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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.”

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As I had posted in the post JCI Standard MCI.20.1 – patient based data and aggregate data, in a process available to aggregate data to meet the needs of internal and external users (this link will open in a new tab of your current browser window), in this post I shall continue on infection prevention and control. This post is also a follow-up from the previous post on risk management in 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).

Infection prevention and control is one of a hospital’s four (4) performance improvement (PI) activities other than risk management, utility system management, and utilisation review PI activities a hospital is required to meet the Joint Commission International (JCI) Standard MCI.20.1, Measurable Element (ME) 1 which requires that a hospital as “The organization has a process to aggregate data in response to identified user needs.”

Although the details of infection prevention control are beyond the scope of this post and blog, I shall embark to highlight some aspects of infection prevention and control here. It is going to be a long post.

Health care–associated infections (HAIs) or also referred to as health care–acquired Infections, are infections acquired in the hospital or other health care facilities that were not present or incubating at the time of the patient’s admission. Hospital (or ‘nosocomial’) infection is infection acquired either by patients while they are in hospital, or by members of hospital staff.  (eds. Adam & Christina 2009) define the term infection as “generally used to refer to the deposition and multiplication of bacteria and other micro-organisms in tissues or on surfaces of the body with an associated tissue reaction.”

At the time of the patient’s admission due to an illness – which impairs the body’s normal defense mechanisms, often the reason for hospital admission, the patient is in the state of risk for infection in which the patient is at increased risk for being invaded by pathogenic organisms because the patient has not been exposed to in the past what the hospital environment now provides the exposure to a variety of virulent organisms, therefore the patient has not developed any resistance to these organisms.

Health care personnel in hospitals who usually fail (eds. Adam & Christina 2009) to practice proper handwashing procedures or to change gloves between patient contacts, contribute to most HAIs been transmitted  to hospitalised patients who are at risk from the most common HAI endemic infections in hospitals caused by multi-resistant tuberculosis, Clostridium difficile one of the major hospital infections in the elderly, vancomycin-resistant enterococci in some specialised units, and cross-infection with methicillin-resistant Staphylococcus aureus (MRSA) that affect the urinary tract, upper and lower respiratory tracts, gastrointestinal tract, conjunctiva, and skin.

HAIs have received increased attention due to their overwhelming consequences in terms of cost, morbidity, and mortality.  One of the reasons for this increased attention is that these infections which are preventable through the adherence to numerous strict guidelines, legal requirements and other recommendations when caring for patients, is that they frequently occur in people whose health is already compromised by disease, age, or injury.

The data presented in the 1999 Institute of Medicine (IOM) study reported that an estimate of  between 44,000 and 98,000 patients die as the result of preventable medical errors in hospitals each year and also reported that hospital-acquired infections, many of which can be prevented, take another 100,000 lives.

In the United States of America, payers have begun to refuse reimbursement for additional care resulting from treatment for an infection not present on admission with the underlying rationale that HAIs are preventable complications and denying reimbursement provides a strong incentive for quality improvement actions to avert them.

Then there are site-specific infection prevention to reduce (i) postoperative surgical wound infections through the use of appropriate surgical site preparation and also prophylactic antibiotic therapy, (ii) ventilator-associated pneumonia by for example minimizing the duration of intubation, (iii) central venous catheter infections for example with the use of sterile technique and full barrier precautions, (iv) urinary tract infection by avoiding unnecessary or prolonged use of indwelling bladder catheters, and (v) resistant organisms for example methicillin-resistant Staphylococcus aureus (MRSA) by employing (a) active surveillance procedures in which cultures are routinely obtained at scheduled intervals to promote earlier identification of resistant organisms, and (b) careful management of antibiotic use.

To address each type of HAI, many hospitals have adopted a series of practices called a “bundle” at a significant cost,  failure to use all the measures prescribed in the “bundle”, for example in the approach to preventing central line-associated bloodstream infections  (CLBSI) (this bundle includes the entire procedure for insertion, the daily cleaning protocols, and the protocols for use of the central line catheter) may adversely affect patient outcomes but adopting a “bundle” has been shown to decrease the incidence of the target infection, and thus been effective  in improving quality of care which may then offset the significant cost.

Transmission of infection as an occcupational hazard in all hospital settings is a major concern when caring for infected patients made worse by the presence of resistant organisms which causes extra concern and makes treatment difficult.

Universal precautions are usually mandated for use with patients who pose the hidden danger when they have not been diagnosed as having an infection and for whom specific infection control measures have therefore not been prescribed. Universal precautions is a critical protective strategy with measures that include hand decontamination upon entering and leaving every patient encounter, isolation and the use of disposable gowns and gloves in addition to hand decontamination for patients with certain particularly dangerous types of infections. Provision of sharps containers wherever needles were used and the provision of a supply of gloves and protective eyewear for employee use are some other measures as part of universal precautions.

Blood-borne pathogens are not the only pathogens of concern in the healthcare environment. Body Substance Precautions are also used in all hospital settings to protect patients and staff members from infections that might be transmitted by any body substance, for example to protect staff members from the tuberculosis (TB) organism.

Confidentiality should be maintained at all times by Health Information Management (HIM) / Medical Records (MR) practitioners who may be needed to provide medical records of staff members exposed to HBV, HCV and HIV infection for review at the time of exposure of the source of their occupational exposure to the bloodborne pathogens including results of blood tests, admitting diagnosis and past medical history.

HIM / MR practitioners may be needed to work closely with an infection control officer at most hospitals which usually designate this officer who has the expertise to guide the staff in planning appropriate infection control procedures to protect staff members from blood-borne pathogens to prevent the spread of HIV, hepatitis B, and other such blood-borne pathogens.

HIM / MR practitioners may be involved in the development of policies and procedures is a key role for any infection control team. The central document is a collection of procedures (sometimes called an infection control policy or infection control manual).

As I have said in my previous posts, most hospitals today are involved in processes of quality improvement.

In the context of HAI, (eds. Adam & Christina 2009,  p. 5) defines ‘surveillance which is a vital component of infection control as ‘the ongoing systematic collection and analysis of data about a disease (or organism) that can lead to action being taken to control or prevent the disease.’

As part of these processes, ongoing data are collected and analysed for problems or opportunities for improvement including using infection control and quality improvement data to improve care. An example of the use of infection control data reviewed from interviews in regard to care practices for patients with catheters in an intensive care unit (ICU) about the series of urinary tract infections for example by the same strain of Serratia as the infective agent that had been identified in all patients in that unit, showed that a deviation from the standard protocol for the unit with the use of one measuring container used by an infected patient cultured positive for the Serratia, and using it from patient to patient easily had transmitted the organism to another patient’s catheter, and the infectious agent could have been spread from patient to patient in this manner.

Quality of care aggregate data takes many forms, revealing such things as infection rates and unplanned returns to the operating room. Infection rates for example MRSA wound infections per 1000 bed days or per 1000 admissions are commonly computed rates like other rates for example average length of stay, based on discharge statistics data that are accumulated when patients are discharged. At the local level, (eds. Adam & Christina 2009) infection rates from surgical wound infections fed back to practising surgeons can demonstrate results in lowering infection rates.

Other forms quality of care aggregate data on HAIs is the reporting of infections.

A daily report generated by a laboratory-based system is able to give information based around ‘alert’ organisms that have the potential to cause outbreaks, for example the percentage of Staphylococcus aureus that are methicillin resistant and/or the percentage of wound swabs showing S. aureus.

Reporting is generated as recommended by (eds. Adam & Christina 2009) through (i) weekly reports by the Infection Control Nurse (ICN) and sent to the wards, departments and clinicians containing  information on alert organisms and infectious patients including simple graphs that provide rapid feedback on current issues while they are still fresh, (ii) monthly reports sent to all members of the Infection Control Team (ICT) within two or three days of the new calendar month, (iii) quarterly reports that includes recommendations to management and education data on who attends the sessions, and (iv) a comprehensive annual report intended for the board members.

Local data must include ‘details’ of wards and consultants – to establish the ‘ownership’ of the data as well as the competitive element,  needs to be analysed promptly and sent to the ward/clinician as daily and weekly reports.

All of the above are my observations, experiences and readings on infection prevention and control activities and processes in a hospital setting to aggregate data in response to identified user needs. They are by no means complete, in future posts I shall document on latest trends and developments in infection prevention and control activities.

In my next post on JCI Standard MCI.20.1, ME 1 I shall dwell on utilisation review PI activities a hospital is required to meet the JCI) Standard MCI.20.1, ME 1.

References:
Adam, PF & Christina, B (eds.) 2009, Ayliffe’s Control of Healthcare-Associated Infection A practical: handbook, 5th edn, Hodder Arnold, London, UK

Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

Janice, RE, Celia, LH 2012, Nursing in todays world : trends, issues & management, 10th edn, Wolters Kluwer Health | Lippincott Williams & Wilkins, Philadelphia, PA, USA

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

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.”

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A hospital collects and analyses aggregate data to support patient care and its organisation management.

Aggregate data provides a profile of the hospital over time and allows the comparison of the hospital’s performance with other hospitals. Thus, aggregate data are an important part of the hospital’s performance improvement (PI) activities.

PI facilitates desired outcomes by monitoring and evaluating the quality and appropriateness of patient care, measuring both process and outcome and conducting trend analyses, pursuing opportunities to improve patient care, ensuring high-quality care, and developing standards for monitoring quality of care.

Most hospitals are involved in processes of quality improvement. As part of these processes, on-going data are collected regarding outcomes and analysed for problems or opportunities for improvement. When outcomes are known, then addressing areas for possible improvement in outcomes becomes possible. In response to identified user needs, hospitals can understand its current performance by monitoring and evaluating aggregate data through risk management, utility system management, infection prevention and control, and utilisation review and identify opportunities for improvement.

Allow me to take you about the PI activities of risk management, utility system management, infection prevention and control, and utilisation review.  We will look at how a hospital through the PI activities of risk management, utility system management, infection prevention and control, and utilisation review meets the Joint Commission International (JCI) Standard MCI.20.1, Measurable Element (ME) 1 which requires that a hospital as “The organization has a process to aggregate data in response to identified user needs.”

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Risk is defined as the chance of loss. Risk management can be defined as identifying circumstances that put patients or a hospital at risk for adverse outcomes and putting into operation methods that avoid, prevent, and to mitigate (reduce or eliminate) the risks. Hospital adopted risk management when there were many problems in malpractice that caused risk to be a potential problem for hospitals, thus sentinel event monitoring was added to the hospital accreditation process in the mid-1990s.

Risk management is about the focus on an individual case, investigation of the post-event, implementing strategies to address the event, regulatory compliance with legal standard of care, unexpected outcomes which drive the process despite performing all of the regulatory requirements in a timely and competent manner, and been reactive that is relying (Barbara 2011) “on lessons learned from past mistakes, which they apply to the case at hand in order to “defend” the actions of those involved.”

Risk management is about the various strategies to fix problems. Examples of risk management techniques are practice modification (an example of risk management is avoiding the use of a code cart that has not been restocked properly or as for an individual patient, it may be confirming that all the protocols are followed when giving intravenous medications to the patient), insurance transfer, or risk avoidance such as when we eliminate the risk by closing of an obstetrics unit or mental health services or reducing the privileges of a specific provider who may not have the requisite skill to safely perform a specific procedure.

I remember the relatively low numbers of sentinel events reported annually from hospitals that had to report such events, – as it was then and I am sure it is still today,  commonly recognised that there are limitations of a reporting system. However, I am certain that aggregate data collected over the years have proved invaluable toward understanding specific types of hospital based errors. In Malaysia, sentinel events in private hospitals is part of a mandatory incident reporting system in accordance to the ACT 586, Private Healthcare Facilities And Services Act 1998, Private Healthcare Facilities And Services (Private Medical Clinics Or Private Dental Clinics) Regulations 2006, Regulation 13. Ministry of Health Malaysia hospitals are required to follow THE MALAYSIAN INCIDENT REPORTING AND LEARNING SYSTEM, in incident reporting for adverse events with the general objective “To facilitate a learning organisation through the reporting of and learning from adverse incidents, “near misses” and hazards so that a just and safe culture will be nurtured amongst health care providers, in our efforts to enhance the safety of the Malaysian health care system.”, which requires mandatory reporting of specific event types to further foster the sharing of lessons learned. Despite this shared learning, I am sure we still have medical errors occurring in our hospitals and clinics every day.

Health Information Management (HIM) / Medical Records (MR) practitioners need to know that their HIM / MR Department that supplies the raw material (i.e., the medical-record documentation), serves as one of the strongest allies of the risk management activities and risk and quality managers turn to this department regularly for support and services. It is common for routine requests for case review analysis with expedited requests made during times of accreditation surveys and on-site inspections.

The role of this department in identifying adverse events and quality-of-care concerns hospital-acquired conditions (HAC) – examples of HACs are foreign object retained after surgery, air embolism, blood incompatibility, catheter-associated urinary tract infection.

HIM / MR practitioners working in a HIM / MR department may be required to identify these HACs and initiate a report to the risk and quality departments for peer review and quality analysis.  HIM / MR practitioners must also be aware that another early indicator for a potential claim against a hospital is a request for medical records, especially by a lawyer. Medical-records staff should notify their risk management / QA department and the hospital top management upon receipt of such requests.

Readers, I know for a fact I have not been able to cover all aspects of risk management in this post but it is enough to give you a brief overview of what risk management is about and how it affects the HIM / MR practitioner. In a future post, I will expand on discoverability of medical records in medical-malpractice cases that is the written discovery as the first phase of the discovery process in a medical-negligence case, when there is a request to produce documents and tangible items, such as medical records, films, and pathology slides.

As I posted in the post JCI Standard MCI.20.1 – patient based data and aggregate data, in a process available to aggregate data to meet the needs of internal and external users (this link will open in a new tab of your current browser window), given the wide issues of concern for the two requirements about JCI Standard MCI.20.1, I shall continue on the other PI activity of infection prevention and control in another post.

References:
Barbara JY 2011, Principles of risk management and patient safety, Jones & Bartlett Learning, Sudbury, MA, USA

Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

Janice, RE, Celia, LH 2012, Nursing in todays world : trends, issues & management, 10th edn, Wolters Kluwer Health | Lippincott Williams & Wilkins, Philadelphia, PA, USA

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

Patient Safety Unit, Medical Care Quality Section, Medical Development Division 2012, INCIDENT REPORTING & LEARNING SYSTEM: “From Information to Action”, Ministry of Health Malaysia, viewed 28 November 2012, <http://hkbatas.moh.gov.my/v2/uploads/UPDATED_INCIDENT_REPORTING_2012_KKM.pdf>

Private Healthcare Facilities And Services Act 1998, Private Healthcare Facilities And Services (Private Medical Clinics Or Private Dental Clinics) Regulations 2006, viewed 28 November 2012, <http://www.mma.org.my/Portals/0/pdf/prv_health_fac.pdf>

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Wager, KA, Frances, WL & John PG 2005, Managing health care information systems : a practical approach for health care executives,1st edn, Jossey-Bass A Wiley Imprint, San Francisco, CA, USA

Towards ICD-11 for Malaysia

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The World Health Organization (WHO) International Classification of Diseases (ICD) is the global health information standard for mortality and morbidity statistics. ICD (WHO 2012) “is the foundation for the identification of health trends and statistics globally. It is the international standard for defining and reporting diseases and health conditions. It allows the world to compare and share health information using a common language.”

