Category Archives: QPS.4.2

JCI Standard MCI.20.2 – Using or participating in external databases

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In order to compare its performance and to identify opportunities for improvement, a Hospital needs a mechanism for comparing its performance to that of other similar hospitals locally, nationally, and internationally with recognised, internationally accepted standards.

The mechanism must be designed to transform input forces and movement by (i) operate or interact by participating in external performance databases, (ii) compare its performance to that of other similar hospitals,  into a desired set of output forces and movement when the hospital can identify opportunities for improvement and hence documenting its performance level.

This arrangement of connected parts in a system of parts of individual hospital performances like those parts of a machine is surely an effective tool to demonstrate the quality and safety that are being provided in the hospital and can be thought of as benchmarks of success when the hospital participates through reference databases.

I can think of the following initiatives in the US when hospitals as providers participate through reference databases to improve by benchmarking their performance against others, encourage private insurers and public programs to reward quality and efficiency, and help patients make informed choices:

  1. Hospital Compare which encourages hospitals to improve the quality of care they provide and for patients to find hospitals and compare the quality of their care  and make decisions about which hospital will best meet their health care needs;
  2. Quality Improvement Organization (QIO) – a private, mostly not-for-profit contractor of the Centers for Medicare & Medicaid Services (CMS) to improve the quality of health care for all Medicare beneficiaries;
  3. ORYX® data reported on The Joint Commission website at Quality Check® which permits user comparisons of hospital performance at the state and national levels; and
  4. hospitals complete The Leapfrog Hospital Survey, the gold standard for comparing hospitals’ performance on the national standards of safety, quality, and efficiency

In all instances, hospitals need to check if they are required by local laws or regulations to contribute to some external databases. Hospitals also need to maintain security and confidentiality of data and information at all times when operating or interacting with external databases.

ff your hospital is a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then the JCI Standard MCI.20.2 requires it to have a mechanism in place with the following characteristics:

  1. there is a process to participate in or to use information from external databases, thus satisfying the JCI Standard QPS.4.2, ME 2 which states that “Comparisons are made with similar organizations when possible.”;
  2. the hospital contributes data or information to external databases in accordance with laws or regulations, thus satisfying for example both the JCI Standard PCI.10.4, ME 1 which states that “Health care–associated infection rates are compared to other organizations’ rates through comparative databases.” and the JCI Standard QPS.4.2, ME 2; and
  3. the hospital compares its performance using external reference databases, also satisfying the JCI Standard QPS.4.2, ME 2; and the hospital maintains security and confidentiality when contributing to or using external databases.

References:

  1. Facts about ORYX® for Hospitals (National Hospital Quality Measures), The Joint Commission, viewed 8 March 2013, < http://www.jointcommission.org/facts_about_oryx_for_hospitals/ >
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Prathibha, V (ed.) 2010, Medical quality management : theory and practice, 2nd edn,  Jones and Bartlett Publishers, Sudbury, MA, USA
  4. Quality Improvement Organizations, Centers for Medicare & Medicaid Services, viewed 6 March 2013, < http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs/index.html?redirect=/qualityimprovementorgs >
  5. Welcome to the Leapfrog Hospital Survey, The Leapfroggroup, viewed 8 March 2013, < https://leapfroghospitalsurvey.org/ >

Making comparisons via data analysis for improvement efforts

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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