Once a leader is appointed to champion MCI Standards, one of the first steps leading this challenge is to gather a team to define a terms of reference (ToR) document.for a Medical Records Review Committee (MRRC) which will oversee the mechanism to conduct the Medical Records Review.

In this post, I shall propose a ToR for a MRRC.

But before that a little about what this ToR document is all about. It defines all aspects of how a MRRC will conduct a regular assessment of “patient clinical record content and the completeness of patient clinical records” as part of a hospital’s performance improvement activities, as required by JCI Standard MCI.19.4

The ToR also defines the objective and the scope of the evaluation, outlines the responsibilities of the MRRC and provides a clear description of the resources available to conduct the study, in this case the hospital’s multidisciplinary professionals and authorised groups enable this through a process of regular review and evaluation of patient care records,

The ToR document includes the definition and function – when is one needed, and what are its objectives, what should be included in the review(content),  what needs to be in place(preparation) for a member of the MRRC to facilitate the completion of a high quality evaluation, what steps (process) should be taken to develop an effective ToR, and the roles and responsibilities of designated members.

Now, below is one sample of a ToR for a MRRC I like to propose.

MEDICAL RECORDS REVIEW COMMITTEE (MRRC)

TERMS OF REFERENCE(ToR)

INTRODUCTION

Medical records form the basis for patient care planning, support diagnoses and treatment. They also provide the basis to evaluation of the patient’s condition, treatment as well as continuity of care. It is therefore pertinent that every doctor, nurse, allied health practitioner and those authorised to make entries in the patient records ensure that the content and timeframes of clinical documentation conform to the highest professional standards, to meet patient, legal and accrediting bodies’ requirements.

OBJECTIVE

The MRRC is established as part of the hospital’s quality improvement activities to ensure standards of patient care documentation are maintained in conformance to legal and regulatory bodies, including professional and accrediting agency standards. The hospital’s multidisciplinary professionals and authorised groups enable this through a process of regular review and evaluation of patient care records.

KEY FUNCTIONS

The Committee shall on a regular basis, review and evaluate medical records to ensure:

1. that they are maintained in a complete, legible and timely manner and with pertinent and useful clinical information and overall adequacy to provide the highest standard of patient care.
2. that the records are adequately completed at all times so as to facilitate continuity of care and communication among all those providing patient care services as well as allowing quality improvement activities to be performed.
3. ¹that the review and evaluation includes records of patients currently receiving care (active patients) as well as records of discharged patients, and covers inpatient areas, outpatient clinics and emergency room and is based on a sample representing the practitioners providing care and the types of care provided
4. that record contents required by laws or regulations are included in the review process
5. that the patient record review is carried out by conducted by the medical staff, nursing staff, and other relevant clinical professionals who are authorized to make entries in the medical record or to manage medical records

MEMBERSHIP

ROLES AND RESPONSIBITIES

Chairman

1. He / she shall lead the team and be responsible for setting directions, goals and objectives.
2. He / she shall provide and update to the ²JCI Management Committee and relevant regulatory / accrediting bodies concerning patient care standards documentation and quality of clinical records keeping in the hospital.
3. He / she shall lead the team during the JCI MCI – Medical Records Interview

Co-Chair

1. He / she shall assist the team in achieving set directions, goals and objectives.
2. He / she shall chair the meeting in the absence of the Chairman.

Members

1. He / she shall be familiar with the key ³Licensing & Accreditation requirements including Joint Commission International Accreditation Standards and document control procedures pertaining to medical records.
2. He /she shall review identifies problems relating to patient care standards documentation and document control.
3. He /she shall initiate, recommend or provide solutions to non-conforming standards and deficient clinical records, through designated channels; verify the implementation of preventive measures and monitor its effectiveness.

MEETING

1. The Committee shall meet at least once a month.
2. Ad-hoc meeting may be convened to discuss urgent matters.
3. The members shall serve for a minimum of a 2-year period and may be re-appointed to another term.
4. The quorum shall be seventy-five present (75%) of membership.

¹ The TOR must specifiy what type of medical records will be reviewed and evaluated, example the MRRC may review and evaluate inpatient medical records only

²Main committee overseeing quality improvements

³Example, International Standards Organisation(ISO)

Once the ToR document is ready, it is time for discussion and approval by the MRRC and then forwarded to the MCI Committee for its endorsement.

Next, I shall be presenting a ToR for the MCI Committee and followed by the methodolgy to conduct a review and last, some discussion on presenting the results to senior leaders in quality.

References:

• Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th Edition, USA, JCI
• Dawn,R., Nidhi, K., and Arianne, W., 2011, Writing Terms Of Reference For An Evalaution: A  How-To Guide, Independent Evaluation Group(IEG), The World Bank, Washington, USA

With this post, it is the finish line for the relevant standards that apply to the Patient Clinical Record expounded from the JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 4th Edition.

But the finish line is not quite over.

This last standard that applies to the Patient Clinical Record (PCR), Standard MCI.19.4 states that “As part of its performance improvement activities, the organization regularly assesses patient clinical record content and the completeness of patient clinical records”.

Here I present a Q&A format to review this standard.

	How often does a hospital assess its PCRs?
	PCRs are to be reviewed on a regular basis, measureable by ME 1.
	Do you review all PCRs in the hospital?
	NO, the review  “uses a representative sample”, measureable by ME2. It is important to ensure that this representative sample includes “records of active and discharged patients” as will be accessed for compliance by ME6. In my next post for this standard, I shall elaborate more on this process, for example on how I conducted the selection of the representative sample.
	Who conducts this review?
	“The review is conducted by physicians, nurses, and others authorized to make entries in patient records or to manage patient records”, measureable by ME 3.
	What is the objective of this review?
	“The review focuses on the timeliness, legibility, and completeness of the clinical record” ”, measureable by ME 4. You would have read the post regarding “the timeliness, legibility, and completeness of the clinical record “from the post JCI Standard MCI.19.2 & MCI19.3 – Patient Clinical Record
	Is anything else checked in the review process?
	“Record contents required by laws or regulations are included in the review process”, measureable by ME 5. In Malaysia, neither specific laws nor regulations govern records contents. Guideline exist, I did post about the MMC guideline for medical records contents from the post Malaysian Medical Council (MMC) – acceptable contents of a patient’s medical record
	How are the results of this review process utilised by a hospital?
	“The results of the review process are incorporated into the organization’s quality oversight mechanism”, measureable by ME 7.

More on the “quality oversight mechanism“, and also on a future post, how as the JCI MCI Champion¹, I prepared the results of the review in a comprehensive report for management.

¹A staff selected by management to spearhead all related activities to a specific chapter or chapters from the JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS.