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Making comparisons via data analysis for improvement efforts

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The hospital you work at will have many data-driven processes in place to assess ways to improve patient care. Data is collected and analysed, data analysed is usually used to evaluate its current performance and also to be able to compare your hospital’s performance with other similar hospitals, all of which is to find the opportunity to improve in four ways:

  1. analysis of its past historical data with itself over time , such as month to month, or one year to the next or last year’s value to the current year, or a time series of several years, provides an initial baseline for examining trends and allows judgment on the direction of the measure;
  2. making competitor and industry comparisons what other similar hospitals are achieving provides crude guidelines. Competitor and industry comparisons has direct bearing on the hospital’s profitability, especially the privately owned hospital;
  3. (a) with standards, such as those set by accrediting and professional bodies such as through reference databases collected and analysed from data on hospital performance frequently made available through publicly available hospital quality comparison Web sites aimed at patients for example, data that can be viewed from Hospital Compare from the Centers for Medicare and Medicaid Services, Quality Check from the Joint Commission on Accreditation of Healthcare Organizations and the Leapfrog Group’s Hospital Quality and Safety Survey Results; comparing standards set for example by the Joint Commission International (JCI) also enables a hospital to improve its desirable practices; also, (b) it is common knowledge that hospitals are legally responsible for ensuring the quality of medical care; as healthcare practitioners we are aware that the hospital management of a public hospital or in the case of a private hospital – the hospital board, is responsible for exercising the duty of care based on those set by laws or regulations – for example the legal requirement of the Private Healthcare Facilities And Services (Private Medical Clinics Or Private Dental Clinics) Regulations 2006, Private Healthcare Facilities And Services Act 1998 in Malaysia, on behalf of the patients and the community and on behalf of doctors who desire to participate, and the hospital as a whole is liable for damages should they fail.; and
  4. with recognised desirable practices identified in the literature as best or better practices or practice guidelines, for example in determining the success or failure of medical audit assessment by monitoring actual or suspected problems through (i) sentinel cases, (ii) criterion-based audit, (iii) comparison of small groups in the same field applicable at local hospital levels, (iv) conducting surveys like patient satisfaction surveys, and (v) peer review.

These comparisons help the hospital understand the source and nature of undesirable change and help focus improvement efforts that can be achieved through re-education, retraining, facilitation in small groups, or by more active persuasion.

If your hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then it must be able to show evidence that it has a process or processes that incorporates data analysis measures to make relevant comparisons (i) over time within the hospital, (ii) with similar hospitals when possible, (iii) with standards when appropriate , and (iv) with known desirable practices, in order to satisfy the JCI QPS.4.2 Standard which states that “The analysis process includes comparisons internally, with other organizations when available, and with scientific standards and desirable practices.

How do Health Information Management (HIM) / Medical Records (MR) practitioners fit into this JCI Standard?

I can think of two ways as I come to the end of  this post.

In my opinion, HIM /MR practitioners must facilitate diagnostic excellence from rapid communication of patients’ current needs and understanding of the clinically indicated responses by ensuring that recording is made faster and more complete in medical records , include safeguards to improve accuracy, and speed transmission of patient-related information. For example, the penalty for incomplete medical records (usually a temporary loss of privileges) is quickly and routinely applied. A word of caution though about imposing the penalty. As we are fully aware, reality, however, does not always match with what is desired since I believe many doctors still enjoy the  part of their job which is talking to their patients and in this context, medical records tends to assume lesser importance. I think it is also not desirable to have a culture among doctors to be obsessive record writers who ‘spent all the time writing and didn’t even look at me’, a common complaint among patients.

HIM /MR practitioners must also exercise caution in the retrieval of medical records of the sample of patients designated as appropriate for example,a medical records audit. For example, the retrieval of medical record through diagnostic coding for Myocardial Infarction (MI) cases, after a patient’s discharge, may not enable the retrieval of a record of a patient who had a dissecting aneurysm of the aorta mismanaged as an MI for the first 12 hours of his/her care

References:
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Kenneth RW, and John RG 2010, The well-managed healthcare organization, 7th edn, Health Administration Press, Chicago, Illinois, USA

Srinivasan, AV 2008, Managing a modern hospital, 2nd edn, Response Books, SAGE, New Delhi, India

10 Ways ICD-10 Changed Everything In Malaysian Healthcare

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I stumbled upon this chart below from AAPC, that provides education and professional certification to physician-based medical coders and to elevate the standards of medical coding (by clicking on this chart, the  chart will open in a new tab of your current window and you can then click the image again from the new tab to view a larger and clearer image).

ICD-10 will change everything

Chart credit: aapc.com/

As Malaysia had already implemented ICD-10 by 1 January 1999, I felt like doing this post based on the chart above showing the things that changed since the transition period in 1998 from ICD-9 till we switched to using ICD-10, as you can view from the presentation below (by clicking on this presentation, the presentation will open in a new tab of your current window and you can then click the image again from the new tab to view a larger and clearer image).

10-Ways-ICD-10-Changed-Everything-In-Malaysian-Healthcare

Written Discovery – Introduction

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written-discovery-logThis post is a follow-up to the subject of written discovery I talked about in the post JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” (this link will open in a new tab of your current browser window).

I am writing from common knowledge and experiences and I must confess I am no legal authority but I have used facts in this post based on matters relating to public domain circulars and proceedings I had been part of.

In Malaysia and even in your country it is increasing common when individual healthcare providers and hospitals face a real threat of becoming defendants in malpractice lawsuits.

Some common potential-litigation warning signs of an impending malpractice lawsuit may include instances when (i) the hospital administration receives an executed patient authorisation for release of medical records produced by a lawyer and usually accompanied (if not at a later date) request for copies of medical records/medical report(s), ,films and billing records, (ii) when patient and/or family that is very upset about an unexpected or dramatic outcome sends in a written compliant or even heated verbal exchanges occur in the care area(s) or when the patient and/or family present themselves at the hospital administration, and (iii) when a letter is sent to the press and is published in the newspapers or a press conference is called by the aggrieved parties. Whatever the circumstances maybe, the requests for the production of documents and tangible items already signals that there is reasonable belief that a lawsuit may be filed.

I shall not cover a spoliation action, a type of action not yet a phenomenen in Malaysia when a patient can seek damages not for negligent medical care, but for a breach of the duty to preserve medical evidence from the loss of medical information like key medical records or films,  medical devices or instruments used during the care and treatment, and even the loss of non-medical information such as phone records.

In preventing a spoliation action and in general, I think Health Information Management (HIM) / Medical Records (MR) practitioners should always maintain health information, and communication protocols for preserving health information with effective medical information maintenance policies and procedures through consistent and established policies. Your actions and practices will help control unnecessary hospital litigation losses and increase efficiency when answering inquires from legal, regulatory, or accreditation agencies.

Before I write more on my next post on written discovery, I think some knowledge on some law terms is necessary.

In a civil action like for a medical-malpractice lawsuit, a claimant (“plaintiff”) will state the defendant’s actions, or omissions, which caused the claimant’s loss and files a civil claim (“lawsuit”) against the defendant(s) who usually are individual(s) doctors, hospital(s), and doctor or medical practice group(s).

The claim is to seek recovery for injuries that the plaintiff believes were caused by the defendant’s failure to meet an established professional duty of care.  

8 ways for identifying opportunities for improvement and documenting a hospital’s performance level

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8-ways-for-identifying-opportunities-for--improvement-and--documenting-a-hospital’s--performance-level-2

References:
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

A hospital’s performance improvement activities as opportunities for improvement

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syringe-with-MCI.20.1-PI-activitiesIn three previous posts, I brought to you how aggregate data are an important part of the hospital’s performance improvement activities. In particular, the three posts were about aggregate data from risk management, utility system management, infection prevention and control, and utilisation review and how they can help the hospital understand its current performance and identify opportunities for improvement.

The posts were:

(i)                  JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” ;

(ii)                JCI Standard MCI.20.1, ME 1 (Part 2) – infection prevention and control, in “The organization has a process to aggregate data in response to identified user needs.” ;

and

(iii)             JCI Standard MCI.20.1, ME 1 (Part 3) – utility system management and utilisation review, in “The organization has a process to aggregate data in response to identified user needs.”

Each of the links above will open in a new separate tab of your current browser window.

In this review of those 3 posts, I like to emphasise that a hospital chooses which clinical and managerial processes and outcomes are most important to monitor based on its mission patient needs and services provided. The hospital’s leaders must identify key measures (indicators) to monitor the hospitals’s clinical and managerial structures, processes and outcomes.

A required clinical monitoring which includes structure, process or outcomes data selected by the leaders is on aspects of infection control, surveillance and reporting. For managerial monitoring, a required managerial monitoring which includes structure, process or outcomes data selected by the leaders is on aspects of risk management and utilisation review/management.

The hospital collects and analyses aggregate data from clinical monitoring and managerial monitoring to support patient care and organisation management. Aggregate data provides a profile of the hospital over time and allows the comparison of the hospitals’s performance with other hospitals.

To measure the hospital’s performance improvement activities, hospitals usually prepare a master plan to reduce evident risks in the environment or individual plans which incorporates a comprehensive program and plan inclusive of :

  1. a program and plan to reduce the risk of health care-associated infections in patients, health care workers and visitors
  2. a program and plan that includes utility systems – electric, water and other utility systems,  maintained to minimise risk of failure

There is also a written plan for an organisation-wide quality improvement and patient safety program that includes clinical and managerial processes for risk management, utility system management, infection prevention and control, and utilisation review.

References:
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA