Category Archives: JCI Standards QPS

Making comparisons via data analysis for improvement efforts

Posted on by
Reply

The hospital you work at will have many data-driven processes in place to assess ways to improve patient care. Data is collected and analysed, data analysed is usually used to evaluate its current performance and also to be able to compare your hospital’s performance with other similar hospitals, all of which is to find the opportunity to improve in four ways:

  1. analysis of its past historical data with itself over time , such as month to month, or one year to the next or last year’s value to the current year, or a time series of several years, provides an initial baseline for examining trends and allows judgment on the direction of the measure;
  2. making competitor and industry comparisons what other similar hospitals are achieving provides crude guidelines. Competitor and industry comparisons has direct bearing on the hospital’s profitability, especially the privately owned hospital;
  3. (a) with standards, such as those set by accrediting and professional bodies such as through reference databases collected and analysed from data on hospital performance frequently made available through publicly available hospital quality comparison Web sites aimed at patients for example, data that can be viewed from Hospital Compare from the Centers for Medicare and Medicaid Services, Quality Check from the Joint Commission on Accreditation of Healthcare Organizations and the Leapfrog Group’s Hospital Quality and Safety Survey Results; comparing standards set for example by the Joint Commission International (JCI) also enables a hospital to improve its desirable practices; also, (b) it is common knowledge that hospitals are legally responsible for ensuring the quality of medical care; as healthcare practitioners we are aware that the hospital management of a public hospital or in the case of a private hospital – the hospital board, is responsible for exercising the duty of care based on those set by laws or regulations – for example the legal requirement of the Private Healthcare Facilities And Services (Private Medical Clinics Or Private Dental Clinics) Regulations 2006, Private Healthcare Facilities And Services Act 1998 in Malaysia, on behalf of the patients and the community and on behalf of doctors who desire to participate, and the hospital as a whole is liable for damages should they fail.; and
  4. with recognised desirable practices identified in the literature as best or better practices or practice guidelines, for example in determining the success or failure of medical audit assessment by monitoring actual or suspected problems through (i) sentinel cases, (ii) criterion-based audit, (iii) comparison of small groups in the same field applicable at local hospital levels, (iv) conducting surveys like patient satisfaction surveys, and (v) peer review.

These comparisons help the hospital understand the source and nature of undesirable change and help focus improvement efforts that can be achieved through re-education, retraining, facilitation in small groups, or by more active persuasion.

If your hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then it must be able to show evidence that it has a process or processes that incorporates data analysis measures to make relevant comparisons (i) over time within the hospital, (ii) with similar hospitals when possible, (iii) with standards when appropriate , and (iv) with known desirable practices, in order to satisfy the JCI QPS.4.2 Standard which states that “The analysis process includes comparisons internally, with other organizations when available, and with scientific standards and desirable practices.

How do Health Information Management (HIM) / Medical Records (MR) practitioners fit into this JCI Standard?

I can think of two ways as I come to the end of  this post.

In my opinion, HIM /MR practitioners must facilitate diagnostic excellence from rapid communication of patients’ current needs and understanding of the clinically indicated responses by ensuring that recording is made faster and more complete in medical records , include safeguards to improve accuracy, and speed transmission of patient-related information. For example, the penalty for incomplete medical records (usually a temporary loss of privileges) is quickly and routinely applied. A word of caution though about imposing the penalty. As we are fully aware, reality, however, does not always match with what is desired since I believe many doctors still enjoy the  part of their job which is talking to their patients and in this context, medical records tends to assume lesser importance. I think it is also not desirable to have a culture among doctors to be obsessive record writers who ‘spent all the time writing and didn’t even look at me’, a common complaint among patients.

HIM /MR practitioners must also exercise caution in the retrieval of medical records of the sample of patients designated as appropriate for example,a medical records audit. For example, the retrieval of medical record through diagnostic coding for Myocardial Infarction (MI) cases, after a patient’s discharge, may not enable the retrieval of a record of a patient who had a dissecting aneurysm of the aorta mismanaged as an MI for the first 12 hours of his/her care

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

Kenneth RW, and John RG 2010, The well-managed healthcare organization, 7th edn, Health Administration Press, Chicago, Illinois, USA

Srinivasan, AV 2008, Managing a modern hospital, 2nd edn, Response Books, SAGE, New Delhi, India

The frequency of data analysis

Posted on by
Reply

A Health Information Management (HIM) / Medical Records (MR) practitioner at any HIM / MR department in any hospital knows pretty well how often his or her hospital has determined how often different sets of clinical and administrative data that are collected during or in the time closely surrounding the patient encounter, are aggregated and analysed at his or her department or in other relevant departments. Patient records, uniform billing information, and discharge data sets are the main sources of the data that go into the literally hundreds of aggregate reports or queries that are developed and used by care providers and executives in hospitals. The frequency depends on the activity or area being measured, the frequency of measurement, and the hospital’s priorities.

What can these data then tell you about the hospital and the care provided to its patients?

How can you process these data into meaningful information?

The number of aggregate reports that could be developed from patient records or other patient related information – example accounting information, is practically as you already know is limitless.

Data quality management programs are essential for clinical improvement. Thus, HIM / MR practitioners must realise there is a need for the continuous quality improvement to ensure the accuracy and completeness of data collection at their end.  HIM / MR practitioners frequently generate reports that yield data from their data collection. Such reports can then be used to help monitor patient outcomes and identify areas in which improved care is needed. However,  HIM / MR practitioners need to regularly run and act upon them to improve areas of missing or incomplete data. They must also ensure that standard operating procedures in data management processes are in place, remedy inconsistent data collection methods, or minimise missing paper records. So I guess that more training and onsite audits could help facilitate additional improvement in data quality and efficiency.

In the post Data must be aggregated, analysed, and transformed into useful information by expert individuals (this link will open in a new tab of your current browser window), I had outlined the importance of data analysis that must involve individuals who understand information management, have skills in data aggregation methods, and know how to use various statistical tools.

HIM / MR practitioners must ensure that data collection up-to-date (data currency) and must be able to relate the frequency of data analysis (timeliness) appropriate to a process under study and develop processes that match frequency of data analysis to meet the hospital’s requirements.

The categories of statistics that are routinely gathered by  HIM / MR practitioners in a hospital for data analysis include:

  1. Census statistics including the average daily census and bed occupancy rates from data collected in wards to reveal the number of patients present at any one time in a hospital.
  2. Discharge statistics like average length of stay, death rates, autopsy rates, infection rates, and consultation rates calculated from data accumulated when patients are discharged.

HIM / MR practitioners also participate in generating quality reports which may be used for the purpose of improving customer service, quality of patient care, or overall operational efficiency. Examples of aggregate data that relate to quality reports include:

  1. customer service – the average time it takes to get an appointment at a clinic and the average referral volume by the doctor
  2. quality of patient care -clinical laboratory quality control data may be analyzed weekly to meet local regulations, and patient fall data may be analyzed monthly if falls are infrequent, infection rates, unplanned returns to the operating room
  3. overall operational efficiency – cost per case, average reimbursement by Diagnosis Related Groups (DRG), and staffing levels by patient acuity

HIM / MR practitioners in a hospital routinely gather such data to produce easy-to-use ad hoc statistical reports and trend analyses reporting that is available with the hospital’s databases which gives them access to any number of summary reports based on the data elements collected during the patient encounter. Such statistics are frequently used to describe the characteristics of the patients within a hospital and also provide a basis for planning and monitoring patient services.

Here are some examples I can think of when a hospital determines how often data are aggregated and analysed, the frequency depending on the activity or area being measured, the frequency of measurement, and the hospital’s priorities.

The patient census application is needed daily to provide sufficient day-to-day operations staffing, such as nursing and food service. However, annual or monthly patient census data are needed for the facility’s strategic planning.

Hospital management often wants to know summary information about particular diseases or treatment from the disease and procedure index function generally handled as a component of the patient medical record system or the registration and discharge system. Examples of questions that might be asked are: What is the most common diagnosis in the hospital? What percentage of diabetes patients are of a particular ethic group? What is the most common procedure performed on patients admitted with gastritis (or heart attack or any other diagnosis)? Here the process under study is related to the frequency of data analysis of diseases and procedures and the retrieval of information is based on the International Classification of Diseases (ICD) and procedure codes that are collected and entered into discharge system on a daily frequency by  HIM / MR practitioners. Such summary information to meet the hospital’s internal requirements could be required for example on an ad hoc basis or daily or weekly or monthly period – which is the frequency of data analysis.

Another type of aggregate information that can be created on an ad hoc basis are register lists that generally contain the names, and sometimes other identifying information, of patients seen in a particular area of the hospital, for example numbers of patients seen in the emergency department or operating room.

Specialised trauma and tumor registries found in hospitals with high-level trauma or cancer centers are used to track information about patients over time and to collect detailed information for research purposes.

If your hospital is at the point of then what I have tried to bring in this post when (JCI, 2010 p. ) “the aggregation of data at points in time enables a hospital to judge a particular process’s stability or a particular outcome’s predictability in relation to expectations”, is truly relevant to the Joint Commission International (JCI) Standard QPS.4.1 which states that “The frequency of data analysis is appropriate to the process being studied and meets organization requirements.” if your hospital had acquired JCI accreditation status or one that is seeking JCI accreditation status.

Nevertheless, regardless of the type of hospital you work at,  HIM / MR practitioners must perform the frequency of data analysis appropriate to the process being studied and ensure that the data analysis meets their hospital’s requirements.

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

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

Data must be aggregated, analysed, and transformed into useful information by expert individuals

Posted on by
1

A hospital’s primary purpose is to provide patient care and to work to improve patient care outcomes over time by applying quality improvement principles. To reach conclusions and to make decisions on how to work to improve patient care outcomes over time, requires access to a wide range of information from varying sources.

Each time patients receive health care, a record is generated to document the patient’s current symptoms,medical history, results of examination, treatments rendered along with outcomes, ancillary report results (e.g., laboratory), diagnoses, and plans for treatment. This patient data is organised, analysed, and maintained by Health Information Management (HIM) / Medical Records (MR) practitioners working in hospital settings to ensure the delivery of quality health care.

Data collection and analysis processes entail combining patient care data from various sources and transformed into useful information.  But the ability to collect and analyse data within and across hospitals is hampered by different information systems and processes, and by the highly complex and fragmented nature of health care systems.

Converting data into meaningful information for decision making calls for the expertise of trained and qualified professionals. The data analysis process involves individuals who will be among medical, nursing, and other departmental heads who participate in relevant quality improvement and patient safety processes. These indivuals must understand information management, have skills in data aggregation methods, and know how to use various statistical tools and techniques when suitable, and participate in the process.

Understanding statistical techniques is helpful in data analysis, especially in interpreting variation and deciding where improvement needs to occur. Every system has variation; some of this is due to the system itself, known as common cause variation; some of it is due to singular incidents or special situations; this is special cause variation. 94 percent of problems (or possibilities for improvement) lie with the system as common-cause variation; 6 percent are special causes (Deming, 1982). In understanding trends and variation in health care, statistical tools for example run charts, control charts, histograms, and Pareto charts can prove to be useful statistical tools to know. Examining data over a period of time and making decisions based on trends or other patterns, will save time, energy, and other resources.

HIM/MR practitioners are trained in managing patient health information and medical records, administering computer information systems, and coding diagnoses and procedures for health care services provided to patients, and have an understanding of statistical techniques as part of their training and education.  I believe their unique knowledge and expertise in hospital management information systems will enable strong partnerships beween them and with clinical and management teams to advance the quality and safety of patient care delivery.

Image credit : http://www.dashboardinsight.com/

Data analysis must provide continuous feedback of quality management information to help those individuals make decisions and providing continuous quality improvement, and allocating limited resources to optimise quality and effectiveness. Thus, results of data analysis need to be reported to those individuals responsible for the process or outcome being measured  and who are accountable for taking action of the results.

Hospitals which have adopted the Joint Commission International (JCI) hospital accreditation program, and who are already JCI acredited or hospitals seeking JCI accreditation status or hospitals that are seeking for a re-survey for JCI accreditation status, have to comply with JCI Standard QPS.4, which specifically requires that individuals in  a hospital with appropriate experience, knowledge, and skills systematically aggregate and analyze data using statistical tools and techniques when suitable and transform the data into useful information. This standard also requires that  “Results of analysis are reported to those accountable for taking action.”

It is imperative from the above that HIM/MR practitioners practicing in hosptitals with a quality improvement and patient safety program such as hospital accreditation are likely individuals who will be among medical, nursing, and other departmental heads who participate in relevant quality improvement and patient safety processes. HIM/MR practitioners as trained individuals to understand healthcare information management, have skills in data aggregation methods, and know how to use various statistical tools and techniques, and thus I believe they will be best suited for this role.

References :
American Health Information Management Association (AHIMA) 2011, HIM Functions in Healthcare Quality and Patient Safety, Viewed 15 September 2012 < http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049122.hcsp?dDocName=bok1_049122>

Deming, WE 1982, Out of the Crisis, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA

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

Plan of posts on Quality Improvement and Patient Safety (QPS) standards

Posted on by
Reply

I first introduced an approach to make real improvements that help patients and reduce risks through international accreditation standards in my post An overview of quality indicators under the JCI QPS approach (this link will open in a new tab of your current browser window).

In that post I prepared the ground for future posts on patient safety in the accreditation process of the Joint Commission International  (JCI) from the chapter “Quality Improvement and Patient Safety (QPS)”. In promoting the quality agenda in hospitals, this QPS chapter from the  JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 4TH EDITION manual describes a comprehensive approach to quality improvement and patient safety.

In this post, I shall present my plan to discuss how best I think Health Information Management (HIM) / Medical Records (MR) practitioners can contribute and benefit by applying the QPS standards to their daily work to understand how processes can be more efficient, resources can be used more wisely, and physical risks can be reduced.

The QPS chapter presents the standards into five (5) sections (as I shall refer the layout of the standards from this chapter ) of standards as follows :

  1. Section 1 : Leadership and Planning
  2. Section 2 : Design of Clinical and Managerial Processes
  3. Section 3 : Measure Selection and Data Collection (Data Collection for Quality Measurement)
  4. Section 4 : Validation and Analysis of Measurement Data (Analysis of Measurement Data)
  5. Section 5 : Gaining and Sustaining Improvement (Improvement)

Section 1 is about hospital management (leaders) collaboration to carry out a quality improvement and patient safety program.

Design of new and modified systems and processes according to quality improvement principles is covered in standards from Section 2.

Selection and data collection of key measures for each of the hospital’s clinical and managerial structures, processes, and outcomes are requirements for standards under Section 3.

Section 4 has several standards that outlines what, when, who and how on validation and analysis stages of data collected from identified key measures in Section 3.

Knowledge gained from data analysis of Section 4 is gainfully used (acheieved) to identify potential improvements or to reduce (or prevent) adverse events and sustained through an ongoing program of risk management. Data collected is also used to identify improvement and safety activities for the priority areas identified. An ongoing program of risk management is used to identify and to reduce unanticipated adverse events and other safety risks to patients and staff. These are improvement and safety activities covered under the standards from Section 5.

I believe that HIM/MR practitioners will be involved from the initial stage of collaboration with hospital management and other departmental leaders to carry out a quality improvement and patient safety program to the period when risk management activities continue to sustain the hospital’s Quality Improvement and Patient Safety program.

My next post on QPS standards for quality improvement and safety activities will begin with standards found under Section 4. I plan to walk through these standards first as I think they will involve health information contained in medical records, directly involving HIM/MR practitioners in data collection and analysis of clinical structures, processes, and outcomes.

However, I shall be paying visits to the other standards in the QPS chapter and cross-referencing them or making separate posts for any QPS standard apart from those from Section 4. I believe there is no one right way to approach quality improvement and safety activities by using the framework enshrined in the JCI QPS chapter but I plan to approach the way I feel the best way I can do in benefit of HIM/MR practitioners.

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

JCI Standard MCI.19.4 – Patient Clinical Record, the “quality oversight mechanism“

Posted on by
Reply

It is a common sight in hospitals as doctors and nurses make their rounds assessing patient needs and providing care. It is not uncommon as managers, support staff like HIM/MR professionals, and others in a hospital also make their rounds around their tasks assessing processes and resources and exercise set professional standards to their daily work, thereby understanding how processes can be more efficient, how resources can be used more wisely, and physical risks(safety) to the patients and staff can be reduced.

Thus, quality and safety is entrenched in the needs and care of patients as individual health care professionals and other staff execute their daily work.

As these individual health care professionals and other staff go about their daily work, the organisation continuously plans, designs, measures, analyses, and improves clinical and managerial processes to achieve maximum benefit from its quality and safety efforts.

It is no doubt to my mind that all these efforts to get quality and safety measures well organised requires no less clear leadership, needs some kind of mechanism and an organisational framework to oversee and improve those processes. As most clinical care processes, managerial processes and quality issues are interrelated and involve more than one department or unit and may involve many individual jobs, accentuates the need for clear leadership, a mechanism to work around with the help of an organisational framework for quality and safety.

This framework will develop greater leadership support for an organisation wide program, train and involve more staff, set clearer priorities for what to measure, base decisions on measurement data, and make improvements based on comparison to other organisations, nationally and internationally.

The framework and the mechanism to guide quality improvement and patient safety efforts in a hospital rest with a quality improvement and patient safety oversight group or committee.

All of the above explains  the “quality oversight mechanism“ I talked about in the post JCI Standard MCI.19.4 – Patient Clinical Record.

Abridged, and adapted from Quality Improvement and Patient Safety (QPS), Governance, Leadership, and Direction (GLD), and Management of Communication and Information (MCI) chapters of the JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 4th Edition