Category Archives: JCI Standards

JCI Standard MCI.19 Patient Clinical Record

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I continue my tirade(certainly not trading an angry or violent speech here, but what I actually mean is trying to strongly  inform you that more than working behind the confines of the HIM/MR Department walls you work in, there exists overseeing matters that we need to pay attention at the same time) on STANDARDS for example, JCI’s standards for Management of Communications and Information (MCI) chapter.

In my earlier post on JCI Accreditation Standards for Hospitals – Introductory Post, I started off with mention of the MCI standards chapter, and subsequently dwelled on the its first standard in the JCI Standard MCI.1 post.

Here now before I discuss other standards of MCI, I like to direct you to one subject matter dearest to all of you as HIM/Medical Records professionals.

The matter is about the Patient Clinical Record, be it paper based or EMR. I think the concepts hold true for both media.

Let us look at the standard pertaining to a Patient Clinical Record, which is MCI.19

The structure of this standard is made of one main standard(MCI.19), four sub-standards(MCI.19.1, MCI.19.2, MCI.19.3  and MCI.19.4 ) and one sub-sub-standard(MCI.19.1.1), all pertaining of course to a Patient Clinical Record – this categorisation is entirely mine, just to makes things easier to understand I think (at least for me) and clearer.

The standards as quoted from JCI’s manual, page 231 goes like this:

  • MCI.19 The organization initiates and maintains a clinical record for every patient assessed or treated.
  • MCI.19.1 The clinical record contains sufficient information to identify the patient, to support the diagnosis, to justify the treatment, to document the course and results of treatment,and to promote continuity of care among health care practitioners.
  • MCI.19.1.1 The clinical record of every patient receiving emergency care includes the time of arrival, the conclusions at termination of treatment, the patient’s condition at discharge, and follow-up care instructions.
  • MCI.19.2 Organization policy identifies those authorized to make entries in the patient clinical record and determines the record’s content and format.
  • MCI.19.3 Every patient clinical record entry identifies its author and when the entry was made inthe record.
  • MCI.19.4 As part of its performance improvement activities, the organization regularly assesses patient clinical record content and the completeness of patient clinical records.

Knowing these standards will help us know if our records keeping ways do keep up with a benchmark, in this instance that set by JCI. In this way, I believe we can then excel in records keeping and maintain high standards of professionalism in our work.

Pals, I am aware I am taking you into a discourse deeper and deeper related to a techinical discussion.

I wish and I shall try to relate to these standards with a social theme, since I did profess that this website-blog would be largely a social medium, but sadly it does not seem so as I do not see any interaction of ex-colleagues nor persons actively engaged still in HIM/Medical Records. My intention is to get people talking here, so this website-blog behaves like a social media thing where people connect and exchange views and as examples, to know where each other are located and working at and for whom, how they are doing in their chosen profession etc.

Nevertheless, I shall discuss more on MCI.19 in a future post.

An overview of quality indicators under the JCI QPS approach

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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.

JCI Standard MCI.1

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I am going to watch a movie on ASTRO Fox Movies Premium after this, and cannot help but post this off as I have finished it already.

Pals, I need to stop blogging here pretty soon, as I got other blogs to maintain as well, amongst which – one in particular, so posts here will be delayed or less frequent, unless I am fully energised and wish to rush a post here.

So here goes!

In the JCI Accreditation Standards for Hospitals – Introductory Post dated May 23, 2012 I had posted about the Management of Communication and Information (MCI) function and its direct and indirect relationship to the management of medical records.

In this post I shall talk about the first standard under this MCI function, namely “Communication with the Community, MCI.1” which states “The organization communicates with its community to facilitate access to care and access to information”.*

As part of a hospital, the Malaysian Medical Records Department (MRD) communicates directly to individuals but it is not normally authorised to communicate through public media and through agencies within the community or third parties.

There are 21 standards for this function, including 4 sub-standards and one sub=sub-standard for standard MCI.19, and 2 sub-standards for standard MCI.20.

Each standard has specific requirements. The Measurable Elements (MEs) are these specific requirements for each standard. The MEs simply list what is required to be in full compliance with the standard. The MEs will be reviewed and assigned a score during the accreditation survey process.

For MCI.1, the MEs measure the compliance of the MRD of the hospital to the requirements of this standard.  The MEs measure if:

  • the MRD has identified its communities and populations of interest.
    • I think these defined key groups will include all forms of patient contact with the hospital such as emergency care patients, outpatients discharged patients, and non-patient groups like the next of kin, members of the general public, students, the Polis, and sometimes even members of the Press and Media.
  • there is a communication strategy plan incorporating an on-going communication plan with its defined key groups of their communities and patient populations
  • there is information provided to the public and to referral sources on MRD services, hours of operation, and the process to obtain care
  • the MRD provides information on the quality of services to the public and to referral sources

If the MRD fully meets these requirements (full compliance), then I think the MRD as part of the organisation, has succeeded in communicating with its community to facilitate access to care and access to information.

Please note that this standard also applies to other departments of the hospital that also communicate with the community to facilitate access to care and access to information, for example the Public Relations Department.

JCI Accreditation Standards for Hospitals – Introductory Post

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I have some free time this evening here, and it’s just 9:25pm as I finish this post for you, I worked on after dinner.

I am posting this post which introduces a subject matter close to my heart, Quality in Healthcare.

In this respect, I wish to share my experiences when I managed quality management with the Pantai Group of Hospitals, by putting together relevant posts which would benefit the quality of medical records you are managing.

These posts will be specific to the process of accreditation of the International Standards for Hospitals, developed by the Joint Commission International (JCI), USA. The JCI Accreditation Standards for Hospitals has been updated, and now is in its fourth edition, effective 1 January 2011.

You already know accreditation is usually a voluntary process “in which an entity, separate and distinct from the health care organization, usually nongovernmental, assesses the health care organization to determine if it meets a set of requirements (standards) designed to improve the safety and quality of care.”* 

How is the health care organisation assessed?  What are then these  JCI standards to improve the safety and quality of care?

The standards are organised around the important functions common to all health care organisations, namely the Patient-Cantered Standards related to providing patient care, and the Health Care Organisation Management Standards – those related to providing a safe, effective, and well-managed organisation.

One must not forget that all these functions apply to the entire hospital as an organisation as well as to each department, unit, or service within the hospital.

You will also be aware of a survey process which gathers standards compliance information throughout the entire hospital, and the accreditation decision is based on the overall level of compliance found throughout the entire hospital.

I think I shall wrap up this very brief introduction on accreditation, and move on to  what I wish to share.

What I wish to share primarily is to convey in my subsequent posts on the JCI accreditation process which specifically relates to the standards relevant to the Management of Communication and Information (MCI) function, and their direct and indirect relationship to the management of medical records.

I need to tell you that these MCI standards relate to the communication process to and with the community, patients and their families, and other health professionals as well on the information about the science of care(of medicine), of individual patients, of the care provided, of the results of care, and their own performance.

 * Joint Commission International, Joint Commission International Accreditation Standards for Hospitals, page 1, 2010, U.S.A