Category Archives: JCI Standards ACC

JCI Standard MCI.4 – accuracy and timeliness of information in the hospital through effective communication

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My intention in bringing this post to a Health Information Management (HIM) / Medical Records (MR) practitioners reader specifically and to all other readers in general, is to understand the dynamics of communication and your role in managing patient-specific information in a hospital setting when the leaders of the hospital agree to an essential condition  whereby effective communication must prevail among and between professional groups; structural units, such as departments; between professional and non-professional groups; between health professionals and management; between health professionals and families; and with outside organisations.

In making this agreement for effective communication throughout the hospital setting, I agree the stipulations that this issue is primarily a leadership function of the hospital’s leaders. This agreement is stipulated in the Joint Commission International (JCI) Standard MCI.4 which states that “Communication is effective throughout the organization”, especially so if you are practising in a hospital accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

The reader as a leader of a structural unit setting and relevant service needs to be aware of the following conditions in this agreement for effective communication:

  1. for patient care to appear seamless, processes must be in place for communicating relevant information in an accurate and timely manner throughout one’s structural unit, such as the HIM / MR department and between other structural units in the hospital; this is to ensure that the processes are designed and implemented to support continuity and coordination of care as patients move through the hospital from admission to discharge or transfer, several departments and services and many different health care practitioners may be involved in providing care; for example from emergency services to inpatient admission
  2. the hospital defines the patient-specific information, example patient’s weight and other physiological information available from the medical record, required for an effective review process and is facilitated by a record (profile) i.e via medication administration records (MAR) or medication list, also to be found within a medical record for all medication administered to a patient except emergency medications and those administered as part of a procedure; the medical record folder is updated after a review of a patient receiving medications, example the folder is tagged with an alert sticker for allergies or sensitivity; this review also facilitates the medication reconciliation process across the continuum of care and the process continues upon discharge and transfer of the patient, and the complete list of patient medications is shared with the next provider of patient care
  3. effective communication occurs in the hospital among the hospital’s programs ranging from the emergency services, inpatient admission, diagnostic services and treatment services, surgical and non-surgical treatment services and outpatient care programs for seamless care
  4. since patients frequently require follow-up care to meet on-going health needs or to achieve their health goals, there is a plan by the hospital’s leaders with the leaders of other health care organisations in its community for effective communication to occur between the leaders of these other health care organisations in its community during referrals; the plan establishes contact with known resources i.e. the patient’s home community and identified specific individuals and agencies that are most associated with the hospital’s services and patient population in order that they help support continuing health promotion and disease prevention education
  5. there are policies and procedures developed to support and to promote patient and family participation in care processes to ensure that continuity and coordination are evident to the patient; effective communication thus occurs with patients and families in these circumstances:
    1. patients and families are involved in care decisions by effective communication thus occurs with patients and families when (i) they understand how and when they will be told of planned care and treatment(s), (ii) understand their right to participate in care decisions to the extent they wish and learn about how to participate in care decisions
    2. inpatients and outpatients who leave against medical advice when patients, or those making decisions on their behalf, may decide not to proceed with the planned care or treatment or to continue care or treatment after it has been initiated guided by a process for the management and follow-up of such cases
    3. effective communication thus occurs with patients and families when those who provide education encourage patients and their families to ask questions and to speak up as active participants
    4. effective communication occurs with patients and families when indicated, planning for referral and/or discharge begins early in the care process ie. soon after admission as inpatients and, when appropriate, includes the family
    5. effective communication occurs with patients and families when patients are reassessed to plan for continued treatment or discharge
    6. effective communication occurs with patients and families such that symptoms and complications are prevented to the extent reasonably possible during the care of the dying patient
  6. and finally. the reader as a leader must not only set the parameters of effective communication but also serve as role models with effective communication of the hospital’s mission and appropriate policies, plans, and goals to all staff.

