Category Archives: JCI Standards PFE

JCI Standard MCI.4 – accuracy and timeliness of information in the hospital through effective communication

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My intention in bringing this post to a Health Information Management (HIM) / Medical Records (MR) practitioners reader specifically and to all other readers in general, is to understand the dynamics of communication and your role in managing patient-specific information in a hospital setting when the leaders of the hospital agree to an essential condition  whereby effective communication must prevail among and between professional groups; structural units, such as departments; between professional and non-professional groups; between health professionals and management; between health professionals and families; and with outside organisations.

In making this agreement for effective communication throughout the hospital setting, I agree the stipulations that this issue is primarily a leadership function of the hospital’s leaders. This agreement is stipulated in the Joint Commission International (JCI) Standard MCI.4 which states that “Communication is effective throughout the organization”, especially so if you are practising in a hospital accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

The reader as a leader of a structural unit setting and relevant service needs to be aware of the following conditions in this agreement for effective communication:

  1. for patient care to appear seamless, processes must be in place for communicating relevant information in an accurate and timely manner throughout one’s structural unit, such as the HIM / MR department and between other structural units in the hospital; this is to ensure that the processes are designed and implemented to support continuity and coordination of care as patients move through the hospital from admission to discharge or transfer, several departments and services and many different health care practitioners may be involved in providing care; for example from emergency services to inpatient admission
  2. the hospital defines the patient-specific information, example patient’s weight and other physiological information available from the medical record, required for an effective review process and is facilitated by a record (profile) i.e via medication administration records (MAR) or medication list, also to be found within a medical record for all medication administered to a patient except emergency medications and those administered as part of a procedure; the medical record folder is updated after a review of a patient receiving medications, example the folder is tagged with an alert sticker for allergies or sensitivity; this review also facilitates the medication reconciliation process across the continuum of care and the process continues upon discharge and transfer of the patient, and the complete list of patient medications is shared with the next provider of patient care
  3. effective communication occurs in the hospital among the hospital’s programs ranging from the emergency services, inpatient admission, diagnostic services and treatment services, surgical and non-surgical treatment services and outpatient care programs for seamless care
  4. since patients frequently require follow-up care to meet on-going health needs or to achieve their health goals, there is a plan by the hospital’s leaders with the leaders of other health care organisations in its community for effective communication to occur between the leaders of these other health care organisations in its community during referrals; the plan establishes contact with known resources i.e. the patient’s home community and identified specific individuals and agencies that are most associated with the hospital’s services and patient population in order that they help support continuing health promotion and disease prevention education
  5. there are policies and procedures developed to support and to promote patient and family participation in care processes to ensure that continuity and coordination are evident to the patient; effective communication thus occurs with patients and families in these circumstances:
    1. patients and families are involved in care decisions by effective communication thus occurs with patients and families when (i) they understand how and when they will be told of planned care and treatment(s), (ii) understand their right to participate in care decisions to the extent they wish and learn about how to participate in care decisions
    2. inpatients and outpatients who leave against medical advice when patients, or those making decisions on their behalf, may decide not to proceed with the planned care or treatment or to continue care or treatment after it has been initiated guided by a process for the management and follow-up of such cases
    3. effective communication thus occurs with patients and families when those who provide education encourage patients and their families to ask questions and to speak up as active participants
    4. effective communication occurs with patients and families when indicated, planning for referral and/or discharge begins early in the care process ie. soon after admission as inpatients and, when appropriate, includes the family
    5. effective communication occurs with patients and families when patients are reassessed to plan for continued treatment or discharge
    6. effective communication occurs with patients and families such that symptoms and complications are prevented to the extent reasonably possible during the care of the dying patient
  6. and finally. the reader as a leader must not only set the parameters of effective communication but also serve as role models with effective communication of the hospital’s mission and appropriate policies, plans, and goals to all staff.

I acknowledge the role of effective communication and its pervasiveness in creating, gathering and sharing health information in meeting challenges and improving health care outcomes. In this post, I think I have achieved to address some pertinent issues relevant to effective communication when implementing the requirements of the JCI Standard MCI.4 specifically and also delving into the issues of effective communication in general.

References:

  1. Dale, EB & Daena, JG (eds.) 2009, Communicating to manage health and illness, Routledge, London, UK
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
  4. Sheila, P & Sandra, H (eds.) 2007, Health communication Theory and practice, Open University Press, McGraw-Hill Education, England, UK

The assessment findings from patient’s and family’s ability to learn and willingness to learn are documented in the patient’s record

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A patient education plan should be among the contents of a medical record. Health Information Management (HIM) / Medical Records (MR) practitioners need to know that assessment findings of patients and their family of their knowledge and skill strengths and deficits documented in the patient’s medical records, are used to plan the education.

I think HIM/MR practitioners also need to know and understand why this documentation forms part of a medical record.

HIM/MR practitioners must understand  that patient and family education is an integral part of patient care. Caregivers at a hospital must assist the patient to identify the learning needs and resources to help restore and maintain an optimal level of functioning. A knowledge deficit about the course of illness and self-care practices hinders a patient’s recovering from illness or engaging in health-promoting behaviors.

To help bridge the gap between what a patient knows and what a patient needs to know in order to achieve optimum health, a plan must be formulated to determine if the patient and family are willing and capable to learn. The patient and family ability to learn and willingness to learn are then assessed

Thus, the HIM/MR practitioners will find documentation of the assessment findings based on many patient variables that determine if the patient and family are willing and capable to learn. Therefore, to plan the education, the hospital assesses:

  1. the patient’s and family’s beliefs and values since different people attach different values to different types of risk. and patients of different cultures react to illness with their own ingrained broader health belief systems encompassing just about everything seen, heard or felt since their birth; this is especially so as the world becomes borderless and with the new wave of medical tourists searching for the cutting-edge medical expertise and technology, it is common in hospital settings to receive an increasing number of incoming medical tourism patients and immigrant patients from various ethnic and cultural backgrounds
  2. their literacy, educational level, and language as health care teaching involves the use of printed materials, involves reading, comprehension, basic mathematical abilities, and the ability to make health care decisions
  3. emotional barriers – anxiety, fear, anger, depression and inability to comprehend and motivations – frequent reinforcement of learning through immediate feedback and continual reassessment of effectiveness enhances the value of the learning
  4. physical limitations – affecting learning that involves physical application of knowledge for example when a patient learns to give himself or herself an injection, and cognitive limitations – affecting learning that involves the acquisition of facts and data often used in problem solving and decision-making
  5. the patient’s willingness to receive information

HIM/MR practitioners working in a hospital setting that has acquired the Joint Commission International (JCI) accreditation status or is planning to be accredited or been re-surveyed by JCI, must know that JCI mandates that medical records should contain documentation on patient teaching and learning. The JCI Standard PFE.2.1 requires that “The patient’s and family’s ability to learn and willingness to learn are assessed.” and also requires that “The assessment findings are documented in the patient’s record.”

However, HIM/MR practitioners need to realise that patient education is a standard and essential component of medical and nursing practice, teaching interventions and the patient’s response must be documented in all practice settings. Elements of a patient education plan include:

  1. content taught
  2. teaching methods used
  3. who was taught (e.g., patient, which family member, other caretaker)
  4. patient and family response to teaching activities

One approach of documentation for patient and family teaching is by using codes that helps nurses, doctors and other health care providers to document and track patient education in a Patient and Family Education Record. Nurses, doctors and other health care providers make an assessment of need, provide education and then document the encounter using codes found in the form. The codes allow the educator a quick method of documenting that education took place during a given patient visit or stay. The form informs everyone using the form that a given patient received education on specific topics and encourage subsequent health professionals to do the appropriate follow-up.

Click here (this link opens in a new tab of your current window browser) for an example of a Patient and Family Education Record.

Such documentation promotes (Sue and Patricia, 201) continuity of care and facilitates accurate communication to other health care providers.

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

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

University of Connecticut Health Center USA, PATIENT AND FAMILY TEACHING RECORD – Family Education of the Hospitalized Infant, viewed 12 September 2012 <http://nursing.uchc.edu/unit_manuals/ccmc_nicu/FORMS/FORM%20-%20Family%20Education%20of%20the%20Hospitalized%20Infant%20(9-1-11).pdf>

Medical records should contain the patient’s educational needs assessment documentation

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The Seven Dimensions of Patient-Centered Care described by the Picker Institute Inc., an international non-profit organisation dedicated to advancing the principles of patient-centered care through education, research and the public recognition of best practices,  provide an excellent starting point for any hospital to begin a customer focused improvement effort. These dimensions of care can be viewed from the image below.

Image credit : http://pickerinstitute.org/about/picker-principles/

I shall focus my discussion of this post with reference to two (2) out of these 7 dimensions, namely (i) involving information, communication and education and (ii) the involvement of family and friends.

As consumers (patients) or as member(s) of the patient’s family, many readers are already acquainted with the situation when you as the patient or as member(s) of the patient’s family believe that information is often being withheld from you or your family and that they are not being completely informed about their condition or prognosis. The patient or  as member(s) of the patient’s family often experience anxiety over clinical status, treatment and prognosis, the impact of the illness on themselves and family, and the financial impact of illness.

Many readers will also be already acquainted with the situation when you as the patient will address the role of your family and friends with your hospital experience, often expressing concern about the impact your illness has on your family and friends.

In recognition of the needs of family and friends and the involvement of family and friends, a hospital and its doctors, nurses and other caregivers must accommodate family and friends on whom the patient relies for social and emotional support, and also give support for family members as caregivers as well as to support the patient “advocate’s” role in decision-making of the care process.

Image credit : http://fibrocarecenter.com/

It is only appropriate that  any hospital dedicated to advancing the principles of patient-centered care through education provides patient/family education to enhance the patient/family knowledge, skills, and behaviours s/he needs to restore quality of life and make informed health care decisions.

Patient/family education is initiated at the time of admission and, as needed, throughout the patient’s stay at the hospital.

Education by the hospital staff is provided to patients and families when a patient or family directly participates in providing care (for example, changing dressings, feeding the patient, administering medications and treatments), they need to be educated.

Education focuses on the specific knowledge and skills the patient and family will need to make care decisions, participate in their care, and continue care at home. This is in contrast to the general flow of information between staff and the patient that is informative but not of an educational nature.

But in order to understand the educational needs of each patient and his or her family, assessments are done to evaluate if:

  1. the patient mutually meets established goals and objective
  2. ihe patient’s attitudes has changed
  3. the patient can cope better with illness imposed limitations
  4. identify the types of surgeries, other invasive procedures and treatments planned and if the patient understands the accompanying nursing needs
  5. the family understand health problems and know how to help
  6. the patient and family understand and can demonstrate skills the continuing care needs following discharge

This assessment permits the patient’s care givers to plan and to deliver the needed education. Once the educational needs are identified, they are recorded uniformly by all staff in the patient’s medical record. This helps all the patient’s caregivers participate in the education process.

Education is also provided as part of the process of obtaining informed consent for treatment (for example, for surgery and anaesthesia) when patients and families learn about the process for granting informed consent.

Overall, education by the hospital staff makes patients and families learn:

  1. about how to participate in care decisions
  2. about their conditions and any confirmed diagnoses
  3. their rights to participate in the care process

At hospitals that are Joint Commission International (JCI) accredited or seeking JCI accreditation status or re-applying for JCI accreditation status, they are required to comply with the JCI Standard PFE.2 which requires that each patient’s educational needs are assessed prior to providing the appropriate levels of education.

The JCI Standard PFE.2 also requires that a patient’s medical records should contain the patient’s educational needs assessment documentation. Such documentation includes the following:

  1. assessment and identification of educational needs
  2. the patient’s ability to learn/understand the information
  3. teaching interventions to meet identified needs
  4. the patient/family understanding of the instruction or education provided

Documentation of patient/family education could be located on a special form, for example a Multidisciplinary Education Form/ Patient Education Sheet or in progress notes.

I think it is appropriate that Health Information Management (HIM) / Medical Records (MR) practitioners should give comments when a hospital reviews, plans and decides the location and format for educational assessment, planning, and delivery of information in the patient’s medical record.

The JCI Standard PFE.2 is listed in the Medical Records Review Tool form to check for compliance against this standard during a Medical Records Review process.

References :
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

Picker Institute, Principles Of Patient-Centered Care, viewed 9 September 2012, <http://pickerinstitute.org/about/picker-principles/>

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA