Category Archives: JCI Standards

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

8 ways for identifying opportunities for improvement and documenting a hospital’s performance level

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8-ways-for-identifying-opportunities-for--improvement-and--documenting-a-hospital’s--performance-level-2

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

A hospital’s performance improvement activities as opportunities for improvement

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syringe-with-MCI.20.1-PI-activitiesIn three previous posts, I brought to you how aggregate data are an important part of the hospital’s performance improvement activities. In particular, the three posts were about aggregate data from risk management, utility system management, infection prevention and control, and utilisation review and how they can help the hospital understand its current performance and identify opportunities for improvement.

The posts were:

(i)                  JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” ;

(ii)                JCI Standard MCI.20.1, ME 1 (Part 2) – infection prevention and control, in “The organization has a process to aggregate data in response to identified user needs.” ;

and

(iii)             JCI Standard MCI.20.1, ME 1 (Part 3) – utility system management and utilisation review, in “The organization has a process to aggregate data in response to identified user needs.”

Each of the links above will open in a new separate tab of your current browser window.

In this review of those 3 posts, I like to emphasise that a hospital chooses which clinical and managerial processes and outcomes are most important to monitor based on its mission patient needs and services provided. The hospital’s leaders must identify key measures (indicators) to monitor the hospitals’s clinical and managerial structures, processes and outcomes.

A required clinical monitoring which includes structure, process or outcomes data selected by the leaders is on aspects of infection control, surveillance and reporting. For managerial monitoring, a required managerial monitoring which includes structure, process or outcomes data selected by the leaders is on aspects of risk management and utilisation review/management.

The hospital collects and analyses aggregate data from clinical monitoring and managerial monitoring to support patient care and organisation management. Aggregate data provides a profile of the hospital over time and allows the comparison of the hospitals’s performance with other hospitals.

To measure the hospital’s performance improvement activities, hospitals usually prepare a master plan to reduce evident risks in the environment or individual plans which incorporates a comprehensive program and plan inclusive of :

  1. a program and plan to reduce the risk of health care-associated infections in patients, health care workers and visitors
  2. a program and plan that includes utility systems – electric, water and other utility systems,  maintained to minimise risk of failure

There is also a written plan for an organisation-wide quality improvement and patient safety program that includes clinical and managerial processes for risk management, utility system management, infection prevention and control, and utilisation review.

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

JCI Standard MCI.20.1, ME 1 (Part 3) – utility system management and utilisation review, in “The organization has a process to aggregate data in response to identified user needs.”

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Well, I am not yet quiet finished on trying to tell you all about the Joint Commission International (JCI) Standard MCI.20.1. In this post I wish to share on the what, why and how about utility system management and utilisation review, the remaining two other important parts of the improvement activities of a hospital by which the hospital attempts to aggregate data to provide a profile of the hospital over time which then will allow the comparison of the hospital’s performance with other hospitals. Utility system management and utilisation review are the last of the four improvement activities of a hospital identified in the intent statement of the JCI Standard MCI.20.1.

My intent is to discuss in this post:

  1. in brief about utility system management and utilisation, as this single post cannot cover all about utility system management and utilisation review; and
  2. more importantly to highlight to management and hospital leaders when one is entrusted to champion the course of all the JCI Management of Communication and Information (MCI) standards, the probability when a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, is expected to present the case of a process for both utility system management and utilisation review, when surveyors examine evidence under JCI Standard MCI.20.1 ME 1 the process to aggregate data from utility system management and utilisation review at a hospital in response to identified user needs  – in order to satisfy the requirement for the Measurable Element 1 of MCI.20.1 which states that “The organization has a process to aggregate data in response to identified user needs”.

Before I go on, my intent (ii) above is true for aggregate data from risk management as well as for infection prevention and control as  I have posted in JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” and in JCI Standard MCI.20.1, ME 1 (Part 2) – infection prevention and control, in “The organization has a process to aggregate data in response to identified user needs.” respectively (each of these links will open in a new tab of your current browser window).

Medical insurance in Malaysia, provided by insurance companies and banks which provide a few plans for anyone to choose from based on own budget and needs, functions as a form of protection to cover unforeseen expenses arising from illness, injury or accidents – which can be very expensive, especially if hospitalisation and / or surgery is required.

Malaysian readers will already be aware that insurance companies in Malaysia provide coverage plans for medical services for their clients at any hospital. Malaysian readers will also be aware that health insurance companies in Malaysia request medical reports for approval of claims to confirm that any insurance plan provides for the coverage of medical services rendered.  While this is true for Malaysia, I have never known the need for utilisation review to review a request for medical treatment in Malaysia.

Let us now assume that utilisation review by insurance companies is practised in your settings and take this discussion from there.

Utilisation review refers to reviews of past medical treatment, for example in the United States where insurance companies perform an utilisation review to review a request for medical treatment. I have below a cropped infographic which provides the anatomy of health insurance coverage in the U.S. (click the infographic which will open in a new tab of your current window for a larger view).

health-insurance infographic croppedThe purpose of the review is to confirm that the plan provides coverage for a patient’s medical services typically found on an insurance policy’s precertification list.  The utilisation review also help an insurance company minimise costs and determine if the recommended treatment is appropriate. The company could deny coverage as a result of a utilisation review.

What about care based on medical necessity in the future, for example for approval for additional treatments while you’re undergoing medical care (a concurrent review)?

Utilisation management is the process of preauthorisation for medical service as it refers to requests for approval of future medical needs, and this term is often used interchangeably with utilisation review since both utilisation review and utilisation management involve the review of care based on a medical necessity.

Thus, the term “utilization review” refers to a retrospective review – the review of treatments or services that have already been administered, and involves the review of medical records in comparison with treatment guidelines. The insurance company uses the results to approve or deny coverage a patient has already received, and the information can also be used in a review of the insurance company’s coverage guidelines and criteria for a particular condition. The insurance company looks through a patient’s medical records for evidence of appropriate low-cost health care. It then compares this patient’s medical records to those of other patients with the same condition. It will then review, and possibly revise, its treatment guidelines and criteria to ensure that the provided care is adequate, and medically current, for the condition.

Therefore, hospitals get actively drawn into the process of the collection of information, including the symptoms, diagnosis, results of any lab tests and list of required services by providing clinical documentation that supports their treatment decisions.

I think Health Information Management (HIM) / Medical Records (MR) practitioners have a clear role in utilisation review if their setting is appropriate. HIM /MR practitioners will need to be aware (i) of the existence of an utilisation review policy and the relevant processes, and (ii) to contribute to good records keeping since a high retrieval rate of medical records can be expected when patients’ medical records are examined for evidence of appropriate low-cost health care and for comparison of treatment among other patients’ medical records for a similar condition, by the insurance companies.

I think to round-up the discussion on utlisation review, it is safe to justify then if a hospital –  which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, satisfies the requirement for the Measurable Element 1 of MCI.20.1 which states that “The organization has a process to aggregate data in response to identified user needs”, if the hospital can provide evidence of documentation of a process to aggregate data i.e. in response to the identified user needs when data is aggregated for utilisation review.

Now, allow me to move forward to present utility system management.

Hospitals have different medical equipment and utility system needs based on their mission, patient needs, and resources. Regardless of the type of system and level of its resources, a hospital needs to protect patients and staff in emergencies, such as system failure, interruption, or contamination. The safe, effective, and efficient operation of utility and other key systems in the hospital is essential for patient, family, staff, and visitor safety and for meeting patient care needs.

The business of utility system management in a hospital is about:

  1. a constant potable water and electrical power supply
    1. first identifying  the areas and services at greatest risk when power fails or water is contaminated or interrupted, secondly to reduce the risks of such events and thus ensuring an uninterrupted (24-hour basis, every day of the week) source of clean water and electrical power, and when necessary regular and alternative sources of power and water must be identified that can be sourced in emergencies
    2. emergency processes to protect hospital occupants in the event of water or electrical system disruption, contamination, or failure
    3. testing its emergency water and electrical systems on a regular basis appropriate to the system and the results documented
  2. regular inspection and maintainance of electrical (example, frayed electrical lines), water, waste (example, waste contamination in food-preparation areas), ventilation  (example, inadequate ventilation in the clinical laboratory), medical gas  (example, oxygen cylinders that are not secured when stored, or leaking oxygen lines, and other key systems that all pose hazards and when appropriate, they must be improved
  3. designated individuals or authorities monitor regularly the quality of water received from a source, and the water used in chronic renal dialysis
  4. collection of monitoring data for the utility system management program
    1. monitoring essential systems helps the hospital prevent problems
    2. monitoring data that are collected and documented are used to plan the hospital’s long-term needs on system improvements and in planning for upgrading or replacing utility systems

It is almost to the end of this rather long post.

I think it is also safe to justify from the foregoing discussion on utility system management that when a hospital – which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, satisfies the requirement for the Measurable Element 1 of MCI.20.1 which states that “The organization has a process to aggregate data in response to identified user needs”, if the hospital can provide evidence of documentation of a process to aggregate data i.e. in response to the identified user needs, when data is aggregated for utility system management.

This post ends what I wish to share all about the JCI Standard MCI.20.1, ME 1.

References:
Barbara JY 2011, Principles of risk management and patient safety, Jones & Bartlett Learning, Sudbury, MA, USA

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

Prathibha, V (ed.) 2010, Medical quality management : theory and practice, 2nd edn,  Jones and Bartlett Publishers, Sudbury, MA, USA

Pre-sedation assessment documentation

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Image credit: patientsafetyauthority.org/

My purpose of including this post about pre-sedation assessment is because it warrants a provision to check for compliance against the Joint Commission International (JCI) Standard ASC.3 which requires documentation of a pre-sedation assessment and monitoring of the patient during administration of moderate or deep sedation or anesthesia using the Medical Records Review Tool (MMRT) form, similar to the situation  when the JCI Standard AOP.1.4. which also examines the documentation in a medical record during a Medical Records Review (MMR) session.

Sedation (JCI, 2011 p.245) at three (3) levels of sedation – minimal sedation (patient can respond to command), moderate sedation (depressed level of consciousness; patient can breathe without assistance, respond to pain, and follow some commands. protective reflexes are maintained),  and deep sedation (patient cannot be easily aroused, but can respond after repeated stimulation. respiration may need to be supported), is “the administration of medication to an individual, in any setting, for any purpose, by any route to induce a partial or total loss of sensation for the purpose of conducting an operative or other procedure.” as defined in the Glossary  of the JCI Hospital Acceditation Standards For Hospitals, 4th Edition Manual.

So what needs to be checked for compliance against this JCI Standard ASC.3, which states that “Policies and procedures guide the care of patients undergoing moderate and deep sedation.” in the medical record of a patient due for the purpose of conducting an operative or other procedure on the patient.” and specifically its Measurable Element (ME) 3 which requires that “There is a pre-sedation assessment performed that is consistent with organization policy to evaluate risk and appropriateness of the sedation for the patient.?

Such aforesaid policies and procedures of a hospital must define the scope and content of a pre-sedation assessment to guide the care of patients undergoing moderate and deep sedation. A responsible qualified individual competent in (a) techniques of various modes of sedation, (b) appropriate monitoring, (c) response to complications, (d) use of reversal agents, and (e) at least basic life support, conducts a pre-sedation assessment of the patient to ensure the planned sedation and determine the appropriate level of sedation for the patient that is consistent with hospital policy to evaluate risk and appropriateness of the sedation for the patient. Pre-sedation assessment is important in particular for moderate and deep sedation levels because the degrees of sedation occur on a continuum, and a patient may progress from one degree to another, based on the medications administered, route, and dosages.

A pre-sedation assessment will include the following to ensure a patient’s ability to maintain protective reflexes; an independent, continuous patent airway; and the capability to respond to physical stimulation or verbal commands :

a) how planning will occur as I covered in the post Anaesthesia plan in the patient’s medical record (this link will open in a new tab of your current browser window), including the identification of differences between adult and paediatric populations or other special considerations for patients with significant underlying medical conditions (e.g., extremes of age; severe cardiac, pulmonary, hepatic, or renal disease; pregnancy; drug or alcohol abuse, uncooperative patients, morbid obesity, potentially difficult airway, sleep apnea);

b) documentation required for the care team to work and to communicate effectively;

c) informed consent must be obtained for all non-emergency procedures and special consent  for example when informed consent is obtained moments before a patient will undergo a major, potentially life-threatening or disfiguring procedure;

d) frequency and type of patient-monitoring requirements;

e) special qualifications or skills of staff involved in sedation process as I posted under the post Anesthesia care must be given by a qualified individual (this link will open in a new tab of your current browser window); and

f ) availability and use of specialised equipment.

Recommendations on Pre-Anaesthetic Assessment , one of the six (6) Clinical Practice Guidelines (CPGs) of the Malaysian Society of Anaesthesiologists (MSA) recommends that  “A written summary of the pre-anaesthetic assessment, orders or arrangements should be explicitly and legibly documented in the patient’s anaesthetic record”.

Likewise, another MSA CPG – Recommendations for Standards of Monitoring During Anaesthesia and Recovery, makes special mention on sedation and recommends that (i) A patient who is to be given any form of sedation for a procedure should be assessed by a qualified medical practitioner and his medical status noted.”, and (ii) “A written record of the time and dosages of the drugs used must be kept as part of the patients records. This record must also note the monitored values of the patients vital signs( i.e. blood pressure, pulse rate. respiration, and oxygen saturation) .”

Examples of presedation assessment forms for adults and paediatrics with links from this post are as follows :

Adult Sedation Pre-Sedation Assessment Form example (this link will open in a new tab of your current browser window)

Paediatric Sedation Pre-Sedation Assessment Form example (this link will open in a new tab of your current browser window)

It is also possible to find pre-sedation assessment recorded in the anaesthesia record.

Before I close the discussion on pre-sedation assessment in this post, I like to recommend the following based on my experiences:

  1. a special, separate special pre-sedation medication form or the pre-sedation medication form printed on the reverse side of the anaesthetic record form or elements of the pre-sedation assessment included as part of the anaesthetic record form;
  2. team members of a MMR session must be briefed about (a) the pre-sedation assessment process compliance check for JCI Standard ASC.3 in the MMRT form, and (b) about the presence of a pre-sedation assessment form in a medical record for patients undergone pre-sedation assessment and monitoring during the administration of moderate or deep sedation;
  3. a medical record is just not complete if there is no pre-sedation assessment form in a medical record for patients undergone pre-sedation assessment and monitoring during the administration of moderate or deep sedation, so Health Information Management (HIM) / Medical Records (MR) practitioners must ensure a medical record for such patients is completed with a pre-sedation assessment record;
  4. reporting the presence of a  pre-sedation assessment form in a medical record for patients undergone pre-sedation assessment and monitoring during the administration of moderate or deep sedation is not enough just to satisfy the completion of the process of a MMR session but I believe it is beyond just checking for completeness of the medical record and merely to complete the  MMRT form;
  5. team members of a MMR session must be briefed not only to check for a pre-sedation assessment form in a medical record but also its completeness and team members must notify the MMR session team leader of any incompleteness found; and
  6. the team leader of a MMR session must record such observations of incompleteness found in the pre-sedation assessment form so as to make the MMR session report as value added as possible and to improve the quality improvement activities of the Anaesthesiology Department of the hospital.

References:
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

Children’s Hospital Central California, 2013, Paediatric Sedation Pre-Sedation Assessment Form example, viewed 5 January 2013 < http://www.chccsedation.org/downloads/PreProceduralSP.pdf >

Darthmouth-Hitchcock Medical Centre, Adult Sedation Pre-Sedation Assessment Form example, viewed 5 January 2013 < http://www.dhmcsedation.com/as/downloads/PreAssessmentExample.pdf  >

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

Malaysian Society of Anaesthesiologists (MSA), 2013, Recommendations on Pre-Anaesthetic Assessment, viewed 5 January 2013 < http://www.acadmed.org.my/view_file.cfm?fileid=222 >

Malaysian Society of Anaesthesiologists (MSA), 2013, Recommendations for Standards of Monitoring During Anaesthesia and Recovery, viewed 5 January 2013 < http://www.acadmed.org.my/view_file.cfm?fileid=180 >

Malaysian Society of Anaesthesiologists (MSA), 2013, Recommendations On Pre-Anaesthetic Assessment, viewed 5 January 2013 < http://www.acadmed.org.my/view_file.cfm?fileid=222 >

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Ronald, DM & Manuel, CP Jr 2011, Basics Of Anesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA