Category Archives: MCI.20

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.”

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A hospital collects and analyses aggregate data to support patient care and its organisation management.

Aggregate data provides a profile of the hospital over time and allows the comparison of the hospital’s performance with other hospitals. Thus, aggregate data are an important part of the hospital’s performance improvement (PI) activities.

PI facilitates desired outcomes by monitoring and evaluating the quality and appropriateness of patient care, measuring both process and outcome and conducting trend analyses, pursuing opportunities to improve patient care, ensuring high-quality care, and developing standards for monitoring quality of care.

Most hospitals are involved in processes of quality improvement. As part of these processes, on-going data are collected regarding outcomes and analysed for problems or opportunities for improvement. When outcomes are known, then addressing areas for possible improvement in outcomes becomes possible. In response to identified user needs, hospitals can understand its current performance by monitoring and evaluating aggregate data through risk management, utility system management, infection prevention and control, and utilisation review and identify opportunities for improvement.

Allow me to take you about the PI activities of risk management, utility system management, infection prevention and control, and utilisation review.  We will look at how a hospital through the PI activities of risk management, utility system management, infection prevention and control, and utilisation review meets 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.”

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Image credit : http://blog.jotmi.org

Risk is defined as the chance of loss. Risk management can be defined as identifying circumstances that put patients or a hospital at risk for adverse outcomes and putting into operation methods that avoid, prevent, and to mitigate (reduce or eliminate) the risks. Hospital adopted risk management when there were many problems in malpractice that caused risk to be a potential problem for hospitals, thus sentinel event monitoring was added to the hospital accreditation process in the mid-1990s.

Risk management is about the focus on an individual case, investigation of the post-event, implementing strategies to address the event, regulatory compliance with legal standard of care, unexpected outcomes which drive the process despite performing all of the regulatory requirements in a timely and competent manner, and been reactive that is relying (Barbara 2011) “on lessons learned from past mistakes, which they apply to the case at hand in order to “defend” the actions of those involved.”

Risk management is about the various strategies to fix problems. Examples of risk management techniques are practice modification (an example of risk management is avoiding the use of a code cart that has not been restocked properly or as for an individual patient, it may be confirming that all the protocols are followed when giving intravenous medications to the patient), insurance transfer, or risk avoidance such as when we eliminate the risk by closing of an obstetrics unit or mental health services or reducing the privileges of a specific provider who may not have the requisite skill to safely perform a specific procedure.

I remember the relatively low numbers of sentinel events reported annually from hospitals that had to report such events, – as it was then and I am sure it is still today,  commonly recognised that there are limitations of a reporting system. However, I am certain that aggregate data collected over the years have proved invaluable toward understanding specific types of hospital based errors. In Malaysia, sentinel events in private hospitals is part of a mandatory incident reporting system in accordance to the ACT 586, Private Healthcare Facilities And Services Act 1998, Private Healthcare Facilities And Services (Private Medical Clinics Or Private Dental Clinics) Regulations 2006, Regulation 13. Ministry of Health Malaysia hospitals are required to follow THE MALAYSIAN INCIDENT REPORTING AND LEARNING SYSTEM, in incident reporting for adverse events with the general objective “To facilitate a learning organisation through the reporting of and learning from adverse incidents, “near misses” and hazards so that a just and safe culture will be nurtured amongst health care providers, in our efforts to enhance the safety of the Malaysian health care system.”, which requires mandatory reporting of specific event types to further foster the sharing of lessons learned. Despite this shared learning, I am sure we still have medical errors occurring in our hospitals and clinics every day.

Health Information Management (HIM) / Medical Records (MR) practitioners need to know that their HIM / MR Department that supplies the raw material (i.e., the medical-record documentation), serves as one of the strongest allies of the risk management activities and risk and quality managers turn to this department regularly for support and services. It is common for routine requests for case review analysis with expedited requests made during times of accreditation surveys and on-site inspections.

The role of this department in identifying adverse events and quality-of-care concerns hospital-acquired conditions (HAC) – examples of HACs are foreign object retained after surgery, air embolism, blood incompatibility, catheter-associated urinary tract infection.

HIM / MR practitioners working in a HIM / MR department may be required to identify these HACs and initiate a report to the risk and quality departments for peer review and quality analysis.  HIM / MR practitioners must also be aware that another early indicator for a potential claim against a hospital is a request for medical records, especially by a lawyer. Medical-records staff should notify their risk management / QA department and the hospital top management upon receipt of such requests.

Readers, I know for a fact I have not been able to cover all aspects of risk management in this post but it is enough to give you a brief overview of what risk management is about and how it affects the HIM / MR practitioner. In a future post, I will expand on discoverability of medical records in medical-malpractice cases that is the written discovery as the first phase of the discovery process in a medical-negligence case, when there is a request to produce documents and tangible items, such as medical records, films, and pathology slides.

As I 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), given the wide issues of concern for the two requirements about JCI Standard MCI.20.1, I shall continue on the other PI activity of infection prevention and control in another post.

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

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

Patient Safety Unit, Medical Care Quality Section, Medical Development Division 2012, INCIDENT REPORTING & LEARNING SYSTEM: “From Information to Action”, Ministry of Health Malaysia, viewed 28 November 2012, <http://hkbatas.moh.gov.my/v2/uploads/UPDATED_INCIDENT_REPORTING_2012_KKM.pdf>

Private Healthcare Facilities And Services Act 1998, Private Healthcare Facilities And Services (Private Medical Clinics Or Private Dental Clinics) Regulations 2006, viewed 28 November 2012, <http://www.mma.org.my/Portals/0/pdf/prv_health_fac.pdf>

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Wager, KA, Frances, WL & John PG 2005, Managing health care information systems : a practical approach for health care executives,1st edn, Jossey-Bass A Wiley Imprint, San Francisco, CA, USA

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

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Health data collection at hospitals is a responsibility of the health information department and  performed by Health Information Management (HIM) / Medical Records (MR) practitioners. It is common for hospitals to generate monthly and annual reports that describe the number of patients treated and the types of services delivered. The data to generate the monthly and annual reports are typically based on patient data relating to a single patient, such as his/her diagnosis, name, age, earlier medical history etc. from a single patient-health care worker interaction.

For instance, when a patient visits a hospital, a variety of details may be recorded, such as the patient’s temperature, their weight, and various blood tests. Should this patient be diagnosed as having “Vitamin B 12 deficiency anaemia, unspecified”, HIM/MR practitioners are all too familiar to code the diagnosis as corresponding to ICD-10 code D51.9, this particular interaction might eventually get recorded as an instance of “Anaemia” in an aggregate based system, that is reported in the monthly morbidity report, for example.

Patient based data is important when you want to track longitudinally i.e concerned with the development of patients over time. For example, if we want to track how a patient is adhering to and responding to the process of TB treatment in Malaysia (typically taking place over 6-9 months), we would need patient based data.

Aggregated data differs from patient based data.

It is the consolidation of data relating to multiple patients, and therefore cannot be traced back to a specific patient. They are merely counts, such as incidences of Malaria, TB, or other diseases. Typically, the routine data that a hospital deals with is this kind of aggregated statistics, and is used for the generation of routine reports and indicators, and most importantly, strategic planning within the health system. Aggregate data cannot provide the type of detailed information which patient level data can, but is crucial for planning and guidance of the performance of health systems.

HIM/MR practitioners know very well that patient data is highly confidential and therefore must be protected so that no one other than doctors can get it. For HIM/MR practitioners who continue to work with paper-based medical records, they are very aware that it must be properly stored in a secure place. For HIM/MR practitioners who choose to work with computers (EMRs/EHRs), they are aware that patient data needs secure systems with passwords and restrained access.

With the kind of introduction above laid out before you, I am going to write about the Joint Commission International (JCI) Standard MCI.20.1 which states that “The organization has a process to aggregate data and has determined which data and information are to be regularly aggregated to meet the needs of clinical and managerial staff in the organization and agencies outside the organization.”

JCI Standard MCI.201. has specific requirements.

The first requirement for JCI Standard MCI.20.1 is to ensure that hospitals as “The organization has a process to aggregate data in response to identified user needs.”

The second requirement is when the hospital as “The organization provides needed data to agencies outside the organization.”

Given the wide issues of concern for the above two requirements  I shall not rush to complete writing about JCI Standard MCI.20.1 for the sake of publishing on the web in a hurry while compromising the quality of the posts.

I like to say once again that what I am blogging about in posts like this one is simply a collection of my experiences and working knowledge accrued over the long years. I hope the posts I bring you in this blog convey best practices in HIM/MR which I hope young HIM/MR practitioners can learn to improve and the senior ones to compare, re-learn and adapt to bring HIM/MR practices to a higher level.

However, I am not implying what I am blogging here is all the gospel truth about standards to maintain or processes and procedures which need to be followed, as what I have written about are not carved in stone.

I ask you as the reader to make meaningful comments on posts I bring. I wish to continue to learn in the process and grow.

I shall post about the first requirement of the two requirements for this standard in my next post for this standard.

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

JCI Standard MCI.20 – Aggregate data and information must support the quality management program of a hospital

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The post JCI Standard MCI.20 – Aggregate data and information support patient care, organisation management, and the quality management program (this link will open in a new tab of your current browser window) supported how aggregate data and information support patient care and organisation management. This post will continue where I left off from there, and now discuss further on the Joint Commission International (JCI) Standard MCI.20 which requires that aggregate data (based on performance, utilisation, and resource management) and information also support the quality management program of a hospital.

But before I change to higher gears and bring you coverage of activities on the quality management program of a hospital, I am sure Health Information Management (HIM) / Medical Records (MR) practitioners following this blog will be wondering if they can skip this post as they might postulate that quality management programs have nothing to do with HIM/MR management. I think HIM/MR practitioner readers need to hold on and read on as they have a role to play in the quality management program of a hospital.

To be honest there is so much to write about this area of concern but I think I shall restrain myself to be brief but as complete as possible. I shall relate the role of HIM/MR practitioners play where I think they need to.

During their formative training, HIM/MR practitioners may become aware that some licensed professionals or hospital staff are involved in utilisation review, quality improvement, utility system management, infection prevention and control, and risk management activities; but I am think only few are aware of the rich scientific base and health tradition that frames these fields. Let’s understand these activities first.

Utilisation management (UM) or Utility System Management (USM) activities directly impact the quality of outcomes through the most efficient and effective manner of delivering health care for the patient and the population. A mix of clinical, administrative, and financial methods are used to evaluate the appropriateness, the processes, the facilities, and the providers of care.

The UM process includes interventions that take place before, during, and after a clinical event occurs. Data for this process must be accurate, timely, relevant, and easily collectible at a reasonable cost. Defensible administrative or clinical types of data that have been validated are used when evaluating performance for UM. HIM/MR practitioners can anticipate that clinical data in medical records will be used in the design and data collection for UM studies.

My experiences in measuring and improving hospital quality provides insights that quality improvement is an important challenge in any attempt to improve the health care system. The Agency for Healthcare Research and Quality (AHRQ) describes quality improvement (QI) as “doing the right thing at the right time for the right individual to get the best possible results.” Continuous Quality Improvement (CQI) is a tool that can be used to respond to identified problems, prevent problems, and improve upon the status quo. Total Quality Management (TQM) on the other hand is a management philosophy that emphasises a commitment to excellence throughout the organisation; implemented in combination with CQI.

Information management involving HIM/MR practitioners enables hospitals to support patient safety improvement efforts by providing accurate and complete data. HIM/MR practitioners must be able to identify data elements for use in quality and patient safety measures and ensure these measures are being reported correctly and resolve any issues that may exist with data consistency and completeness. HIM/MR  practitioners should also identify opportunities to participate in standards development or reviews at the hospital and provide reviews and comments on new and revised standards and quality and patient safety measures.

A nurse administered the wrong medication to a patient. A visitor slips and falls on a wet floor, even though the wet floor was well-marked. The wrong medication to a patient is a medical error, while when the visitor slipped and fell on a wet floor, is an accident that results in personal injury. Medical error or an accident that results in personal injury or loss of property are all circumstances that put patients, visitors or a hospital at risk for adverse outcomes. Incident reports are generated on patients and visitors about a potentially compensable event (PCE).