The  version 10 (ICD-10 ) was constructed between 1982-89 and was endorsed in May 1990 by the Forty-third World Health Assembly. In a sense 117 countries around the world, including Malaysia are using a 20-25 year old medical information standard!

An alternative to ICD-10 is the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT), used on electronic medical record ontologies to catalog problem lists (diagnosis) of patients.

According to the International  Health Terminology Standard Development Organisation (IHTSDO) which owns, maintains and distributes the SNOMED CT, it claims that “SNOMED CT is the most comprehensive, multilingual clinical healthcare terminology in the world.”

The alpha phase of ICD-11 has been used as the first phase where the development was limited to “in-house”. ICD-11 development is now open to “public” but is not a functional tool yet, ICD-11 is now in beta phase.

The base version of ICD-11 from WHO is expected in May 2015. In the future, there is a proposed merger of sorts between ICD and  SNOMED in ICD-11.

Malaysia, are we ready for ICD-11? Here are some questions we need to find answers. These are known issues, but I think not given much emphasis, direction, motivation,  and mission and vision. Anyways these issues are not peculiar to Malaysia and other countries who have implemented ICD-10 or still using ICD-9  will need to address for continuous improvement.

  • Is ICD-10 implemented correctly in Malaysia?
  • Who will check the balance between scientific accuracy and completeness?
  • Who will continuously monitor by scientific peer review and other quality assurance methods?
  • The earliest ICD-11 would be available for study would be let’s say 2017. When can Malaysia implement ICD-11? If ICD-11 is available for example in 2017, would we need another 4 years to implement it? – which brings us out to 2021. What do we do from now 2012 to 2021 – 9 long years more from now or 4 years from 2017 to 2021 or if ICD-11 is ready for adoption in 2015 – 6 years from  2015 to 2021? After all Malaysia only started using ICD-10 in 1999, some 9 1/2 years since May 1990!
  • Malaysia is member of the Morbidity Topic Advisory Group (MbTAG) – an ICD-11 Revision committee – Revision Steering Group (RSG). Is there someone or a group preparing Malaysia for ICD-11?

However, let us not forget that there are then several other standards for various disciplines such as Logical Observation Identifiers Names and Codes (LOINC) to think about.  LOINC is a response to the demand for electronic movement of  clinical data from laboratories that produce the data to hospitals,  physician’s offices, and payers who use the data for clinical care and  management purposes.

Big Data – Introduction

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There is a lot of buzzes and there is a lot of emerging hype on Big Data, and I like to begin a series of posts on everything, well almost everything that I can capture, store, search, share, analyse and visualise there is to know about Big Data. I think I will by no means have discussed everything there is to know about Big Data in a running series of posts in this blog as I think Big Data is so huge that I can start an entire blog devoted to just this.

As this blog is about healthcare data and information issues,  the issue of Big Data in healthcare is that there’s a tremendous amount of data and information about the patient. I wish to think it is organised, but the real issue is, that it isn’t organised as well as it should be and all that data is a mixture of structured and unstructured data. Here is when I like to agree with Joe Petro, senior vice president of healthcare research and development at Nuance Communications who sums up the current state of big data. Petro believes that there’s a tremendous amount of information when you’re in the institution – it is a big data problem, you’re trying to figure out what’s going on and how to report on something and you’re dying of thirst in a sea of information, and the issue is how to tap into that to make sense of what’s going on.

Big Data is everywhere, not just in healthcare but as well in as many other sectors of the global economy.

WHERE HAS BIG DATA IN HEALTHCARE COME FROM?

