Category Archives: JCI Standards ACC

JCI Standard MCI.2 – Communication with Patients and Families, about care and services and how to access those services

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JCI Standard MCI.2 states clearly that “The organization informs patients and families about its care and services and how to access those services.”, thereby a hospital must meet 3 of its requirements to match this standard.

Let us now see what a hospital must do to live up to the expectations and hopes of sick patients and their families when they get to a hospital.

Organisation ethics requires that a hospital offer to inform patients and their families complete information they wish to know on the care and services at the hospital. Patient and families have a right to reasonable access to care as well as how to access those services. Information provided also includes information on the proposed care for a patient.

This openness and trustworthiness shown by a hospital when it works to build and establish trust and open communication with patients and their families, and when it also trys to understand and protect each patient’s cultural, psychosocial and spiritual values, helps create a bond between patients and their families.

Let’s now see how the Joint Commission International quality standards fits into this picture of openness by a hospital.

By providing all the needed information with the openness of the hospital, awareness and knowledge gained and learnt of the care and services through this openness, trust bonded between patients and their families and the hospital, the hospital easily complies with two of the JCI Standard MCI.2 requirements  namely ME 1 and ME 2.

If the hospital includes information on the proposed care for a patient.in its initial plan to inform patients and their families, then the hospital meets the requirement by the JCI Standard ACC.1.2, ME 2

At the hospital, it is only normal when patients and their families learn of the hospital’s capability to match their expectations of care and services.

When patients and their families learn that their needs fall beyond the scope of  the hospital’s competence, mission and capabilities, then the hospital is obligated to provide information to the patient and their families on alternative sources of care and services. Such alternative sources of care and services may be available at another hospital in the district, and the hospital then co-ordinates with the other hospital with the needed services, and ensures that such patients are appropriately referred to the other facility with services that meets their ongoing care needs.

The hospital will thus comply with the JCI Standard MCI.2 requirement ME3 if the hospital is able to provide information to the patients and their families on alternative sources of care and services when their needs fall beyond the scope of  the hospital’s competence, mission and capabilities.

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

10 facts about a discharge summary

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When a patient is discharged from a hospital, a discharge summary or clinical résumé to document the care provided to the patient during his or her inpatient hospitalisation is prepared by any qualified individual such as the patient’s physician, a house medical officer, or a clerk.

This discharge summary placed in the patient’s record provides information for continuity of care and facilitates a medical staff committee review and it can also be used to respond to requests from authorised individuals or agencies (e.g., a copy of the discharge summary will suffice instead of the entire patient record).

10 contents of a discharge summary documents the patient’s hospitalisation which includes:

  1. the reason(s) for admission
  2. significant physical and other findings(e.g. brief clinical statement of chief complaint and history of present illness)
  3. significant diagnoses and co-morbidities(example, Principal diagnosis: Cellulitis and gangrene, left foot and lower leg. Comorbidities: Diabetes mellitus, insulin dependent, controlled. Staphylococcus aureus coagulase positive septicemia. Urinary retention)
  4. diagnostic and therapeutic procedures(example, Principal procedure: Amputation, left leg, above knee. Secondary procedures: Suprapubic cystostomy with permanent suprapubic drainage)
  5. significant medication and treatments(medical and surgical) and patient’s response to treatment, including any complications and consultations
  6. patient’s condition/status at discharge
  7. discharge medications and all medications to be taken at home
  8. follow-up instructions(patient education when applicable), to patient and/or family (relative to physical activity, medication, diet, and follow-up care)  including instructions for self-care, and that the patient/responsible party demonstrated an understanding of the self-care regimen
  9. unless contrary to policy, laws, or culture, patients are given a copy
  10. a copy is provided to the practitioner responsible for patient’s continuing or follow-up care

I am sure your hospital policy and procedures defines when a discharge summary must be completed, and that it must be placed in the record.

Such a policy and procedures are affirmed by the Joint Commission International(JCI) standard ACC.3.2 which states that “the clinical records of inpatients contain a copy of the discharge summary” and requires that a discharge summary must be prepared at discharge by a qualified individual, it contains follow-up instructions, that a copy  is placed in the patient record, the patient is given a copy of the discharge summary unless not allowed by hospital policy, laws, or culture, and a copy of the discharge summary is provided to the practitioner responsible for the patient’s continuing or follow-up care.

JCI Standard ACC.3.2 is expanded by JCI Standard ACC.3.2.1 which further qualifies the contents of a complete discharge summary.

The above 10 facts listed above covers all that is required by the 6 MEs of ACC.3.2 and the 6 MEs of ACC.3.2.1, when the discharge summary placed in a medical record is reviewed during a Medical Records Review.

Note : In Malaysia, the patient’s physician or a senior medical officer but NEVER a clerk, is responsible to prepare the discharge summary.

5 transfer process entries that must be entered in a medical record

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A patient might require a hospital transfer for a number of reasons. The patient or the family might want a second opinion, the current hospital cannot address the needs of the patient, or the new hospital offers more advanced care among other reasons.

When a patient is transferred to another hospital or health care organisation, the transfer process is documented in the patient’s medical record.

A HIM/MR professional needs to be aware of five transfer process entries which must be included in a medical record when a patient is transferred to another hospital or health care organisation.

These 5 transfer process entries as documented in the medical record will state and/or contain :

  1. the name of the hospital or health care organisation and name of the individual agreeing to receive the patient
  2. any documentation or other notes as required by the policy of the transferring hospital for example, a signature of the receiving nurse or physician, name of the individual who monitored the patient during transport
  3. the reason(s) for transfer
  4. any special conditions related to transfer such as when space at the receiving hospital or health care organisation is available, or the patient’s status
  5. any change in patient condition or status during transfer for example, the patient dies or requires resuscitation

If your hospital is in the process of becoming a Joint Commission International(JCI) accredited hospital, you need to know that the JCI Standard ACC.4.4 requires that a transfer process from one hospital(health care organisation) includes the above mentioned 5 transfer process entries in the patient’s medical record.

However, do take note that the JCI Medical Records Review Tool does not list documentation required by policy requirements of the transferring hospital, as one of its measurable elements.