Risk management is about identifying circumstances that put patients, visitors or a hospital at risk, been responsible for coordinating and monitoring risk management activities, analysing trends of incidents, and establishing priorities for dealing with high-risk areas, and putting into operation methods that avoid, prevent, and control such risks. The goal is to ensure patient safety.

HIM/MR practitioners need to know that incident reports are considered a secondary source of patient information. They must ensure that incident reports are never filed in the patient’s medical record, so that incident reports are not subject to disclosure (release) when patient records are subpoenaed or requested (e.g., by an attorney) upon patient authorisation. Incident reports are filed with the hospital’s risk management office or the quality assurance department.

The infection prevention and control process is designed to lower the risk of infection for patients not present on admission, staff, and others. To reach this goal and minimise their overwhelming consequences in terms of cost, morbidity, and mortality, a hospital proactively identifies and track risks, rates, and trends in health care–associated infections (HAI).

A hospital uses measurement information to improve infection prevention and control activities and to reduce HAI rates to the lowest possible levels through consistent, mindful adherence to basic infection control principles and measures which include for example, hand decontamination upon entering and leaving every patient encounter – usually referred to as universal precautions, a critical protective strategy.

A review of 20 medical records for patients who received a overmedication for a particular drug is likely to yield a much higher incidence of overmedication for the particular drug than a random sample of 20 medical records. A more thorough review of the medical records gathers information to help develop a collective picture of a practice that can identify the outlier or unusual event (in this case overmedication for a particular drug) during a particular procedure/process (in this case medication for a particular drug). Screening medical records in this way for the presence of adverse events is a tool for data acquisition for a morbidity and mortality committee to identify contributory factors, which indicate areas for improvement and prevention.

Much of the discussion above is an important part of the hospital’s performance improvement activities with the intent to gather and aggregate data that can be used to create safety alerts and tips, to identify and showcase best practices, and to highlight trends. Aggregate data and information must be seen to support the quality management program of a hospital in order to comply with JCI Standard MCI.20, ME 3, and if in any case help the hospital understand its current performance and identify opportunities for improvement.

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

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

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

JCI Standard MCI.20 – Aggregate data and information support patient care, organisation management, and the quality management program

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Hospitals seeking accreditation status or planning for an accreditation re-survey process for example, accreditation status from the Joint Commission International (JCI), must ensure that their aggregate data and information supports patient care, organisation management, and their hospital quality management program.

Image credit : A representation of data found @ http://www.celframe.com/blogs/ by Jer Thorp, a data artist

Health Information Management (HIM) / Medical Records (MR) practitioners and their HIM/MR department in hospitals are responsible for aggregate data based on performance and utilisation by collecting, retrieving, compiling, calculating, analysing, and reporting descriptive health care statistics regarding for example admission, discharge, and length of stay of patients which are used internally by hospitals to describe the types and numbers of patients treated, that is patient-centric data which is directly related to the patient population treated.

The primary purpose of collecting patient-centric data is to provide factual numerical information using automated computer systems or manually.

HIM/MR practitioners play a vital role in collecting and verifying patient-centric data and are responsible for monitoring operations and overseeing the processes at their hospital which generate the patient-centric data. HIM/MR practitioners must accept that their role is most important as hospital statistics provide a benchmark upon which decisions are made to operate and manage the hospital.

The factual numerical information is used for clinical and management decisions making by summarising them into descriptive statistics.  Descriptive statistics summarise a set of data from the descriptive health care statistics and prepared into various presentation techniques and tools (e.g., bar graphs, pie charts, line diagrams, and so on) which help give meaning to statistics. In addition to reporting the number of patients treated, HIM/MR departments will also calculate rates and percentages of deaths, autopsies, infections, and so on.

Ongoing aggregate data and information related processes based on performance and utilisation that support patient care in a hospital, will meet the requirement of the JCI Standard MCI.20, ME 1.

It is common for hospitals to generate monthly and annual reports that describe the number of patients treated and the types of services delivered. This transformed-based data are used to prepare for example an annual report for the board of directors.  This report is used to make decisions that impact hospital operations and planning. Aggregate data and information used in this way to support organisation management, meets the requirement of the JCI Standard MCI.20, ME 2.

I shall end this post here and continue more on the JCI Standard MCI.20 in another post. I think the aspect of data quality is most important and deserves another post.

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

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA