This morning I presented some pertinent questions I think Health Information Management (HIM)/Medical Records professionals face in their roles collecting and managing quality indicators in the hospital.

This evening I like to give an overview about quality indicators and how q-indicators are approached by JCI in the planning, designing, measuring, collecting, and analysing stages.

The JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS manual describes JCI’s approach to improving quality and patient safety concerns, thus reducing the risks to patients and staff. In this manual one can find the Quality Improvement and Patient Safety (QPS), which is devoted to the mainstream activities of quality improvement and patient safety that are found in both clinical processes as well as in the physical environment.

JCI’s approach advocates that the leadership of a hospital must be guided by an overall framework for quality management and improvement activities in the hospital. Thus the leadership must always have a clear vision of its role in this approach and proactively identify and reduce risk and variation by leading and planning the quality improvement and patient safety program at their hospital, with the objective to achieve maximum benefit from this approach

This leadership with the help and coordination of a quality improvement and patient safety oversight group or committee, oversees and ensures that both new clinical and managerial processes are well designed and that these processes implemented are working well through data collection methods. This data is analysed to allow the leadership to focus on priority issues to implement and sustain changes that result in improvement to both clinical processes as well as in the physical environment of the patient.

By applying the QPS standards to daily work, doctors and nurses – who assess patient needs and provide care to patients, hospital managers, support staff, and others like you, can make real improvements that help patients and reduce risks. In this way these groups I believe and conjure will understand how clinical and managerial processes can be more efficient, how to manage them wisely and efficiently, and reduce physical risks in the hospital.

It is important to take into account as most clinical and managerial quality issues involve more than one department or unit, are thus interrelated and may involve many individual job and roles.

So what are then the QPS standards?

They standards as outlined from pages 146 to 147 of the manual are as follows:

QPS.1 Those responsible for governing and managing the organization participate in planning and measuring a quality improvement and patient safety program.

• QPS.1.1 The organization’s leaders collaborate to carry out the quality improvement and patient safety program.
• QPS.1.2 The leaders prioritize which processes should be measured and which improvement and patient safety activities should be carried out.
• QPS.1.3 The leaders provide technological and other support to the quality improvement and patient safety program.
• QPS.1.4 Quality improvement and patient safety information is communicated to staff.
• QPS.1.5 Staff are trained to participate in the program.

Design of Clinical and Managerial Processes
QPS.2 The organization designs new and modified systems and processes according to quality improvement principles.

• QPS.2.1 Clinical practice guidelines, clinical pathways, and/or clinical protocols are used to guide clinical care.

Data Collection for Quality Measurement
QPS.3 The organization’s leaders identify key measures in the organization’s structures, processes, and outcomes to be used in the organizationwide quality improvement and patient safety plan.

• QPS.3.1 The organization’s leaders identify key measures for each of the organization’s clinical structures, processes, and outcomes.
• QPS.3.2 The organization’s leaders identify key measures for each of the organizations managerial structures, processes, and outcomes.
• QPS.3.3 The organization’s leaders identify key measures for each of the International Patient Safety Goals.

Analysis of Measurement Data
QPS.4 Individuals with appropriate experience, knowledge, and skills systematically aggregate and analyze data in the organization.

• QPS.4.1 The frequency of data analysis is appropriate to the process being studied and meets organization requirements.
• QPS.4.2 The analysis process includes comparisons internally, with other organizations when available, and with scientific standards and desirable practices.

QPS.5 The organization uses an internal process to validate data.

• QPS.5.1 When the organization publishes data or posts data on a public Web site, the leaders of the organization ensure the reliability of the data.

QPS.6 The organization uses a defined process for identifying and managing sentinel events.
QPS.7 Data are analyzed when undesirable trends and variation are evident from the data.
QPS.8 The organization uses a defined process for the identification and analysis of near-miss events.

Improvement
QPS.9 Improvement in quality and safety is achieved and sustained.
QPS.10 Improvement and safety activities are undertaken for the priority areas identified by the organization’s leaders.
QPS.11 An ongoing program of risk management is used to identify and to reduce unanticipated adverse events and other safety risks to patients and staff.

JCI says “the framework presented in these standards is suitable for a wide variety of structured programs and less-formal approaches to quality improvement and patient safety. This framework can also incorporate traditional measurement programs, such as those related to unanticipated events (risk management) and resource use (utilization management).”

JCI further states that “over time, organizations that follow this framework will

• • develop greater leadership support for an organizationwide 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 organizations, nationally and internationally.”

In my next posts to this QPS chapter, I shall discuss the roles of Health Information Management (HIM)/Medical Records professionals, how you fit into the framework presented in these standards for a structured program and less-formal approaches at your hospital to quality improvement and patient safety, that could result in improvement to both clinical processes as well as in the physical environment of the patient. It would then be clearer on your roles managing quality indicators in the hospital in the continuous planning, designing, measuring, collecting, and analysing stages of hospital-wide quality indicators.