Category Archives: MCI.20

JCI Standard MCI.20.2 – Using or participating in external databases

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In order to compare its performance and to identify opportunities for improvement, a Hospital needs a mechanism for comparing its performance to that of other similar hospitals locally, nationally, and internationally with recognised, internationally accepted standards.

The mechanism must be designed to transform input forces and movement by (i) operate or interact by participating in external performance databases, (ii) compare its performance to that of other similar hospitals,  into a desired set of output forces and movement when the hospital can identify opportunities for improvement and hence documenting its performance level.

This arrangement of connected parts in a system of parts of individual hospital performances like those parts of a machine is surely an effective tool to demonstrate the quality and safety that are being provided in the hospital and can be thought of as benchmarks of success when the hospital participates through reference databases.

I can think of the following initiatives in the US when hospitals as providers participate through reference databases to improve by benchmarking their performance against others, encourage private insurers and public programs to reward quality and efficiency, and help patients make informed choices:

  1. Hospital Compare which encourages hospitals to improve the quality of care they provide and for patients to find hospitals and compare the quality of their care  and make decisions about which hospital will best meet their health care needs;
  2. Quality Improvement Organization (QIO) – a private, mostly not-for-profit contractor of the Centers for Medicare & Medicaid Services (CMS) to improve the quality of health care for all Medicare beneficiaries;
  3. ORYX® data reported on The Joint Commission website at Quality Check® which permits user comparisons of hospital performance at the state and national levels; and
  4. hospitals complete The Leapfrog Hospital Survey, the gold standard for comparing hospitals’ performance on the national standards of safety, quality, and efficiency

In all instances, hospitals need to check if they are required by local laws or regulations to contribute to some external databases. Hospitals also need to maintain security and confidentiality of data and information at all times when operating or interacting with external databases.

ff your hospital is a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then the JCI Standard MCI.20.2 requires it to have a mechanism in place with the following characteristics:

  1. there is a process to participate in or to use information from external databases, thus satisfying the JCI Standard QPS.4.2, ME 2 which states that “Comparisons are made with similar organizations when possible.”;
  2. the hospital contributes data or information to external databases in accordance with laws or regulations, thus satisfying for example both the JCI Standard PCI.10.4, ME 1 which states that “Health care–associated infection rates are compared to other organizations’ rates through comparative databases.” and the JCI Standard QPS.4.2, ME 2; and
  3. the hospital compares its performance using external reference databases, also satisfying the JCI Standard QPS.4.2, ME 2; and the hospital maintains security and confidentiality when contributing to or using external databases.

References:

  1. Facts about ORYX® for Hospitals (National Hospital Quality Measures), The Joint Commission, viewed 8 March 2013, < http://www.jointcommission.org/facts_about_oryx_for_hospitals/ >
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Prathibha, V (ed.) 2010, Medical quality management : theory and practice, 2nd edn,  Jones and Bartlett Publishers, Sudbury, MA, USA
  4. Quality Improvement Organizations, Centers for Medicare & Medicaid Services, viewed 6 March 2013, < http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs/index.html?redirect=/qualityimprovementorgs >
  5. Welcome to the Leapfrog Hospital Survey, The Leapfroggroup, viewed 8 March 2013, < https://leapfroghospitalsurvey.org/ >

8 ways for identifying opportunities for improvement and documenting a hospital’s performance level

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8-ways-for-identifying-opportunities-for--improvement-and--documenting-a-hospital’s--performance-level-2

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

A hospital’s performance improvement activities as opportunities for improvement

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syringe-with-MCI.20.1-PI-activitiesIn three previous posts, I brought to you how aggregate data are an important part of the hospital’s performance improvement activities. In particular, the three posts were about aggregate data from risk management, utility system management, infection prevention and control, and utilisation review and how they can help the hospital understand its current performance and identify opportunities for improvement.

The posts were:

(i)                  JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” ;

(ii)                JCI Standard MCI.20.1, ME 1 (Part 2) – infection prevention and control, in “The organization has a process to aggregate data in response to identified user needs.” ;

and

(iii)             JCI Standard MCI.20.1, ME 1 (Part 3) – utility system management and utilisation review, in “The organization has a process to aggregate data in response to identified user needs.”

Each of the links above will open in a new separate tab of your current browser window.

In this review of those 3 posts, I like to emphasise that a hospital chooses which clinical and managerial processes and outcomes are most important to monitor based on its mission patient needs and services provided. The hospital’s leaders must identify key measures (indicators) to monitor the hospitals’s clinical and managerial structures, processes and outcomes.

A required clinical monitoring which includes structure, process or outcomes data selected by the leaders is on aspects of infection control, surveillance and reporting. For managerial monitoring, a required managerial monitoring which includes structure, process or outcomes data selected by the leaders is on aspects of risk management and utilisation review/management.

The hospital collects and analyses aggregate data from clinical monitoring and managerial monitoring to support patient care and organisation management. Aggregate data provides a profile of the hospital over time and allows the comparison of the hospitals’s performance with other hospitals.

To measure the hospital’s performance improvement activities, hospitals usually prepare a master plan to reduce evident risks in the environment or individual plans which incorporates a comprehensive program and plan inclusive of :

  1. a program and plan to reduce the risk of health care-associated infections in patients, health care workers and visitors
  2. a program and plan that includes utility systems – electric, water and other utility systems,  maintained to minimise risk of failure

There is also a written plan for an organisation-wide quality improvement and patient safety program that includes clinical and managerial processes for risk management, utility system management, infection prevention and control, and utilisation review.

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

JCI Standard MCI.20.1, ME 1 (Part 3) – utility system management and utilisation review, in “The organization has a process to aggregate data in response to identified user needs.”

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Well, I am not yet quiet finished on trying to tell you all about the Joint Commission International (JCI) Standard MCI.20.1. In this post I wish to share on the what, why and how about utility system management and utilisation review, the remaining two other important parts of the improvement activities of a hospital by which the hospital attempts to aggregate data to provide a profile of the hospital over time which then will allow the comparison of the hospital’s performance with other hospitals. Utility system management and utilisation review are the last of the four improvement activities of a hospital identified in the intent statement of the JCI Standard MCI.20.1.

My intent is to discuss in this post:

  1. in brief about utility system management and utilisation, as this single post cannot cover all about utility system management and utilisation review; and
  2. more importantly to highlight to management and hospital leaders when one is entrusted to champion the course of all the JCI Management of Communication and Information (MCI) standards, the probability when a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, is expected to present the case of a process for both utility system management and utilisation review, when surveyors examine evidence under JCI Standard MCI.20.1 ME 1 the process to aggregate data from utility system management and utilisation review at a hospital in response to identified user needs  – in order to satisfy the requirement for the Measurable Element 1 of MCI.20.1 which states that “The organization has a process to aggregate data in response to identified user needs”.

Before I go on, my intent (ii) above is true for aggregate data from risk management as well as for infection prevention and control as  I have posted in JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” and in JCI Standard MCI.20.1, ME 1 (Part 2) – infection prevention and control, in “The organization has a process to aggregate data in response to identified user needs.” respectively (each of these links will open in a new tab of your current browser window).

Medical insurance in Malaysia, provided by insurance companies and banks which provide a few plans for anyone to choose from based on own budget and needs, functions as a form of protection to cover unforeseen expenses arising from illness, injury or accidents – which can be very expensive, especially if hospitalisation and / or surgery is required.

Malaysian readers will already be aware that insurance companies in Malaysia provide coverage plans for medical services for their clients at any hospital. Malaysian readers will also be aware that health insurance companies in Malaysia request medical reports for approval of claims to confirm that any insurance plan provides for the coverage of medical services rendered.  While this is true for Malaysia, I have never known the need for utilisation review to review a request for medical treatment in Malaysia.

Let us now assume that utilisation review by insurance companies is practised in your settings and take this discussion from there.

Utilisation review refers to reviews of past medical treatment, for example in the United States where insurance companies perform an utilisation review to review a request for medical treatment. I have below a cropped infographic which provides the anatomy of health insurance coverage in the U.S. (click the infographic which will open in a new tab of your current window for a larger view).

health-insurance infographic croppedThe purpose of the review is to confirm that the plan provides coverage for a patient’s medical services typically found on an insurance policy’s precertification list.  The utilisation review also help an insurance company minimise costs and determine if the recommended treatment is appropriate. The company could deny coverage as a result of a utilisation review.

What about care based on medical necessity in the future, for example for approval for additional treatments while you’re undergoing medical care (a concurrent review)?

Utilisation management is the process of preauthorisation for medical service as it refers to requests for approval of future medical needs, and this term is often used interchangeably with utilisation review since both utilisation review and utilisation management involve the review of care based on a medical necessity.

Thus, the term “utilization review” refers to a retrospective review – the review of treatments or services that have already been administered, and involves the review of medical records in comparison with treatment guidelines. The insurance company uses the results to approve or deny coverage a patient has already received, and the information can also be used in a review of the insurance company’s coverage guidelines and criteria for a particular condition. The insurance company looks through a patient’s medical records for evidence of appropriate low-cost health care. It then compares this patient’s medical records to those of other patients with the same condition. It will then review, and possibly revise, its treatment guidelines and criteria to ensure that the provided care is adequate, and medically current, for the condition.

Therefore, hospitals get actively drawn into the process of the collection of information, including the symptoms, diagnosis, results of any lab tests and list of required services by providing clinical documentation that supports their treatment decisions.

I think Health Information Management (HIM) / Medical Records (MR) practitioners have a clear role in utilisation review if their setting is appropriate. HIM /MR practitioners will need to be aware (i) of the existence of an utilisation review policy and the relevant processes, and (ii) to contribute to good records keeping since a high retrieval rate of medical records can be expected when patients’ medical records are examined for evidence of appropriate low-cost health care and for comparison of treatment among other patients’ medical records for a similar condition, by the insurance companies.

I think to round-up the discussion on utlisation review, it is safe to justify then if a hospital –  which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, satisfies the requirement for the Measurable Element 1 of MCI.20.1 which states that “The organization has a process to aggregate data in response to identified user needs”, if the hospital can provide evidence of documentation of a process to aggregate data i.e. in response to the identified user needs when data is aggregated for utilisation review.

Now, allow me to move forward to present utility system management.

Hospitals have different medical equipment and utility system needs based on their mission, patient needs, and resources. Regardless of the type of system and level of its resources, a hospital needs to protect patients and staff in emergencies, such as system failure, interruption, or contamination. The safe, effective, and efficient operation of utility and other key systems in the hospital is essential for patient, family, staff, and visitor safety and for meeting patient care needs.

The business of utility system management in a hospital is about:

  1. a constant potable water and electrical power supply
    1. first identifying  the areas and services at greatest risk when power fails or water is contaminated or interrupted, secondly to reduce the risks of such events and thus ensuring an uninterrupted (24-hour basis, every day of the week) source of clean water and electrical power, and when necessary regular and alternative sources of power and water must be identified that can be sourced in emergencies
    2. emergency processes to protect hospital occupants in the event of water or electrical system disruption, contamination, or failure
    3. testing its emergency water and electrical systems on a regular basis appropriate to the system and the results documented
  2. regular inspection and maintainance of electrical (example, frayed electrical lines), water, waste (example, waste contamination in food-preparation areas), ventilation  (example, inadequate ventilation in the clinical laboratory), medical gas  (example, oxygen cylinders that are not secured when stored, or leaking oxygen lines, and other key systems that all pose hazards and when appropriate, they must be improved
  3. designated individuals or authorities monitor regularly the quality of water received from a source, and the water used in chronic renal dialysis
  4. collection of monitoring data for the utility system management program
    1. monitoring essential systems helps the hospital prevent problems
    2. monitoring data that are collected and documented are used to plan the hospital’s long-term needs on system improvements and in planning for upgrading or replacing utility systems

It is almost to the end of this rather long post.

I think it is also safe to justify from the foregoing discussion on utility system management that when a hospital – which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, satisfies the requirement for the Measurable Element 1 of MCI.20.1 which states that “The organization has a process to aggregate data in response to identified user needs”, if the hospital can provide evidence of documentation of a process to aggregate data i.e. in response to the identified user needs, when data is aggregated for utility system management.

This post ends what I wish to share all about the JCI Standard MCI.20.1, ME 1.

References:
Barbara JY 2011, Principles of risk management and patient safety, Jones & Bartlett Learning, Sudbury, MA, USA

Diane, LK 2007, Applying quality management in healthcare : a systems approach, 2nd edn, Health Administration Press, Chicago, Illinois, USA

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

Prathibha, V (ed.) 2010, Medical quality management : theory and practice, 2nd edn,  Jones and Bartlett Publishers, Sudbury, MA, USA

JCI Standard MCI.20.1, ME 1 (Part 2) – infection prevention and control, in “The organization has a process to aggregate data in response to identified user needs.”

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Image credit : http://www.tsft.nhs.uk/

As I had posted in the post JCI Standard MCI.20.1 – patient based data and aggregate data, in a process available to aggregate data to meet the needs of internal and external users (this link will open in a new tab of your current browser window), in this post I shall continue on infection prevention and control. This post is also a follow-up from the previous post on risk management in JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” (this link will open in a new tab of your current browser window).

Infection prevention and control is one of a hospital’s four (4) performance improvement (PI) activities other than risk management, utility system management, and utilisation review PI activities a hospital is required to meet the Joint Commission International (JCI) Standard MCI.20.1, Measurable Element (ME) 1 which requires that a hospital as “The organization has a process to aggregate data in response to identified user needs.”

Although the details of infection prevention control are beyond the scope of this post and blog, I shall embark to highlight some aspects of infection prevention and control here. It is going to be a long post.

Health care–associated infections (HAIs) or also referred to as health care–acquired Infections, are infections acquired in the hospital or other health care facilities that were not present or incubating at the time of the patient’s admission. Hospital (or ‘nosocomial’) infection is infection acquired either by patients while they are in hospital, or by members of hospital staff.  (eds. Adam & Christina 2009) define the term infection as “generally used to refer to the deposition and multiplication of bacteria and other micro-organisms in tissues or on surfaces of the body with an associated tissue reaction.”

At the time of the patient’s admission due to an illness – which impairs the body’s normal defense mechanisms, often the reason for hospital admission, the patient is in the state of risk for infection in which the patient is at increased risk for being invaded by pathogenic organisms because the patient has not been exposed to in the past what the hospital environment now provides the exposure to a variety of virulent organisms, therefore the patient has not developed any resistance to these organisms.

Health care personnel in hospitals who usually fail (eds. Adam & Christina 2009) to practice proper handwashing procedures or to change gloves between patient contacts, contribute to most HAIs been transmitted  to hospitalised patients who are at risk from the most common HAI endemic infections in hospitals caused by multi-resistant tuberculosis, Clostridium difficile one of the major hospital infections in the elderly, vancomycin-resistant enterococci in some specialised units, and cross-infection with methicillin-resistant Staphylococcus aureus (MRSA) that affect the urinary tract, upper and lower respiratory tracts, gastrointestinal tract, conjunctiva, and skin.

HAIs have received increased attention due to their overwhelming consequences in terms of cost, morbidity, and mortality.  One of the reasons for this increased attention is that these infections which are preventable through the adherence to numerous strict guidelines, legal requirements and other recommendations when caring for patients, is that they frequently occur in people whose health is already compromised by disease, age, or injury.

The data presented in the 1999 Institute of Medicine (IOM) study reported that an estimate of  between 44,000 and 98,000 patients die as the result of preventable medical errors in hospitals each year and also reported that hospital-acquired infections, many of which can be prevented, take another 100,000 lives.

In the United States of America, payers have begun to refuse reimbursement for additional care resulting from treatment for an infection not present on admission with the underlying rationale that HAIs are preventable complications and denying reimbursement provides a strong incentive for quality improvement actions to avert them.

Then there are site-specific infection prevention to reduce (i) postoperative surgical wound infections through the use of appropriate surgical site preparation and also prophylactic antibiotic therapy, (ii) ventilator-associated pneumonia by for example minimizing the duration of intubation, (iii) central venous catheter infections for example with the use of sterile technique and full barrier precautions, (iv) urinary tract infection by avoiding unnecessary or prolonged use of indwelling bladder catheters, and (v) resistant organisms for example methicillin-resistant Staphylococcus aureus (MRSA) by employing (a) active surveillance procedures in which cultures are routinely obtained at scheduled intervals to promote earlier identification of resistant organisms, and (b) careful management of antibiotic use.

To address each type of HAI, many hospitals have adopted a series of practices called a “bundle” at a significant cost,  failure to use all the measures prescribed in the “bundle”, for example in the approach to preventing central line-associated bloodstream infections  (CLBSI) (this bundle includes the entire procedure for insertion, the daily cleaning protocols, and the protocols for use of the central line catheter) may adversely affect patient outcomes but adopting a “bundle” has been shown to decrease the incidence of the target infection, and thus been effective  in improving quality of care which may then offset the significant cost.

Transmission of infection as an occcupational hazard in all hospital settings is a major concern when caring for infected patients made worse by the presence of resistant organisms which causes extra concern and makes treatment difficult.