The separation of data among hospital systems – clinical components, laboratories, and radiology are all separate repositories for information. The main issue is with leveraging all of these data. Their use is to provide clinical care or provide scheduling information or operational information. Often there is a problem if we want systems to talk to each other. An organisation can also end up with redundant information due to a legacy system, a system we may continue to use, sometimes well past its vendor-supported lifetime, resulting in support and maintenance challenges. It may be that the system still provides for the users’ needs, even though newer technology or more efficient methods of performing a task are now available.

WHAT IS BIG DATA, IN A NUTSHELL?

Big Data thus refers to sets of data that are so large, that they become awkward and complex that traditional database management tools struggle to capture, store, analyse and share this information. Difficulties include capture, storage, search, sharing, analytics, and visualizing.

IBM (IBM 2012) claims that “every day, we create 2.5 quintillion bytes of data — so much that 90% of the data in the world today has been created in the last two years alone. This data comes from everywhere: sensors used to gather climate information, posts to social media sites, digital pictures and videos, purchase transaction records, and cell phone GPS signals to name a few.” IBM adds that “This data is big data.”

Big data spans three dimensions, sometimes referred to as the 3 “Vs”: Volume, Velocity, and Variety. But IBM says Big Data spans four dimensions: Volume, Velocity, Variety, and Veracity.

Image credit : : http://www.asigra.com

I shall leave this post for now with this infographic(Click on the image above to view the image in a new tab of your current window and in order to obtain a larger image or a closer view of the image in this new tab, zoom in) and continue with the “Vs” and Big Data Basics in the next post on Big Data.

References:
Lorraine, F, Michele, O’C,  & Victoria, W 2012, Data, Bigger Outcomes, American Health Information Management Association, viewed 18 November 2012,
< http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049741.hcsp?dDocName=bok1_049741 >

Michelle, MN 2012, 5 basics of big data, Healthcare IT News, viewed 18 November 2012,
< http://www.healthcareitnews.com/news/5-basics-big-data >

What is big data? 2012, International Business Machines Corporation (IBM), viewed 18 November 2012, < http://www-01.ibm.com/software/data/bigdata/ >

The risks, benefits, and alternatives of surgery

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I had posted in the post Risks, benefits, and alternatives of anaesthesia (this link will open in a new tab of your current browser window) on the anaesthesia planning process which includes educating the patient, his or her family, or decision maker on the risks, benefits, and alternatives related to the planned anesthesia and postoperative analgesia. This discussion occurs as part of the process to obtain consent for anesthesia (including moderate and deep sedation). In anaesthesia care, an anesthesiologist or a qualified individual provides this education.when the risks, benefits, and alternatives are discussed with the patient, his or her family, or those who make decisions for the patient.

Image credit :http://www.desouzanurse.ca/

Likewise prior to surgery, patients and their families or decision makers receive adequate information to participate in care decisions and to provide the informed consent.

The information provided includes:

  1. the risks of the planned procedure;
  2. the benefits of the planned procedure;
  3. the potential complications; and
  4. the surgical and nonsurgical options (alternatives) available to treat the patient.

In addition, when blood or blood products may be needed, information on the risks and alternatives is discussed.

The patient’s surgeon or other qualified individual provides this information.

Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware that medical records of patients must show evidence of the education process  in an ongoing process prior to surgery. Medical records must contain documentation on this process as required by the Joint Commission International (JCI) Standard ASC.7.1 which clearly states that “The risks, benefits, and alternatives are discussed with the patient and his or her family or those who make decisions for the patient.”, and its three (3) Measurable Elements (ME) which must be met fully at hospitals that are JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

HIM / MR practitioners must also be aware that the Joint Commission International (JCI) Standard PFR.6.4 which clearly states that “Informed consent is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures.” I had posted about informed consent in the post Informed Consents – 5 required documentation in the medical record providing information to patient and family (this link will open in a new tab of your current browser window).

Lastly, HIM / MR practitioners do take note that the JCI Standard ASC.7.1  is checked for compliance in the Medical Record Review Tool form used in the Medical Record Review process if your hospital is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

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