Ethics Committee (HREC 24904) approved the study design, methodology, literature review, document analysis, and key informant interviews for a PhD study. Informed consent was obtained from all individual participants. The study is in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u0026nbsp; Written consent was obtained from participants for this study, including publication of de-identified findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThis research is part of a PhD study for the lead author Trixie Kemp. The other authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funding was received for conducting this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions:\u0026nbsp;\u003c/strong\u003eAuthors Trixie Kemp, Kerryn Butler-Henderson and Jennifer Ayton contributed to the study's conception and design. Trixie Kemp performed material preparation, data collection, and analysis. Trixie Kemp wrote the manuscript's first draft, and all authors commented on previous versions. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbdelhak M, Hanken MA. Health information: management of a strategic resource. St Louis, Missouri, USA: Elsevier/Saunders; 2016.\u003c/li\u003e\n\u003cli\u003eHIMAA. Definition of the Profession Web: Health Information Management Association of Australia; 2021 [Available from: https://himaa.org.au/the-professions/\u003c/li\u003e\n\u003cli\u003eButler-Henderson K, Gray K. A Glimpse at the Australian Health Information Workforce: Findings from the First Australian Census: IOS Press; 2019.\u003c/li\u003e\n\u003cli\u003eInstitute of Medicine Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000.\u003c/li\u003e\n\u003cli\u003eKemp TE, Butler-Henderson K, Allen P, Ayton J. Evolution of the Health Record as a Communication Tool to Support Patient Safety. In: Chisita C, Enakrire R, Durodolu O, Tsabedze V, Ngoaketsi J, editors. Handbook of Research on Records and Information Management Strategies for Enhanced Knowledge Coordination. Advances in Library and Information Science. Hershey, PA, USA: IGI Global; 2021. p. 127\u0026thinsp;\u0026minus;\u0026thinsp;55.\u003c/li\u003e\n\u003cli\u003eKemp TE, Butler-Henderson K, Allen P, Ayton J. The impact of health information management professionals on patient safety: A systematic review. Health information and libraries journal. 2021;38(4):248\u0026thinsp;\u0026minus;\u0026thinsp;58.\u003c/li\u003e\n\u003cli\u003eACSQHC. National Safety and Quality Health Service Standards Australia 2nd edition. Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2021.\u003c/li\u003e\n\u003cli\u003eButler-Henderson K. Health information management 2025: 'What is required to create a sustainable profession in the face of digital transformation?'. Launceston: University of Tasmania; 2017. Contract No.: ISBN 978-1-82695-88-3.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Patient safety research: a guide for developing training programmes: World Health Organization; 2012.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Patient Safety Factsheet 2023 [updated 11/09/2023. Available from: https://www.who.int/news-room/fact-sheets/detail/patient-safety.\u003c/li\u003e\n\u003cli\u003eWoodward S. Rethinking Patient Safety. 1st ed. ed. Portland: Productivity Press; 2017.\u003c/li\u003e\n\u003cli\u003eAustralian Commission on Safety and Quality in Health Care. The state of patient safety and quality in Australian hospitals 2019. Sydney: ACSQHC; 2019.\u003c/li\u003e\n\u003cli\u003eKrasny ME. Values, Beliefs, and Attitudes. Ithaca, NY: Cornell University Press; 2020. p. 101\u0026thinsp;\u0026minus;\u0026thinsp;16.\u003c/li\u003e\n\u003cli\u003eSchwartz SH, Vecchione M, Fischer R, Ramos A, Demirutku K, Dirilen-Gumus O, et al. Refining the Theory of Basic Individual Values. Journal of Personality \u0026amp; Social Psychology. 2012;103(4):663\u0026thinsp;\u0026minus;\u0026thinsp;88.\u003c/li\u003e\n\u003cli\u003eShealy CN, Acheson K. Making sense of beliefs and values : theory, research, and practice. 1st ed. New York, New York: Springer Publishing Company; 2016.\u003c/li\u003e\n\u003cli\u003ePoirier D. Achieve lasting change through a values-driven workforce: Guiding employees\u0026rsquo; attitudes, beliefs can lead to sustainable results. ISE: Industrial \u0026amp; Systems Engineering at Work. 2020;52(5):42.\u003c/li\u003e\n\u003cli\u003eAjzen I. The theory of planned behavior. Organizational behavior and human decision processes : a journal of fundamental research and theory in applied psychology. 1991;50(2):179\u0026ndash;211.\u003c/li\u003e\n\u003cli\u003eCreswell JW, Creswell JD. Research design : qualitative, quantitative \u0026amp; mixed methods approaches: Sage Publishing; 2018.\u003c/li\u003e\n\u003cli\u003eCharmaz K. Constructing grounded theory. 2nd ed. ed: SAGE; 2013.\u003c/li\u003e\n\u003cli\u003eHemberg J, Salmela S. Integrity and Efficiency in Nursing Leadership: An Integrative Review. International journal of caring sciences. 2021;14(2):1496\u0026thinsp;\u0026minus;\u0026thinsp;513.\u003c/li\u003e\n\u003cli\u003eAhmed Z, Ellahham S, Soomro M, Shams S, Latif K. Exploring the impact of compassion and leadership on patient safety and quality in healthcare systems: a narrative review. BMJ Open Quality. 2024;13(Suppl 2):e002651.\u003c/li\u003e\n\u003cli\u003eSaha S, Beach MC. Building a Culture of Quality and Safety in Health Care-The Importance of Respect for Patients. JAMA network open. 2024;7(12):e2450134.\u003c/li\u003e\n\u003cli\u003eBartonickova D, Kalankova D, Ziakova K. How to Measure Patient Safety Culture? a Literature Review of Instruments. Acta Medica Martiniana. 2021;21(2):69\u0026ndash;79.\u003c/li\u003e\n\u003cli\u003eSammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. What is patient safety culture? A review of the literature. J Nurs Scholarsh. 2010;42(2):156\u0026thinsp;\u0026minus;\u0026thinsp;65.\u003c/li\u003e\n\u003cli\u003eFrankel A, Haraden C, Federico F, J. L-E. A Framework for Safe, Reliable, and Effective Care. White Paper.. Cambridge, MA, USA: Institute for Healthcare Improvement and Safe \u0026amp; Reliable Healthcare; 2017.\u003c/li\u003e\n\u003cli\u003eWachter RM, Gupta K. Understanding patient safety. Third edition. ed. New York: McGraw-Hill Education; 2018.\u003c/li\u003e\n\u003cli\u003eButler-Henderson K. Health information management 2025: 'What is required to create a sustainable profession in the face of digital transformation? Launceston: University of Tasmania; 2017. Report No.: 978-1-86295-888-3 Contract No.: ISBN 978-1-82695-88-3.\u003c/li\u003e\n\u003cli\u003eHIMAA. Health Information Workforce Summit Report 2015. Sydney, Australia: Health Information Management Association of Australia; 2016.\u003c/li\u003e\n\u003cli\u003eAdeleke IT, Suleiman-Abdul QB, Aliyu A, Ishaq IA, Adio RA. Deploying unqualified personnel in health records practice: Role substitution or quackery? Implications for health services delivery in Nigeria. Health Information Management Journal. 2019;48(3):152-6.\u003c/li\u003e\n\u003cli\u003eTamata AT, Mohammadnezhad M. A systematic review study on the factors affecting shortage of nursing workforce in the hospitals. Nursing open. 2023;10(3):1247-57.\u003c/li\u003e\n\u003cli\u003eAIHW. Health Workforce Web: Australian Institute of Health and Welfware; 2024 [Available from: https://www.aihw.gov.au/reports/workforce/health-workforce.\u003c/li\u003e\n\u003cli\u003eIFHIMA. Examining Today's HIM Workforce with Recommendations for Elevating the Profession. Internet: International Federation of Health Information Management Associations; 2022.\u003c/li\u003e\n\u003cli\u003eNexhip A, Riley M, Robinson K. Professional identity and workplace motivation: A case study of health information managers. Health Information Management Journal. 2024;53(2):76\u0026ndash;84.\u003c/li\u003e\n\u003cli\u003eWissmann S, Henderson J, Robinson K. The health information management workforce: Looking to the future. Health Information Management Journal. 2024;0(0):18333583241303635.\u003c/li\u003e\n\u003cli\u003eStanfill MH, Marc DT. Health Information Management: Implications of Artificial Intelligence on Healthcare Data and Information Management. Yearb Med Inform. 2019;28(1):056\u0026ndash;64.\u003c/li\u003e\n\u003cli\u003eSchulman KA, Nielsen JPK, Patel K. AI Alone Will Not Reduce the Administrative Burden of Health Care. JAMA : the journal of the American Medical Association. 2023;330(22):2159-60.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical coding, data quality, documentation, health information management, key informants, patient safety, quality, records management, socio-technical","lastPublishedDoi":"10.21203/rs.3.rs-6384767/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6384767/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealth Information Management (HIM) professionals play an integral role in the healthcare system, supporting clinicians and healthcare service management by ensuring that data is trustworthy and reliable for informed decision-making. This study examined the key informant perspectives on whether HIM professionals contribute to patient safety in Australian acute hospitals and what this contribution entails.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis qualitative study involved semi-structured one-to-one interviews with HIM professionals and patient safety experts from across Australia, comprising eight from HIM and six from patient safety. The interviews were recorded, transcribed, and coded. Charmaz\u0026rsquo;s grounded theory informed the data analysis approach. Socio-technical system theory was used to examine the components of society (people and organisation) and technical (tasks and systems).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll participants stated that HIM professionals contribute to patient safety, with 100% of patient safety experts indicating that the contribution is both direct and indirect. The opinions of the HIM experts were mixed. Participants provided various examples of how HIM professionals contribute to patient safety through data, documentation, education, and records management functions. Values, beliefs, and attitudes aligned with key elements of patient safety culture, including teamwork, communication, learning, leadership, and patient-centred care.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eHIM professionals contribute to patient safety by applying their knowledge and skills in managing, interpreting, providing and reporting information. Measuring this impact against National Safety and Quality Healthcare Service (NSQHS) Standards would contribute to understanding the direct impact of HIM professional's role on clinical governance and quality indicators.\u003c/p\u003e","manuscriptTitle":"Perspectives on the role of health information management professionals in enhancing patient safety: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 06:44:12","doi":"10.21203/rs.3.rs-6384767/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-01T07:36:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285880103697178018169185627315092038679","date":"2026-04-01T00:34:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"23583288942606090963589029374222835174","date":"2026-03-25T09:01:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116357135793937806371184203452769811850","date":"2025-12-10T11:04:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-12T12:28:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-11T13:10:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-10T11:33:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-04-10T11:32:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4a9913e9-8079-4656-b6d8-2fb683e4ca04","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-07T06:44:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-07 06:44:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6384767","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6384767","identity":"rs-6384767","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}