Universal precautions are usually mandated for use with patients who pose the hidden danger when they have not been diagnosed as having an infection and for whom specific infection control measures have therefore not been prescribed. Universal precautions is a critical protective strategy with measures that include hand decontamination upon entering and leaving every patient encounter, isolation and the use of disposable gowns and gloves in addition to hand decontamination for patients with certain particularly dangerous types of infections. Provision of sharps containers wherever needles were used and the provision of a supply of gloves and protective eyewear for employee use are some other measures as part of universal precautions.

Blood-borne pathogens are not the only pathogens of concern in the healthcare environment. Body Substance Precautions are also used in all hospital settings to protect patients and staff members from infections that might be transmitted by any body substance, for example to protect staff members from the tuberculosis (TB) organism.

Confidentiality should be maintained at all times by Health Information Management (HIM) / Medical Records (MR) practitioners who may be needed to provide medical records of staff members exposed to HBV, HCV and HIV infection for review at the time of exposure of the source of their occupational exposure to the bloodborne pathogens including results of blood tests, admitting diagnosis and past medical history.

HIM / MR practitioners may be needed to work closely with an infection control officer at most hospitals which usually designate this officer who has the expertise to guide the staff in planning appropriate infection control procedures to protect staff members from blood-borne pathogens to prevent the spread of HIV, hepatitis B, and other such blood-borne pathogens.

HIM / MR practitioners may be involved in the development of policies and procedures is a key role for any infection control team. The central document is a collection of procedures (sometimes called an infection control policy or infection control manual).

As I have said in my previous posts, most hospitals today are involved in processes of quality improvement.

In the context of HAI, (eds. Adam & Christina 2009,  p. 5) defines ‘surveillance which is a vital component of infection control as ‘the ongoing systematic collection and analysis of data about a disease (or organism) that can lead to action being taken to control or prevent the disease.’

As part of these processes, ongoing data are collected and analysed for problems or opportunities for improvement including using infection control and quality improvement data to improve care. An example of the use of infection control data reviewed from interviews in regard to care practices for patients with catheters in an intensive care unit (ICU) about the series of urinary tract infections for example by the same strain of Serratia as the infective agent that had been identified in all patients in that unit, showed that a deviation from the standard protocol for the unit with the use of one measuring container used by an infected patient cultured positive for the Serratia, and using it from patient to patient easily had transmitted the organism to another patient’s catheter, and the infectious agent could have been spread from patient to patient in this manner.

Quality of care aggregate data takes many forms, revealing such things as infection rates and unplanned returns to the operating room. Infection rates for example MRSA wound infections per 1000 bed days or per 1000 admissions are commonly computed rates like other rates for example average length of stay, based on discharge statistics data that are accumulated when patients are discharged. At the local level, (eds. Adam & Christina 2009) infection rates from surgical wound infections fed back to practising surgeons can demonstrate results in lowering infection rates.

Other forms quality of care aggregate data on HAIs is the reporting of infections.

A daily report generated by a laboratory-based system is able to give information based around ‘alert’ organisms that have the potential to cause outbreaks, for example the percentage of Staphylococcus aureus that are methicillin resistant and/or the percentage of wound swabs showing S. aureus.

Reporting is generated as recommended by (eds. Adam & Christina 2009) through (i) weekly reports by the Infection Control Nurse (ICN) and sent to the wards, departments and clinicians containing  information on alert organisms and infectious patients including simple graphs that provide rapid feedback on current issues while they are still fresh, (ii) monthly reports sent to all members of the Infection Control Team (ICT) within two or three days of the new calendar month, (iii) quarterly reports that includes recommendations to management and education data on who attends the sessions, and (iv) a comprehensive annual report intended for the board members.

Local data must include ‘details’ of wards and consultants – to establish the ‘ownership’ of the data as well as the competitive element,  needs to be analysed promptly and sent to the ward/clinician as daily and weekly reports.

All of the above are my observations, experiences and readings on infection prevention and control activities and processes in a hospital setting to aggregate data in response to identified user needs. They are by no means complete, in future posts I shall document on latest trends and developments in infection prevention and control activities.

In my next post on JCI Standard MCI.20.1, ME 1 I shall dwell on utilisation review PI activities a hospital is required to meet the JCI) Standard MCI.20.1, ME 1.

References:
Adam, PF & Christina, B (eds.) 2009, Ayliffe’s Control of Healthcare-Associated Infection A practical: handbook, 5th edn, Hodder Arnold, London, UK

Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

Janice, RE, Celia, LH 2012, Nursing in todays world : trends, issues & management, 10th edn, Wolters Kluwer Health | Lippincott Williams & Wilkins, Philadelphia, PA, USA

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