Category Archives: MCI.19.4

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

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

JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Medical Records Review Protocol, Analysis & Report

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In my previous post on the MMRT form, you noticed I payed attention to the nitty-gritty of forms processing. I took care to make the MMR for my organisation a success by testing out the form myself and gain first hand experiences, so must you!

Let’s us move on.

Now that I am done telling you about the MMR and the MMRT form, and all the relevant other steps in the review process, imagine that a process session had just ended.

Once a review process session is just over, it is only courteous as team leader for you to thank every review team member before they disperse.

You need to collect back all the medical records used during the review and verify with the medical records request form received from the HIM/MR department. You will get someone to assist you on this task. The records are then carted away immediately to the HIM/MR department by their staff.

Collect all MMRT forms and start data entry into a computer pretty soon. Check the forms for accuracy and completeness for doing data entry.

I used MS Excel to enter data from the TOTAL Y/N column from the MMRT form, i.e total scores of Y and  N  respectively for each standard reviewed, into a spreadsheet according to the reviewer’s name. A formula entered in this spreadsheet computed the NA(Not Available) score.

Then I used MS Word and MS Excel together to prepare a report using the total scores for each standard in the MMRT form for all the reviewers. This score for Y, N and NA is for the sample size chosen, that is 100.

The report is a combination of a radar diagram plotted from the absolute values for Y, N and NA for each standard in the MMRT form, a table to show these values from the findings, and the standard stated before each table and graph.

I made no inferences to the findings, the report was merely a report of the findings from the review process, as I felt making inferences was for the quality leaders to make during an appropiate forum/meeting and for them to make appropiate comments and recommend remedial measure(s) for the shortcomings.

Below you can view how a radar graph looks like for the standard AOP.1.8.2 and two of its MEs from one of the MMRs done.

I am not presenting an actual report due to ethical considerations.

So this ends the posts on JCI Standard 19.4!

<Goodluck with JCI Standard 19.4 >

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

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To continue on MMR, I shall discuss a little about the MMR tool form (the form will open in a new tab of your current window), for a start.

I have modified the form with some features that are not available on the form presented in the Hospital Survey Process Guide. I made the modifications based on my experiences leading the team in the MMR process. I think the following changes in the form are to facilitate a successful MMR process:

  • a header section with the hospital’s name printed, and also a box to enter the review date, on all 3 pages of the form
  • the right-most column, the column TOTAL Y/N,  is divided into two columns, one for Y and the other for N
  • standard ACC.3.2 is on one page, on page 3
  • a remarks box, only on page 3
  • a box for the reviewers name and another box for the reviewer’s signature, only on page 3
  • a footer section for all the 3 pages – the page number insert, since the original form does not have a page number

In the form found in the guide, the TOTAL column(the right-most column) was only one column. So after I  counted the number of Ys and Ns for each row, my entry in this column showed as  the number of Ys and Ns separated by a forward slash. For example if I entered “3/5” in this column to denote a count of 3 Ys and 5 Ns. I found it messy and mistake prone when  I  picked-up this entry(this “3/5” way of recording) during data entry into a computer. Thus I modified the form by adding 2 columns under the TOTAL column, i.e. one for Y and another for N, and in doing so I found it easier and mistake free during data entry into the computer..This is an experience you get when you do the data entry yourself in the early stages of testing out the MMR form.

I think the remarks box is important for the reviewer to enter remarks, which was otherwise written haphazardly, when the form found in the guide was used as-is

The form also did not have a place to write the reviewer’s name and his / her signature, I thought these two modifications were important for tracing the form’s author.

The footer section with page numbers is helpful in sorting the forms during data entry into a computer.

These are some of the things I made to the MMRT form. I shall add some tips and guidance at a later date.

There is nothing permanent except change
Diogenes Laërtius in Lives of the Philosophers Book IX, section 8

JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Medical Records Review Protocol, Sampling Technique

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In the post JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Medical Records Review Protocol, I had proposed the simple random sample technique to select the representative sample.

I introduced the use of a random table to select the sample.

An intuitive approach might be to uniquely identify all the units in a (finite) population, by writing a 3 digit number starting from 001 to let’s say 400(finite population) on small pieces of paper, put all the pieces of paper in a hat(use a Texan hat if you like), mix well and draw out enough numbers for a required sample size, for example 100 numbers starting from 001 to 100 to give a sample size of 100. Do not replace the picked pieces of paper back into the hat and ignore all the numbers greater than 100, mixing the hat after each selection of number.

This is the principle used in the selection of winning tickets in a raffle or lottery, and it is the model underlying  the simple random sample.

A simple random sample is a sample chosen in such a way that, at each draw, every number in the hat has the same chance of being chosen. Everybody in the population has the same chance of getting into the sample.

Such samples are representative of the population in so far as no particular block of the population is more likely to be represented than any other. The general term ‘random sample’ refers to the situation when every member of the population has a known (non-zero, but not necessarily the same) probability of selection. Random is thus a term that describes how the sample is chosen, rather than the sample itself.

You could of course choose other sampling techniques.

You could have picked the stratified random sample. The population is divided into groups, or strata, on the basis of certain characteristics, for example age or sex. A simple random sample is then selected from each stratum and the results for each stratum are combined to give the results for the total sample. The object of this type of sample design is to ensure that each stratum in the population is represented in the sample in certain fixed proportions, which are determined in advance. For example, I could have divided the admissions or inpatients into different groups representing the practitioners providing care and the types of care provided. A simple random sample is then selected from each stratum and the results for each stratum are combined to give the results for the total sample.

Then are other ways of sampling you also choose to use in the protocol, like multistage and cluster random sampling, and quota sampling.

Find a good statistics book or books and do some good reading before deciding on the sampling technique to use in the protocol.

Before I leave this post, I leave you with a sample page of a 5 digit random table from a statistic book. Click this link to view a random table from the textbook Basic Concepts in Statistics and Epidemiology, Appendix F, Random Numbers, page 198

References:
Leslie E. D., and Geoffrey J. B., Interpretation and uses of medical statistics, 5th ed, Blackwell Science, UK

Theodore H.M., Basic Concepts in Statistics and Epidemiology, 2007, Radcliffe Publishing, UK