Category Archives: JCI Standards MCI

JCI Standard MCI.2 – Communication with Patients and Families, about care and services and how to access those services

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JCI Standard MCI.2 states clearly that “The organization informs patients and families about its care and services and how to access those services.”, thereby a hospital must meet 3 of its requirements to match this standard.

Let us now see what a hospital must do to live up to the expectations and hopes of sick patients and their families when they get to a hospital.

Organisation ethics requires that a hospital offer to inform patients and their families complete information they wish to know on the care and services at the hospital. Patient and families have a right to reasonable access to care as well as how to access those services. Information provided also includes information on the proposed care for a patient.

This openness and trustworthiness shown by a hospital when it works to build and establish trust and open communication with patients and their families, and when it also trys to understand and protect each patient’s cultural, psychosocial and spiritual values, helps create a bond between patients and their families.

Let’s now see how the Joint Commission International quality standards fits into this picture of openness by a hospital.

By providing all the needed information with the openness of the hospital, awareness and knowledge gained and learnt of the care and services through this openness, trust bonded between patients and their families and the hospital, the hospital easily complies with two of the JCI Standard MCI.2 requirements  namely ME 1 and ME 2.

If the hospital includes information on the proposed care for a patient.in its initial plan to inform patients and their families, then the hospital meets the requirement by the JCI Standard ACC.1.2, ME 2

At the hospital, it is only normal when patients and their families learn of the hospital’s capability to match their expectations of care and services.

When patients and their families learn that their needs fall beyond the scope of  the hospital’s competence, mission and capabilities, then the hospital is obligated to provide information to the patient and their families on alternative sources of care and services. Such alternative sources of care and services may be available at another hospital in the district, and the hospital then co-ordinates with the other hospital with the needed services, and ensures that such patients are appropriately referred to the other facility with services that meets their ongoing care needs.

The hospital will thus comply with the JCI Standard MCI.2 requirement ME3 if the hospital is able to provide information to the patients and their families on alternative sources of care and services when their needs fall beyond the scope of  the hospital’s competence, mission and capabilities.

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

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.