Category Archives: JCI Standards

The frequency of data analysis

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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

Medical and Nursing assessments in 24 hours, updates if less than 30 days old

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My purpose of writing this post is to highlight that the Medical Records Review Tool (MMRT) form contains a provision to check for compliance to “Medical assessment in 24 hours. Updates if less than 30 days old. Nursing assessment in 24 hours” documentation in a medical record during a Medical Records Review (MMR) session.

Members of a MMR session must be able to connect this provision found in the MMRT form to the Joint Commission International (JCI) Standard AOP.1.4.1 which requires that “The initial medical and nursing assessments are completed within the first 24 hours after the patient’s admission as an inpatient or earlier as indicated by the patient’s condition or hospital policy.”

However, most members of the MMR session are usually unaware of this requirement, and it is the duty of the team leader to explain this standard which requires that to begin correct treatment for a patient as quickly as possible, the initial assessments must be completed as rapidly as possible.

Members of the MMR session must be breifed that the hospital determines the time frame for completing assessments, in particular the medical and nursing assessments depending on a variety of factors including:

  1. the types of patients cared for by the hospital,
  2. the complexity and duration of their care, and
  3. the dynamics of conditions surrounding their care.

Nonetheless, it is important for the team leader to stress that all initial medical and nursing assessments must be completed within 24 hours of admission to the hospital and available for use by all those caring for the patient.

The team leader must also indentify situations when the patient’s condition indicates, that the initial medical and/or nursing assessment are conducted and available earlier and supported by a hospital policy which define that certain other patient groups are assessed sooner than 24 hours.

Such certain other patient groups who are assessed sooner than 24 hours will include:

  1. emergency patients
  2. patients seen in a consultant’s private office or other outpatient setting prior to care in the hospital as an inpatient

The above certain other patient groups will be assessed within different time frames as follows :

  1. emergency patients are assessed immediately
  2. when the initial medical assessment is conducted in a consultant’s private office or other outpatient setting prior to care in the hospital as an inpatient, it must be no older than 30 days but (i) if the medical assessment is more than 30 days old, then the medical history must be updated and the physical examination repeated and (ii) if the medical assessment is less than 30 days old but if at the time of admission there are significant changes in the patient’s condition since the assessment was first done, then they are noted in the patient’s medical record at the time of admission to inpatient status.

The team leader may include to explain the rationale why the above 30 days time frame applies when the assessment is completed in a consultant’s private office or other outpatient setting prior to care in the hospital as an inpatient. Such explanation may include (JCI, 2010 p. 80) “the critical nature of the findings, the complexity of the patient, and the planned care and treatment (for example, the review confirms the clarity of the diagnosis and any planned procedures or treatments; the presence of radiographs needed in surgery; any change[s] in the patient’s condition, such as control of blood sugar; and identifies any critical lab tests that may need repeating)”, findings by any qualified individual (medical, nursing, and other individuals and services responsible for patient care) who usually will update and/or re-examine this patient group.

Reader can relate this post to the previous post Assessments within 24 hours (this link will open in a new tab of your current browser window) on the JCI Standard AOP.1.5 which states that “Assessment findings are documented in the patient’s record and readily available to those responsible for the patient’s care.”

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

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.”

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As I had posted in the post JCI Standard MCI.20.1 – patient based data and aggregate data, in a process available to aggregate data to meet the needs of internal and external users (this link will open in a new tab of your current browser window), in this post I shall continue on infection prevention and control. This post is also a follow-up from the previous post on risk management 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.” (this link will open in a new tab of your current browser window).

Infection prevention and control is one of a hospital’s four (4) performance improvement (PI) activities other than risk management, utility system management, and utilisation review PI activities a hospital is required to meet the Joint Commission International (JCI) Standard MCI.20.1, Measurable Element (ME) 1 which requires that a hospital as “The organization has a process to aggregate data in response to identified user needs.”

Although the details of infection prevention control are beyond the scope of this post and blog, I shall embark to highlight some aspects of infection prevention and control here. It is going to be a long post.

Health care–associated infections (HAIs) or also referred to as health care–acquired Infections, are infections acquired in the hospital or other health care facilities that were not present or incubating at the time of the patient’s admission. Hospital (or ‘nosocomial’) infection is infection acquired either by patients while they are in hospital, or by members of hospital staff.  (eds. Adam & Christina 2009) define the term infection as “generally used to refer to the deposition and multiplication of bacteria and other micro-organisms in tissues or on surfaces of the body with an associated tissue reaction.”

At the time of the patient’s admission due to an illness – which impairs the body’s normal defense mechanisms, often the reason for hospital admission, the patient is in the state of risk for infection in which the patient is at increased risk for being invaded by pathogenic organisms because the patient has not been exposed to in the past what the hospital environment now provides the exposure to a variety of virulent organisms, therefore the patient has not developed any resistance to these organisms.

Health care personnel in hospitals who usually fail (eds. Adam & Christina 2009) to practice proper handwashing procedures or to change gloves between patient contacts, contribute to most HAIs been transmitted  to hospitalised patients who are at risk from the most common HAI endemic infections in hospitals caused by multi-resistant tuberculosis, Clostridium difficile one of the major hospital infections in the elderly, vancomycin-resistant enterococci in some specialised units, and cross-infection with methicillin-resistant Staphylococcus aureus (MRSA) that affect the urinary tract, upper and lower respiratory tracts, gastrointestinal tract, conjunctiva, and skin.

HAIs have received increased attention due to their overwhelming consequences in terms of cost, morbidity, and mortality.  One of the reasons for this increased attention is that these infections which are preventable through the adherence to numerous strict guidelines, legal requirements and other recommendations when caring for patients, is that they frequently occur in people whose health is already compromised by disease, age, or injury.

The data presented in the 1999 Institute of Medicine (IOM) study reported that an estimate of  between 44,000 and 98,000 patients die as the result of preventable medical errors in hospitals each year and also reported that hospital-acquired infections, many of which can be prevented, take another 100,000 lives.

In the United States of America, payers have begun to refuse reimbursement for additional care resulting from treatment for an infection not present on admission with the underlying rationale that HAIs are preventable complications and denying reimbursement provides a strong incentive for quality improvement actions to avert them.

Then there are site-specific infection prevention to reduce (i) postoperative surgical wound infections through the use of appropriate surgical site preparation and also prophylactic antibiotic therapy, (ii) ventilator-associated pneumonia by for example minimizing the duration of intubation, (iii) central venous catheter infections for example with the use of sterile technique and full barrier precautions, (iv) urinary tract infection by avoiding unnecessary or prolonged use of indwelling bladder catheters, and (v) resistant organisms for example methicillin-resistant Staphylococcus aureus (MRSA) by employing (a) active surveillance procedures in which cultures are routinely obtained at scheduled intervals to promote earlier identification of resistant organisms, and (b) careful management of antibiotic use.

To address each type of HAI, many hospitals have adopted a series of practices called a “bundle” at a significant cost,  failure to use all the measures prescribed in the “bundle”, for example in the approach to preventing central line-associated bloodstream infections  (CLBSI) (this bundle includes the entire procedure for insertion, the daily cleaning protocols, and the protocols for use of the central line catheter) may adversely affect patient outcomes but adopting a “bundle” has been shown to decrease the incidence of the target infection, and thus been effective  in improving quality of care which may then offset the significant cost.

Transmission of infection as an occcupational hazard in all hospital settings is a major concern when caring for infected patients made worse by the presence of resistant organisms which causes extra concern and makes treatment difficult.

Universal precautions are usually mandated for use with patients who pose the hidden danger when they have not been diagnosed as having an infection and for whom specific infection control measures have therefore not been prescribed. Universal precautions is a critical protective strategy with measures that include hand decontamination upon entering and leaving every patient encounter, isolation and the use of disposable gowns and gloves in addition to hand decontamination for patients with certain particularly dangerous types of infections. Provision of sharps containers wherever needles were used and the provision of a supply of gloves and protective eyewear for employee use are some other measures as part of universal precautions.

Blood-borne pathogens are not the only pathogens of concern in the healthcare environment. Body Substance Precautions are also used in all hospital settings to protect patients and staff members from infections that might be transmitted by any body substance, for example to protect staff members from the tuberculosis (TB) organism.

Confidentiality should be maintained at all times by Health Information Management (HIM) / Medical Records (MR) practitioners who may be needed to provide medical records of staff members exposed to HBV, HCV and HIV infection for review at the time of exposure of the source of their occupational exposure to the bloodborne pathogens including results of blood tests, admitting diagnosis and past medical history.

HIM / MR practitioners may be needed to work closely with an infection control officer at most hospitals which usually designate this officer who has the expertise to guide the staff in planning appropriate infection control procedures to protect staff members from blood-borne pathogens to prevent the spread of HIV, hepatitis B, and other such blood-borne pathogens.

HIM / MR practitioners may be involved in the development of policies and procedures is a key role for any infection control team. The central document is a collection of procedures (sometimes called an infection control policy or infection control manual).

As I have said in my previous posts, most hospitals today are involved in processes of quality improvement.

In the context of HAI, (eds. Adam & Christina 2009,  p. 5) defines ‘surveillance which is a vital component of infection control as ‘the ongoing systematic collection and analysis of data about a disease (or organism) that can lead to action being taken to control or prevent the disease.’

As part of these processes, ongoing data are collected and analysed for problems or opportunities for improvement including using infection control and quality improvement data to improve care. An example of the use of infection control data reviewed from interviews in regard to care practices for patients with catheters in an intensive care unit (ICU) about the series of urinary tract infections for example by the same strain of Serratia as the infective agent that had been identified in all patients in that unit, showed that a deviation from the standard protocol for the unit with the use of one measuring container used by an infected patient cultured positive for the Serratia, and using it from patient to patient easily had transmitted the organism to another patient’s catheter, and the infectious agent could have been spread from patient to patient in this manner.

Quality of care aggregate data takes many forms, revealing such things as infection rates and unplanned returns to the operating room. Infection rates for example MRSA wound infections per 1000 bed days or per 1000 admissions are commonly computed rates like other rates for example average length of stay, based on discharge statistics data that are accumulated when patients are discharged. At the local level, (eds. Adam & Christina 2009) infection rates from surgical wound infections fed back to practising surgeons can demonstrate results in lowering infection rates.

Other forms quality of care aggregate data on HAIs is the reporting of infections.

A daily report generated by a laboratory-based system is able to give information based around ‘alert’ organisms that have the potential to cause outbreaks, for example the percentage of Staphylococcus aureus that are methicillin resistant and/or the percentage of wound swabs showing S. aureus.

Reporting is generated as recommended by (eds. Adam & Christina 2009) through (i) weekly reports by the Infection Control Nurse (ICN) and sent to the wards, departments and clinicians containing  information on alert organisms and infectious patients including simple graphs that provide rapid feedback on current issues while they are still fresh, (ii) monthly reports sent to all members of the Infection Control Team (ICT) within two or three days of the new calendar month, (iii) quarterly reports that includes recommendations to management and education data on who attends the sessions, and (iv) a comprehensive annual report intended for the board members.

Local data must include ‘details’ of wards and consultants – to establish the ‘ownership’ of the data as well as the competitive element,  needs to be analysed promptly and sent to the ward/clinician as daily and weekly reports.

All of the above are my observations, experiences and readings on infection prevention and control activities and processes in a hospital setting to aggregate data in response to identified user needs. They are by no means complete, in future posts I shall document on latest trends and developments in infection prevention and control activities.

In my next post on JCI Standard MCI.20.1, ME 1 I shall dwell on utilisation review PI activities a hospital is required to meet the JCI) Standard MCI.20.1, ME 1.

References:
Adam, PF & Christina, B (eds.) 2009, Ayliffe’s Control of Healthcare-Associated Infection A practical: handbook, 5th edn, Hodder Arnold, London, UK

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

Janice, RE, Celia, LH 2012, Nursing in todays world : trends, issues & management, 10th edn, Wolters Kluwer Health | Lippincott Williams & Wilkins, Philadelphia, PA, USA

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

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.”

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A hospital collects and analyses aggregate data to support patient care and its organisation management.

Aggregate data provides a profile of the hospital over time and allows the comparison of the hospital’s performance with other hospitals. Thus, aggregate data are an important part of the hospital’s performance improvement (PI) activities.

PI facilitates desired outcomes by monitoring and evaluating the quality and appropriateness of patient care, measuring both process and outcome and conducting trend analyses, pursuing opportunities to improve patient care, ensuring high-quality care, and developing standards for monitoring quality of care.

Most hospitals are involved in processes of quality improvement. As part of these processes, on-going data are collected regarding outcomes and analysed for problems or opportunities for improvement. When outcomes are known, then addressing areas for possible improvement in outcomes becomes possible. In response to identified user needs, hospitals can understand its current performance by monitoring and evaluating aggregate data through risk management, utility system management, infection prevention and control, and utilisation review and identify opportunities for improvement.

Allow me to take you about the PI activities of risk management, utility system management, infection prevention and control, and utilisation review.  We will look at how a hospital through the PI activities of risk management, utility system management, infection prevention and control, and utilisation review meets the Joint Commission International (JCI) Standard MCI.20.1, Measurable Element (ME) 1 which requires that a hospital as “The organization has a process to aggregate data in response to identified user needs.”

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Risk is defined as the chance of loss. Risk management can be defined as identifying circumstances that put patients or a hospital at risk for adverse outcomes and putting into operation methods that avoid, prevent, and to mitigate (reduce or eliminate) the risks. Hospital adopted risk management when there were many problems in malpractice that caused risk to be a potential problem for hospitals, thus sentinel event monitoring was added to the hospital accreditation process in the mid-1990s.

Risk management is about the focus on an individual case, investigation of the post-event, implementing strategies to address the event, regulatory compliance with legal standard of care, unexpected outcomes which drive the process despite performing all of the regulatory requirements in a timely and competent manner, and been reactive that is relying (Barbara 2011) “on lessons learned from past mistakes, which they apply to the case at hand in order to “defend” the actions of those involved.”

Risk management is about the various strategies to fix problems. Examples of risk management techniques are practice modification (an example of risk management is avoiding the use of a code cart that has not been restocked properly or as for an individual patient, it may be confirming that all the protocols are followed when giving intravenous medications to the patient), insurance transfer, or risk avoidance such as when we eliminate the risk by closing of an obstetrics unit or mental health services or reducing the privileges of a specific provider who may not have the requisite skill to safely perform a specific procedure.

I remember the relatively low numbers of sentinel events reported annually from hospitals that had to report such events, – as it was then and I am sure it is still today,  commonly recognised that there are limitations of a reporting system. However, I am certain that aggregate data collected over the years have proved invaluable toward understanding specific types of hospital based errors. In Malaysia, sentinel events in private hospitals is part of a mandatory incident reporting system in accordance to the ACT 586, Private Healthcare Facilities And Services Act 1998, Private Healthcare Facilities And Services (Private Medical Clinics Or Private Dental Clinics) Regulations 2006, Regulation 13. Ministry of Health Malaysia hospitals are required to follow THE MALAYSIAN INCIDENT REPORTING AND LEARNING SYSTEM, in incident reporting for adverse events with the general objective “To facilitate a learning organisation through the reporting of and learning from adverse incidents, “near misses” and hazards so that a just and safe culture will be nurtured amongst health care providers, in our efforts to enhance the safety of the Malaysian health care system.”, which requires mandatory reporting of specific event types to further foster the sharing of lessons learned. Despite this shared learning, I am sure we still have medical errors occurring in our hospitals and clinics every day.

Health Information Management (HIM) / Medical Records (MR) practitioners need to know that their HIM / MR Department that supplies the raw material (i.e., the medical-record documentation), serves as one of the strongest allies of the risk management activities and risk and quality managers turn to this department regularly for support and services. It is common for routine requests for case review analysis with expedited requests made during times of accreditation surveys and on-site inspections.

The role of this department in identifying adverse events and quality-of-care concerns hospital-acquired conditions (HAC) – examples of HACs are foreign object retained after surgery, air embolism, blood incompatibility, catheter-associated urinary tract infection.

HIM / MR practitioners working in a HIM / MR department may be required to identify these HACs and initiate a report to the risk and quality departments for peer review and quality analysis.  HIM / MR practitioners must also be aware that another early indicator for a potential claim against a hospital is a request for medical records, especially by a lawyer. Medical-records staff should notify their risk management / QA department and the hospital top management upon receipt of such requests.

Readers, I know for a fact I have not been able to cover all aspects of risk management in this post but it is enough to give you a brief overview of what risk management is about and how it affects the HIM / MR practitioner. In a future post, I will expand on discoverability of medical records in medical-malpractice cases that is the written discovery as the first phase of the discovery process in a medical-negligence case, when there is a request to produce documents and tangible items, such as medical records, films, and pathology slides.

As I posted in the post JCI Standard MCI.20.1 – patient based data and aggregate data, in a process available to aggregate data to meet the needs of internal and external users (this link will open in a new tab of your current browser window), given the wide issues of concern for the two requirements about JCI Standard MCI.20.1, I shall continue on the other PI activity of infection prevention and control in another post.

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

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

Janice, RE, Celia, LH 2012, Nursing in todays world : trends, issues & management, 10th edn, Wolters Kluwer Health | Lippincott Williams & Wilkins, Philadelphia, PA, USA

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

Patient Safety Unit, Medical Care Quality Section, Medical Development Division 2012, INCIDENT REPORTING & LEARNING SYSTEM: “From Information to Action”, Ministry of Health Malaysia, viewed 28 November 2012, <http://hkbatas.moh.gov.my/v2/uploads/UPDATED_INCIDENT_REPORTING_2012_KKM.pdf>

Private Healthcare Facilities And Services Act 1998, Private Healthcare Facilities And Services (Private Medical Clinics Or Private Dental Clinics) Regulations 2006, viewed 28 November 2012, <http://www.mma.org.my/Portals/0/pdf/prv_health_fac.pdf>

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

The risks, benefits, and alternatives of surgery

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I had posted in the post Risks, benefits, and alternatives of anaesthesia (this link will open in a new tab of your current browser window) on the anaesthesia planning process which includes educating the patient, his or her family, or decision maker on the risks, benefits, and alternatives related to the planned anesthesia and postoperative analgesia. This discussion occurs as part of the process to obtain consent for anesthesia (including moderate and deep sedation). In anaesthesia care, an anesthesiologist or a qualified individual provides this education.when the risks, benefits, and alternatives are discussed with the patient, his or her family, or those who make decisions for the patient.

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Likewise prior to surgery, patients and their families or decision makers receive adequate information to participate in care decisions and to provide the informed consent.

The information provided includes:

  1. the risks of the planned procedure;
  2. the benefits of the planned procedure;
  3. the potential complications; and
  4. the surgical and nonsurgical options (alternatives) available to treat the patient.

In addition, when blood or blood products may be needed, information on the risks and alternatives is discussed.

The patient’s surgeon or other qualified individual provides this information.

Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware that medical records of patients must show evidence of the education process  in an ongoing process prior to surgery. Medical records must contain documentation on this process as required by the Joint Commission International (JCI) Standard ASC.7.1 which clearly states that “The risks, benefits, and alternatives are discussed with the patient and his or her family or those who make decisions for the patient.”, and its three (3) Measurable Elements (ME) which must be met fully at hospitals that are JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

HIM / MR practitioners must also be aware that the Joint Commission International (JCI) Standard PFR.6.4 which clearly states that “Informed consent is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures.” I had posted about informed consent in the post Informed Consents – 5 required documentation in the medical record providing information to patient and family (this link will open in a new tab of your current browser window).

Lastly, HIM / MR practitioners do take note that the JCI Standard ASC.7.1  is checked for compliance in the Medical Record Review Tool form used in the Medical Record Review process if your hospital is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

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