I acknowledge the role of effective communication and its pervasiveness in creating, gathering and sharing health information in meeting challenges and improving health care outcomes. In this post, I think I have achieved to address some pertinent issues relevant to effective communication when implementing the requirements of the JCI Standard MCI.4 specifically and also delving into the issues of effective communication in general.

References:

  1. Dale, EB & Daena, JG (eds.) 2009, Communicating to manage health and illness, Routledge, London, UK
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
  4. Sheila, P & Sandra, H (eds.) 2007, Health communication Theory and practice, Open University Press, McGraw-Hill Education, England, UK

JCI Standard MCI.8 – Patient transfers within a hospital

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Patients may be transferred within the hospital during their care or to other settings outside of the hospital based on status and the need to meet their continuing care.

Let us consider the case of a patient who is transferred within the hospital. In this instance, the care team changes and so essential information related to the patient needs to be transferred with him or her to facilitate continuity of care for this patient. Thus, medications and other treatments for this patient can continue uninterrupted, and the patient’s status can be appropriately monitored.

What Health Information Management (HIM) / Medical Records (MR) practitioners need to know is in order to accomplish this information transfer when a patient is transferred within the hospital., the patient’s medical record(s) is transferred or information from the patient’s medical record is summarised at transfer as shown in the graphics below. If you work at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then this specific requirement is as stated for JCI MCI.8 which states that “Information related to the patient’s care is transferred with the patient.”

Patient-transfer-summary-MCI,8-clipboard

Another point to take note by the general reader is when a patient is transferred to other settings outside the hospital, the transfer process is documented in the patient’s medical record including documentation of any change in patient condition or status during transfer just as in the case for a patient transferred within the hospital, as I had posted in the post 5 transfer process entries that must be entered in a medical record (this link will open in a new tab of your current browser window).

I like to conclude that I think it is appropriate for  HIM / MR practitioners who work at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, to take note that transfers within a hospital or to outside the hospital is covered by 1 standard under the Management of Communication and Information (MCI) chapter and by 5 JCI standards under the Access to Care and Continuity of Care (ACC) chapter respectively from the JCI Accreditation Standards For Hospitals, 4th Edition.

References:

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

Must medical records show evidence of specialised assessments?

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Let’s look at a simplified diagnostic process from the diagram below, when hearing, visual and dental tests are three common screening tests during the initial assessment during the review of the complaint, history and physical when the patient arrives with complaint at a hospital.

Simplified Diagnostic Process

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

Auditory testing performed during an initial assessment is usually done with a tuning fork. Tests using a tuning fork are meant for screening only and never used for diagnostic purpose. Auditory testing provides the examiner during initial assessment with a basic idea of whether the patient has for example, a hearing loss. Thus, such a test simply provides an indication of the need for more elaborate testing and referral to a hearing specialist for more accurate testing if a problem is suspected.

Assessment of vision examines both visual acuity and anatomic structures. If you wear glasses, you had your visual acuity tested with the Snellen chart, a chart that contains various-sized letters with standardised numbers at the end of each line of letters. Visual acuity of 20/20 is considered normal. Astigmatism, hyperopia (farsightedness), myopia (nearsightedness) and presbyopia (farsightedness) are common vision related conditions. Assessment of eye structures and function present significant findings and possible causes for condtions like nystagmus and cataracts.

Another initial assessment is the assessment of the mouth, throat, nose, and sinuses which usually follows the examination of the head and neck. Examination of the mouth and throat can help detect abnormalities, for example of the lips. Early detection of oral cancer during an oral examination is an important finding. A deviated septum or detection of sinus infection are two other conditions that maybe detected during this kind of examination. Overall, the patient’s nutritional and respiratory status is also assessed.

From the diagram above, treatment is usually begun once the diagnosis is confirmed by the attending doctor, the initial caregiver. Sometimes, the initial assessment process may identify a need for other assessments.  Thus, patients maybe referred and/or discharged based on their health status and needs for continuing care by other specialised health care providers to support their continuing continued care and learning needs. Patients are referred within the hospital or discharged from the hospital to a health care practitioner outside the hospital, another care setting, home, or family when the additional specialised assessment is identified during the initial assessment.

Health Information Management (HIM) / Medical Records (MR) practitioners must take note that specialised assessments conducted within the hospital should be documented in the patient’s medical record. Medical records documentation must show evidence of specialised assessments conducted within the hospital, especially so if you work at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, when the JCI Standard AOP.1.10 which states that “The initial assessment includes determining the need for additional specialized assessments.” requires complete documentation in the patient’s medical record of the need for additional specialised assessments conducted within the hospital.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Kenneth, RW & John, RG 2010, The well-managed healthcare organization, 7th edn, Health Administration Press, Chicago, Illinois, USA
  3. Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

Medical Records and the continuum of care

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The individual responsible for the coordination of the patient’s care must be identifiable and available through all phases of inpatient care as the patient moves through a hospital from admission to discharge or transfer, several departments and services and many different health care practitioners who may be involved in providing care. Thus if a patient Nancy is under constant professional supervision, making handoffs efficient and accurate and this creates continuity throughout Nancy’s care. Since she is always in contact with trained staff, any new information regarding her behaviour will be properly notated and added to her medical records file.

In the United States, the National Quality Forum had identified in a 2006 report (Barbara 2011 p.72) the practice of information management in the medical record to document the continuity of care to matching healthcare needs with service capability, as one of the 30 safe practices that basically helps to create and sustain a culture of safety with the eventual goal “to improve the things that help and prevent the things that harm”.

In fact, the continuity of care (or continuum of care) is among a list of indicators (Judith, H and Paul, D 2009) including access, effectiveness, communication and participation, care and physical comfort, human needs, efficiency, information, and involvement of family and friends on quality care as identified by consumers (patients) who prefer holistic health care and published by the Picker Institute in Europe.

The opportunity to assess continuity of care issues to “trace” the care experiences that a patient had during his or her stay in the hospital is often used in the individual patient tracer activity conducted during the on-site survey under Tracer methodology, which is an evaluation method used to analyse a hospital’s system of providing care, treatment, and services using actual patients as the framework for assessing a hospital’s Joint Commission International (JCI) international standards compliance, i.e a hospital which is already accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status. The medical records of patients currently receiving care in the unit/setting are often used in such evaluations.

As continuity of care is a critical component of patient safety, Health Information Management (HIM) / Medical Records (MR) practitioners must be able to identify who is the responsible individual expected to provide documentation related to the patient’s plan of care because this individual is usually identified in the patient’s medical record or in another manner made known to the hospital’s staff, for example a list of doctors and their specimen signatures.

HIM / MR practitioners are expected to know that this single individual may be a doctor or other qualified individual who has the overall responsibility for coordination and continuity of the patient’s care or particular phase of the patient’s care. This individual is or was providing the oversight of care for a patient during the entire hospital stay which will improve continuity, coordination, patient satisfaction, quality, and potentially the outcomes and thus is desirable for certain complex patients and others in the hospital.

Patients may be delivered in a wide range of community and hospital-based settings and moved from one phase of care to another (for example, from surgical to rehabilitation). The ability to share information between these settings may be limited and fragmented, as a result what usually happens is delays in care when health care providers who are poorly informed ‘reinvent the wheel’ and begin to duplicate procedures and investigations. If the individual originally responsible for the patient’s care continues to oversee all the patient’s care, then a reduction in the quality of care will not be likely nor will it impair continuity of patient care or threaten the patient’s safety. But if this individual originally responsible for the patient’s care changes, this individual would need to collaborate and needs to communicate with the other health care practitioners.

What if the patient goes to multiple doctors in multiple settings that do not have an integrated information system when the health care delivery organisation cannot provide coordination and continuity? I think a patient can take charge of his or her data although it is a challenging responsibility, and so I would advocate and believe that the personal health records approach can bring together a patient’s health information.

If you are a HIM / MR practitioner practising at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then beware that the JCI Standard ACC.2.1 which states that “During all phases of inpatient care, there is a qualified individual identified as responsible for the patient’s care.”

This will require you to:

  1. be aware that the process of continuity of care according to Michelle and Mary (2011, p.71) includes “documentation of patient care services so that others who treat the patient have a source of information from which to base additional care and treatment”
  2. be able to identify from the medical record the individual responsible for the coordination of the patient’s care through all phases of inpatient care had duly provided documentation in the clinical record related to the patient’s plan of care
  3. maintain a list of individuals who are qualified to assume responsibility for the patient’s care and who can be identified to the hospital’s staff by using a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries; I had covered on this aspect in the post JCI Standard MCI.19.2 & MCI19.3 – Patient Clinical Record
    (this link will open in a new tab of your current browser window)
  4. be aware that other consultants, on-call doctors, locum tenets, or others take responsibility of the patient as identified in a hospital policy that identifies the process for the transfer of responsibility from the responsible individual to another individual during vacations, holidays, and other periods and they assume this responsibility when they duly document their participation/coverage in the medical record
  5. be aware that the JCI Standard ACC.2.1 is included in the Medical Records Review Tool

References:

  1. Barbara JY (ed.) 2011, Principles of risk management and patient safety, Jones & Bartlett Learning, Sudbury, MA, USA
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA
  4. Judith, H and Paul, D (eds.) 2009, Patient Safety First Responsive Regulation In Health Care, Allen & Unwin, New South Wales, Australia
  5. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Wait times documentation in the medical record

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Cartoon credit: theragblog.blogspot.com/

Cartoon credit: theragblog.blogspot.com/

Health Information Management (HIM) / Medical Records (MR) practitioners maybe unaware of information documented in the patient’s medical record when inpatients and outpatients seeking care and/or diagnostic services patients, undergo long waiting periods for diagnostic and/or treatment services or when obtaining the planned care may require placement on a waiting list.

The issue of waiting periods for healthcare may be described from the study by Singh et al. (2010) as patient-related i.e delays referring to the time period from the onset of symptoms to the patient’s seeking of medical advice or health system-related. Singh et al. (2010) define health system delays to the time period from the first contact of the patient with the health care system to definitive treatment, which may also include delays in patient access to first contact. Singh et al (2010) further categorised health system delays into diagnostic delays defined as time from the patient’s first contact with the health care system to diagnosis and treatment delays as time from diagnosis to definitive treatment.

HIM / MR practitioners practising at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, must be aware that the JCI Standard ACC.1.1.3 which states that “The organization considers the clinical needs of patients when there are waiting periods or delays for diagnostic and/or treatment services.” which requires the aforesaid reasons and alternatives on waiting periods to be duly documented in the patient’s medical record and this requirement applies to:

  1. inpatient and outpatient care and/or diagnostic services
  2. does not include minor waits in providing outpatient care or inpatient care, such as when a doctor is behind schedule
  3. does not apply for oncology cases or transplant cases 

To this end, HIM / MR practitioners must:

  1. be able to locate information recorded in the patient’s medical record that will contain the associated reasons for the delay or wait and available alternatives consistent with their clinical needs;
  2. must be aware that the JCI Standard ACC.1.1.3 is included in the Medical Records Review Tool; and
  3. include this requirement in HIM / MR written policies and/or procedures to support consistent practice.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Singh, H, Coster, DC, Shu, E,  Fradette, K, Latosinksy, S, Pitz, M, Cheang, M & Turner, D 2010, Wait times from presentation to treatment for colorectal cancer: A population-based study, Canadian Journal of Gastroenterology, vol. 24, no. 1, pp. 33–39, viewed 2 July 2013, < http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2830632/#__ffn_sectitle>