Category Archives: MCI.19

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

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

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I hope this example will help to explain how a simple random sample is realised. This chart is to help you to understand what I wrote under the Sampling Technique paragraph in the post JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Medical Records Review Protocol

You can click on the above image to view a larger image in a new tab, in the same window.

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

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I have endeavored to make this protocol as general as possible and with no direct references to any organisation. This protocol is a framework you can modify and make it better to suit your organisation and needs.

In this post which is rather long, I shall avoid showing the relevant appendices on random tables, sampling technique example and the Medical Records Review Tool form, but they will appear separately in subsequent posts.

TITLE
Medical Records Review Protocol

SUMMARY
As part of a hospital’s performance improvement activities, hospitals regularly access(review) medical records  based on a sample representing the practitioners providing care and the types of care provided for completeness, accuracy, and timeliness of the information they contain as required by the Joint Commission International(JCI) standards.

DESCRIPTION
Rationale
A medical record (patient clinical record as per Joint Commission International documentation) is a systematic documentation which serves as the business record for a patient encounter for every patient assessed or treated in a health care organisation as an inpatient, outpatient, or urgent care patient.
A medical record contains sufficient information of all health care services provided to a patient, and is a repository of information that includes demographic data(patient’s personal and social data) to identify the patient, as well as documentation to support diagnoses, justify the treatment,  record treatment results, and an account of follow-up and final outcome to promote continuity of care among health care practitioners.
Statutes, accreditation standards, and professional associations frequently impose standards relating to the legibility, accuracy, and completeness of medical records. The Joint Commission International (JCI) standards of accreditation for hospitals require that data be collected in a timely, economic, and efficient manner using the degree of accuracy and completeness necessary for the data’s required use.
A hospital’s bylaws or policies normally require medical staff members to complete patient records within the specified time, and include punitive measures for those who fail to comply.
Usually, the Health Information Management(HIM) /Medical Records(MR) department head has the responsibility for making sure that records are completed within a specific time. Therefore, the HIM/MR department should establish procedures for notifying attending physicians when records are incomplete.

Objective(s)
A Medical Records Review(MMR) ensures the quality of a medical record is complete and accurate with the following objectives:

  1. to ensure only authorised individuals identified by organisational policy make entries in the medical record
  2. to create awareness of the importance of creating an accurate medical record and the legal and medical implications of failing to do so
  3. to enable healthcare professionals to plan and evaluate a patient’s treatment and to ensure the continuity of care among multiple providers
  4. to enable a healthcare provider to establish that a patient received adequate care.

METHODOLOGY
Design
The MMR is based on a sample representing the practitioners providing care and the types of care provided.

Subjects or participants
A sample of subjects is selected by selecting a total number of medical records randomly selected from a total number of medical records of the patients who visited during the current or past year to represent the population of practitioners providing care and the types of care provided.
Medical records of the expired patients are not included in the review.

Sample size
A convenience sample size of one hundred(100) medical records is drawn from a population size of 2 percent(%) of the total admissions or inpatients in one month, in a given year.

DATA MANAGEMENT AND ANALYSIS
Data Collection
Sampling Technique

  • The discharge register listing (computerised) or the admissions register (manual) is used to collect the sample.
  • A time period e.g for example the last calendar month is chosen.
  • Simple random sampling using a five (5) digit random number table available in most statistics textbooks is used to select the sample.
  • A data collection form with columns headers “No.”, “Subject No.”, “Random No.” and “MRN” is used to collect the 100 samples.
  • “No.” is the number in the series, “Subject No.” is the subject number given to a selected sample, “Random No.” is the random number selected from the random table and “MRN” is the Medical Records Number.
  • Each medical record selected using the random table is coded(given) a “Subject No.” beginning with “00” and ends with “99”, denoting the sample size of 100 medical records.
  • From the 5 digit random table, choose the last two-digits from the left of the 5 digit number.
  • Close your eyes and put your pen on one of the numbers in the random number table, for example XXX45. This will be your starting point and the first subject number.
  • Record “45” in column labeled “Random No.” beside column labeled “Subject No.” along the first row labeled number “1” in column labeled “No.”, in the data collection form.
  • Starting with the first selected number, choose a direction (up, down, left or right).
  • Record the next 2 digit random numbers that appear in the table in their respective columns and rows, in the data collection form while moving in the chosen direction until you have selected 100 numbers which lie between 00 and 99.
  • Any numbers which have already been selected are ignored.
  • Using the data collection form and the listing or the register, choose the first entry with the last 2 digits of the MRN in the listing or register for the chosen period which corresponds to the first random number for subject number “00”. Enter the MRN in the “MRN” column in the data collection form.
  • Likewise, check every consecutive entry in the listing or the register and enter each MRN in the “MRN” column in the data collection form for all entries with the last 2 digits of the MRN corresponding to the random numbers recorded in the data collection form.
  • Count the number of entries in the listing or the register checked to collect the sample size(n=100) divided by the total number of discharges or admissions for the chosen month, to derive the percentage of the population sample size.

Medical Records Review Tool
A form is constructed with a listing of the JCI medical records documentation standards.  A criteria “Yes”, “No” and “Not applicable (NA)” is used as the options in the Medical Records Review Tool form to access each standard listed.

Process
The data collection form is used by the HIM/MR Department to retrieve the selected medical records for the medical records review.
The review process is conducted on an arranged date and held periodically as stated in the Terms of Reference(ToR) of the Medical Records Review Committee.
The HIM/MR Department despatches the selected medical records for the medical records review to a predetermined area in the hospital premises for the review process.
The review process is conducted by the medical staff, nursing staff, and other relevant clinical professionals who are authorised to make entries in the patient record.
The MRRT form is used to review and score the selected medical records using the set criteria.
The MRRT forms are completed with reviewer details and signed, and collected by a Person-In-Charge.

Analysis
The MRRT forms are used to prepare a report.
The results of the review process are incorporated into the organisation’s quality oversight mechanism

ETHICAL CONSIDERATIONS
Members of the review process will honor patients’ rights to privacy with respect to information in the medical records. All reports will be free of patient identifiers.

Disclaimer:
I am no expert in statistical methods, however I have prepared this protocol based on my experiences and working knowledge on the  Medical Records Review process similar to the one I had prepared as MCI Champion for the organisation I had worked for.