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JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Medical Records Review Protocol, latest Medical Records Review Tool

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I know that the most frequently viewed post(s) on this blog are regarding Medical Record Review (MMR) using the Joint Commission International (JCI) Accreditation Hospital Standards.

This post is also regarding Medical Record Review. I shall be using ‘Medical Record Review’ rather than ‘Medical Records Review’ from now on to reflect what JCI uses in its manual. I guess this is no big deal, but I shall conform.

I have been using the term MMR Tool (MMRT) but do take note that the MMRT is also referred to as the Medical Record Review Form (MMRF) as in the JCI’s Hospital Survey Process Guide (HSPG).

This post is about the MMRT / MMRF as recommended in the JCI’s HSPG, 4th Edition, Version 2 effective 1 January 2011. All future posts related to the application of the MMRT / MMRF will be based on this latest edition of the JCI’s HSPG.

I have been posting posts related to the application of the MMRT / MMRF (you can view this particular tool /form from this link which will open in a new tab of your current window) as recommended in the JCI’s HSPG, 3rd Edition, effective January 2008.

You can view a sample of the latest MMRT / MMRF from this link, which will open in a new tab of your current window.

The purpose of using the MMRT / MMRF according to JCI (HSPG, 4th edn, p. 70) remains as before, that is to help “validate the hospital’s compliance with the documentation track record”, i.e to also say in JCI’s words (HSPG, 4th edn, p.70) that is “to gather and document compliance with standards that require documentation in the patient’s record”.

Health Information Management (HIM) / Medical Records (MR) practitioners need to know that the MMRT / MMRF is used during closed patient medical record review session(s) in addition to during tracer activities when the same MMRT / MMRF is used during open patient medical record review session(s) using ‘open’ medical records of patients currently staying in the hospital are evaluated.

While I understand that the survey team will provide the latest version of the MMRT / MMRF which will include any approved changes in the standards, an HIM /MR practitioner or the hospital quality assurance (QA) department is usually required to provide the MMRT / MMRF for mock closed or open patient medical record review session(s).

You will notice that both the latest and previous versions of the MMRT / MMRF are organised as follows:

By three (3) topic headings, ‘Consent’, ‘Assessments’ and ‘Other’

  1. Each topic heading includes several standards
  2. Each standard under a topic heading lists the specific standard number e.g ‘ACC.3.2.1’ as listed under the topic heading ‘Other’
  3. Each specific standard under a topic heading lists the standard requirement i.e the specific standard’s requirement as will be printed in the ‘Documentation Requirement’ column in the MMRT / MMRF, e.g the standard ACC.3.2.1 requirement is as printed below:

“Discharge summary contains the following:

      • Reason for admission, diagnoses, and comorbidities
      • Significant physical and other findings
      • Diagnostic and therapeutic procedures performed
      • Significant medications, including discharge medications
      • The patient’s condition/status at the time of discharge
      • Follow-up instructions”

During an accreditation survey,  the surveyor(s) – be they be members of the real JCI accreditation surveyor or members of the hospital’s mock MMR process team, will both use the MMRT / MMRF :

  1. to enter the number of the medical record being reviewed and the type of medical record requested (recorded by diagnosis) on the top of the form, e.g  “Record #1234678  Asthma”)
  2. to review the medical record according to JCI (HSPG, 4th edn, p. 70) so as “briefly to decide what type of patient or care was received (for example, surgery, medical, emergency, and rehabilitation).”

Another request (s) by the survey team or a typical MMR session by the hospital’s mock MMR process team can be read by reading my previous posts as follows  (each of these links will open in a separate tab of your current window) :

  1. JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Medical Records Review Protocol, Medical Records Review Tool
  2. JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Medical Records Review Protocol

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA
  3. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 3rd edn, JCI, USA

Graph Story 3

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An article in the British Medical Journal (BMJ 2013;346;f1563) reported, “With more patients being treated but fewer beds, there’s no doubt that beds are being used more efficiently. But more intensive use could be a problem”.

The trend in fewer beds in use in hospitals can be seen in most countries in the Organisation for Economic Cooperation and Development (Fig 2).

fig 2

Image credit: British Medical Journal (BMJ 2013;346;f1563)

fig 1

Image credit: British Medical Journal (BMJ 2013;346;f1563)

In England this trend in the fewer number of hospital beds in use – by 59% for all beds since 1979 till 2012 can be viewed from Fig. 1, also shows sharp reduction in beds used for acute care, for maternity, geriatric care, mental illness and learning disability.This trend is the direct result of concerns (BMJ 2013;346;f1563) about  “the need to save money and improve labour efficiency in the light of a shortage of nurses and general pressures on health service budgets.”

Since the number of beds in use has reduced but with increases in population, thus with more patients being treated but fewer beds, the time patients spend in hospital i.e the average length of stay (ALOS) a patient spends in hospital also needs to be reduced (shortened). John in (BMJ 2013;346;f1563) gives the example of ALOS for an acute case in England that “has shrunk from around 9.4 days in 1979 to about three days in 2011.”

John (BMJ 2013;346;f1563) adds some reasons in his article as he examined these trends and found new changes as follows that “have helped shift care from the ward to the outpatient department and beyond the walls of hospitals” :

  1. medical practice
  2. drugs
  3. diagnostic procedures
  4. policies which deliberately moved mental health, learning disability, and
    geriatric services out of hospital and     into the community
fig 3

Image credit: British Medical Journal (BMJ 2013;346;f1563)

Fewer beds but more patients being treated means the daily bed occupancy (BOR) rises. For example, daily average BOR data across all hospitals for England reached over 90% on several days (Fig. 3). John (BMJ 2013;346;f1563) infers that “Such high occupancy rates reduce the time available for cleaning between patients and increase the chances of infection.”, although he believes and I believe too that “there’s no doubt that beds are being used more efficiently.”

References:

  1. John, A 2013, The Hospital Bed: On Its Way Out?, March 2013, vol. 346, British Medical Journal, BMJ Publishing Group Ltd, London

MSQH – SERVICE STANDARD 7, Organisation and Management for STANDARD 7.1.1

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MSQH-Book-SS7-HMISOrganisation and Management is the first topic among six (6) topics which make up the standards under SERVICE STANDARD 7 for Health Information Management System (HIMS) based on the 4th Edition of the Malaysian Society for Quality in Health (MSQH) Hospital Accreditation Standards effective January 2013, used by the MSQH, which is the sole Malaysian accreditation body with nationally established standards for health care facilities and services since 1997, dedicated to improving the quality of Malaysia’s health care through voluntary accreditation. You can read about the 6 topics from the post MSQH – Introductory Post (this link will open in a new tab of your current window) as well view the hierarchy of these topics (the green boxes) from the graphic below (click on the graphic to view a larger image which will open in a new tab of your current window).

MSQH Service Standard 7

Standard 7.1.1 is the first standard for Service Standard 7 and the only standard under the topic Organisation and Management (OM) which states that “The Health Information Management System (HIMS) Services shall be organised and administered to facilitate the collation, aggregation and analysis of hospital demographic data through an established system which includes safe keeping and retrieval of medical records and documents related to patient care.

Health Information Management (HIM) / Medical Records (MR) practitioners in Malaysia whose hospitals are engaged in hospital accreditation using the 4th Edition of the Malaysian Society for Quality in Health (MSQH) Hospital Accreditation Standards effective January 2013 for the Service Standard 7 HIMS must truely know that his or her hospital needs to fully satisfy fifteen (15) criteria for compliance to the OM topic for this service standard.

The criteria for compliance to the OM topic for this service standard ranges from the organisation management of the HIM / MR Department through processes planning and continued development, data management of information about major clinical services that meets Malaysian statutory requirements, reporting systems for incident reports, the formation and activities of a Medical Records Committee, and ends with the department’s involvement in quality improvement activities.

You can view the whole range of criteria listed from https://docs.google.com/file/d/0B1XnOSMJXDaqR184d1BsbHQxQWs/edit (this link will open in a new tab of your current window) from the Download List Sub-Menu under the Resources Menu.

Now I like to draw your attention to the variation or differentiation between nearly identical entities and other non-identical entities found under MSQH Service Standard 7, Standard 7.1.1 and those found under the  Joint Commission International (JCI) hospital accreditation standards,

HIM / MR practitioners will find a similarity between JCI hospital accreditation found in Standard MCI.9 (which I have not blogged on as yet) with  the MSQH Service Standard 7, Standard 7.1.1 under Criterias 7.1.1.1 to 7.1.1.10 when both of them try to cover aspects of the HIM / MR department’s mission, services provided, resources, access to affordable technology,and support for effective communication among caregivers

HIM / MR practitioners will find another similarity between JCI hospital accreditation found in Standard MCI.19.4 with the MSQH Service Standard 7, Standard 7.1.1 under Criteria 7.1.1.13 which requires regular Medical Records Review (MRR) sessions. However the MSQH Service Standard 7, Standard 7.1.1 under Criteria 7.1.1.13 does not elaborate the review process nor is there any  MMR tool to use unlike that found under JCI.

Unlike hospital accreditation for JCI accreditation status, a specific Root Cause Analysis (RCA) activity is required of HIM / MR practitioners under  the MSQH Service Standard 7, Standard 7.1.1 under Criteria 7.1.1.12 . I hope HIM / MR practitioners will not be wrongly allocated the task of conducting RCA for all incidents that occur in the hospital but rather they will only be confined to RCA for all incidents that occur for HMIS services only. as I understand from Criteria 7.1.1.11, MSQH Service Standard 7, Standard 7.1.1 which stipulates that “The Head of the HIMS Services shall ensure that the staff of HIMS Services complete incident reports which are discussed by the services with learning objectives and forwarded to the Person In Charge (PIC) of the Facility.”

There is no direct reference to “The Medical Records Committee” to be found in JCI. However, HIM / MR practitioners in Malaysia need to be aware that according to the notes found under Criteria 7.1.1.13, MSQH Service Standard 7, Standard 7.1.1 “The Medical Records Committee is a subcommittee of Medical and Dental Advisory Committee (MDAC) who advises the Governing Body on matters pertaining to HIMS.” and not as reporting directly to the Hospital’s Director or other equivalent top management official.

Quality Assurance (QA) Managers and their departments are normally assigned the duties of facilitating quality improvement (QI) activities for the hospital. I can infer that QA managers have a specialised and trained role in QI, and thus are fully qualified to be the facilitator of such QI activities, Nonetheless, Criteria 7.1.1.15, MSQH Service Standard 7, Standard 7.1.1 has assigned this role with the given and added responsibility to HIM / MR practitioners to be the “facilitator for quality improvement activities of the Facility. Areas of involvement may include:

a) compiling patient care data for clinical review/research;

b) supervising data collection and advising on analysis of data collected by personnel of other services.”

Lastly, I find that MSQH Service Standard 7, Standard 7.1.1 does not have set criteria to cover the clause “safe keeping and retrieval of medical records and documents related to patient care.” while on the contrary Standard MCI.12 of the JCI clearly states that “The organization has a policy on the retention time of records, data, and information.”

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. SERVICE STANDARD 7 Health Information Management System 2013, Malaysian Hospital Accreditation Standards, 4th edn, The Malaysian Society for Quality in Health (MSQH), Malaysia

Written Discovery – Part 1, Requests To Produce

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written-discovery-log“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.”, was how I ended the post Written Discovery – Introduction (this link will open in a new tab of your current window), and now to begin this post on what to anticipate and to respond with the information typically requested in all medical-negligence cases and specific information related to the claim of professional or institutional negligence, in both situations consistently and efficiently to written discovery.

Health Information Management (HIM) / Medical Records (MR) practitioners normally assist such requests when they are required to assemble and reproduce all medical information that pertains to the patient, including medical records, letters/reports including films, drawings, diagrams, photographs, and electronic data. I shall write more about this on my next continuing post on written discovery.

I think HIM / MR practitioners need to be aware of other common information with respect to the care at issue in the lawsuit requested from the hospital management which may include from what I have encountered from my experiences:

  1. any quality improvement activities conducted
  2. identification of any hospital policies relevant to the care and treatment at issue
  3. information regarding the identification and employment status of individuals involved in the relevant care and treatment of the patient or who have knowledge of the medical treatment at issue in the lawsuit
  4. any hospital accreditation status e.g Joint International Commission (JCI) or Malaysian Society of Quality in Health (MSQH) accreditation
  5. medical-staff bylaws, policies, and procedures, or other documents that govern the scope of medical-staff practices

During the pendency of the lawsuit, hospitals may be required to seasonably supplement their written-discovery responses with new or additional information identified during the course of discovery. HIM / MR practitioners may also be required to further assist hospital management in providing any new or additional information identified to complete any supplemental discovery requests.

Periodicity Of Reassessments For 13 Situations Found In Medical Records

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Here is a graphic to show a summary of the periodicity of reassessments in 13 situations which can be found in a medical record. Click the image to view a larger image in a new tab of your current window.

Periodicity-Of-Reassessments-For-13-Situations-Found-In-Medical-Records