Category Archives: JCI

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/ >

Data Validation Process In Summary

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Measurement is about selecting what is to be measured, selecting and testing the
measure, collecting the data, validating the data, and using the data for improvement.

Validating the data is an important tool for understanding the quality of the quality data which is reliable, accurate, and defensible data that has been validated, for establishing the level of confidence decision makers can have in using data and in their implications for clinical practice.

An example of performance measurement is when an area for improvement in structure, process, and/or outcome is identified, new guidelines for patient care and safety are usually developed by the hospital using the data which had been selected, tested, collected, validated for patient care and safety improvement. This change process is normally managed by the hospital and include key stakeholders (e.g., clinicians) affected by the change.

An example of data validation when Health Information Management (HIM) / Medical Records (MR) practitioners who are generally specialised or experts is in disease coding may be involved, is when they provide advice in disease coding validation studies to determine staff training needs.

To ensure that a sample is valid when evaluating performance, it is critical to always determine an appropriate sample size ie. the number of subjects to choose, a procedure to ensure that your sample is representative of the population i.e the degree to which the subjects are similar to those in the intended use, and also determine the types of data to be used (administrative or clinical).

Well, you need to sample so as to try to get one that represents the population as closely as possible. This is because we rarely have enough time and money to look at the entire group of people that we are interested in (for example, the population of everyone attending a clinic at a particular hospital).

In trying to getting a valid sample, let us assume you had limited money, you cannot
study the target population as a whole. By all means do select a small sample size but when you choose a small sample size, there is always a higher risk of sampling error being present, for example when you could only choose only two patients out of the population of 30.

Unclear data definitions and inconsistent coding of data are reasons when data elements are found not to be the same. It is vital to have a list of codes with their definitions that you are going to be using throughout the collection of data. For example, if you are coding ward clerk as 1 and charge nurse as 2, it is important to ensure that you have used the same codes throughout the process of entering data into the dataset. In data validation, It is important to make corrective actions when inconsistent coding of data is found. However, if you do decide to change some data codes, it would be wise to note any changes as you progress.

The chart below characterises the process of data validation (by clicking on the chart below, it will open in a new tab of your current window, and by clicking on the image in this new tab, you can view a larger view of the chart).

Data Validation Process

Data validation to ensure that good, useful data have been collected

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Anyone who deals with data, will know that data is first acquired (collected) and verified (validated) before data input. Data input is then processed or managed which includes data storage, data classification, data update, and data computation. Data output is when the data input and processed or managed is retrieved and data is presented in a meaningful way.

Data acquisition (collection), data verification (validation), data classification, data storage, data update, data computation, data retrieval and data presentation are the eight elements which make up the three phases when we deal with data, that is the data input phase, the data management or processing phase and lastly, the data output phase.

Data are the raw materials that involves both the generation and the collection of accurate, timely, and relevant data through reliable measurements that ensures good, useful data have been collected.

Good, useful data involves using an internal data validation process in the authentication and validation of gathered data from authoritative, valid, and reliable data sources. It is important to consider applying the garbage in garbage out (GIGO) principle in collecting valid data.

If your hospital is implementing or has already begun a quality improvement program for example the Joint Commission International (JCI) hospital accreditation program, the quality of your hospital’s quality improvement program  is only as valid as the data that you have collected through reliable measurements.

When using data for improvement and for establishing the level of confidence decision makers can have in the data when implementing or starting a quality improvement program, JCI (2011, pg. 156) recommends data validation in these following circumstances :

  • a new measure is implemented (in particular, those clinical measures that are intended to help an
  • hospital evaluate and improve an important clinical process or outcome);
  • data will be made public on the hospital’s Web site or in other ways;
  • a change has been made to an existing measure, such as the data collection tools have changed or the
  • data abstraction process or abstractor has changed;
  • the data resulting from an existing measure have changed in an unexplainable way;
  • the data source has changed, such as when part of the patient record has been turned into an electronic
  • format and thus the data source is now both electronic and paper; or
  • the subject of the data collection has changed, such as changes in average age of patients, comorbidities,
  • research protocol alterations, new practice guidelines implemented, or new technologies and treatment methodologies introduced.

JCI (2011, pg. 157) also recommends the following essential elements of a credible data validation process as an important tool for understanding the quality of the quality data:

  1. re-collecting the data by a second person not involved in the original data collection
  2. using a statistically valid sample of records, cases, and other data; a 100% sample would only be needed when the number of records, cases, or other data is very small
  3. comparing the original data with the re-collected data
  4. calculating the accuracy by dividing the number of data elements found to be the same by the total number of data elements and multiplying that total by 100. A 90% accuracy level is a good benchmark
  5. when data elements are found not to be the same, noting the reasons (for example, unclear data definitions) and taking corrective action
  6. collecting a new sample after all corrective actions have been implemented to ensure the actions resulted in the desired accuracy level

Health Information Management (HIM) / Medical Records (MR) practitioners do take note that 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 it must integrate data validation into its quality management and improvement processes, has an internal data validation process that includes (1) through (6) above, and the data validation process must include at least the measures selected as required in Standard QPS.3.1 when “The organization’s leaders identify key measures for each of the organization’s clinical structures, processes, and outcomes.” Such identified key measures is usually integrated as an ongoing standardised process to evaluate the quality and safety of the patient services provided by each medical staff member as required by the JCI Standard SQE.11 In other words, each of the hospital’s clinical structures, processes, and outcomes provided by each medical staff member are evaluated, and conclusions drawn from in-depth analysis of known complications of clinical structures, processes, and outcomes as applicable which are in turn used for all corrective actions to be implemented.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Joseph, T & Payton, FC, 2010, Adaptive health management information systems : concepts, cases, & practical applications, 3rd edn, Jones and Bartlett Publishers, Sudbury, MA, USA

6 steps in documenting hospital screening to identity patients with nutritional or functional needs

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If you have been part or will be part of a Medical Records Review team at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, you will be surprised how so many of the team members do not know the reason for nutritional screening which is the start of the the Nutrition Care Process – even among nurses in the team, and most will even not know where to find such evidence of nutritional screening in the medical record. Most of times, poor documentation in relation to the quality of nutrition documentation can be observed when nutritional screening data is not even gathered and forms left not filled appropriately.

In my opinion, it is the duty of the Medical Records Review team leader to highlight in his or her report non-compliance to nutritional screening among other findings, so that the hospital’s leaders can initiate a structured investigation to identify barriers to compliance for nutritional screening. I also strongly support that there must be an agreed standard for the type and context of screening tool(s) to be used, for example among a group of hospitals under an organisation. I believe standardisation facilitates research into barriers leading to poor documentation in relation to the quality of nutrition documentation, and this will lend credibility and usability of available screening tools for greater compliance.

Below is a diagram which summarises the steps in documenting hospital screening to identity patients with nutritional or functional needs, based on the previous post Hospital screening criteria data to identify patients with nutritional or functional needs (this link will open in a new tab of your current browser).

6 Steps In Documenting Hospital Screening To Identify Patients With Nutritional Or Functional Needs

Hospital screening criteria data to identify patients with nutritional or functional needs

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Patient medical records should show evidence that information on nutritional status or functional status is gathered through the application of screening criteria, when patients who are acutely or chronically unwell and who are experiencing dietary difficulties and deficiencies related to or resulting from their illness, first contact hospital services.

From the post Assessments within 24 hours (this link will open in a new tab of your current browser), it is clear that the initial medical and nursing assessments are completed within 24 hours of admission to the hospital  or when the patient’s condition indicates, the initial medical and/or nursing assessment are conducted and available earlier, for use by all those caring for the patient. This means that patients are screened for nutritional risk as part of the initial assessment with the application of screening criteria to gather information on nutritional status or functional status which is often done by nurses, must also be completed routinely within 24 hours of admission to the hospital or at an earlier time period.

Nutritional screening is usually undertaken by nurses and doctors; assessment by dietitians.

GETTY_H_062112_WeightScale

Image credit: abcnewsradioonline.com

Nurses use individual hospital screening criteria to identify patients with nutritional or functional needs like:

  • unexpected weight loss
  • gastrointestinal symptoms
  • obvious emaciation
  • pressure ulcers
  • intravenous or tube feedings

In each case, the screening criteria are developed by qualified individuals with the aim to identify those who are malnourished or ‘at risk’ of becoming so and so able to further assess and, if necessary, to provide any required patient treatment. For example, screening criteria for nutritional risk may be developed by nurses who will apply the criteria, dietitians who will supply the recommended dietary intervention, and nutritionists able to integrate nutritional needs with the other needs of the patient.

Referencing of all tools available and screening criteria used  is beyond the scope of this single post. However, I like to share with you the desirable qualities of such tools used to carry out the screening which are namely (i) accuracy of the tool(sensitivity and specificity), (ii) easy to use, (iii) reliable so as to produce similar results with repeat testing in the same circumstances and with different users where the patient’s state has not changed it must be acceptable to those being screened, (iv) does not require extensive training, and (v) does not need additional equipment.

For your information too, two commonly used tools developed for hospital-wide application and used with older adults are (i) Mini Nutritional Assessment (MNA), and (ii) Malnutrition Universal Screening Tool (MUST).

Information through these kinds of screening criteria tools provides insight into the patient’s overall physical health. The information may also indicate that patients at risk for nutritional problems according to the criteria, receive further or more in-depth assessment of nutritional status or functional status, including a fall-risk assessment.   This information is viewed as the most effective way and an essential first step in the management of patients’ nutritional care.

The more in-depth assessment mentioned above may be necessary to identify the problem or potential nutrition risk(s) for those high risk patients in need of nutritional interventions and patients in need of rehabilitation services or other services related to their ability to function independently or at their greatest potential. Nurses refer these patients in need of a functional assessment according to the criteria to the hospital Dietitian for full nutrition assessment.. The dietitian will usually first review the medical record of referred patients. Everything from diagnosis, social history, medical history, medication, laboratory data and assessment, and evaluations performed by other medical/clinical personnel are scrutinised  According to Jacqueline (2011), reading the medical record which contains the notes of other clinicians provides necessary context for effective management of the condition(s) being assessed. A dietitian may then take anthropometric measurements in addition to a subjective nutritional assessment.

Subjective data pertaining to the nutritional assessment, identify abnormal findings and client strengths which could include for example, Patient A who is a female, stated age 42 years; reports she had a fever for 2 days a week ago; drinks 4 to 6 glasses of water daily) and anthropometric measurements i.e the objective data could include for example, Height: 5 feet, 5 inches (165 cm); body frame: medium; weight: 128 lb (58 kg); BMI: 21.3). The data is usually clustered to reveal any significant patterns or abnormalities. These data may then be used to make clinical judgments about the status of the patient’s nutritional health.

At this point, I like you to take note that the dietitian uses assessments techniques which vary for the mother and unborn child as well as the complications associated with pregnancy, the lactating mother, infants and children.

Once the dietitian has a a clear understanding of the medical diagnosis and its nutritional implications, intervention is initiated, the patient is carefully monitored to ensure that goals are met and the desired outcome is achieved.

Do take note that if you are working at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, your hospital will need to comply with JCI Standard AOP.1.6 which states that “Patients are screened for nutritional status and functional needs and are referred for further assessment and treatment when necessary.”

I am sure you are already aware that your hospital has in place a program which evaluates its patients’ risk for falls – which could include fall history, medications-and-alcohol-consumption review, gait and balance screening, and walking aids used by the patient, and monitors both the intended and unintended consequences – for example, the inappropriate use of physical restraints or fluid intake restriction which may result in injury, impaired circulation, or compromised skin integrity of measures, taken to reduce falls.

JCI believes that compliance to JCI Standard AOP.1.6 as part of the initial assessment using criteria developed by qualified individuals to identify patients who require further functional assessment, further strengthens a hospital’s fall-risk reduction program.

It is common in hospitals when patients are provided dietetic services after dietary orders by the doctor attending are documented in the patient medical record. Health Information Management (HIM) / Medical Records (MR) practitioners will find within medical records, progress notes with the nutritional care of the patient met in accordance with the doctor’s orders and also the Dietary Progress Note, a progress note documented by the hospital dietitian as part of recognised dietary practices which includes:

  • patient’s dietary needs
  • any dietary observations made by staff (e.g., amount of meal consumed,food likes/dislikes, and so on)

HIM / MR practitioners who are members of a closed Medical Record Review, need to be aware that the Medical Record Review Tool will assess and determine the degree of compliance with standards and elements of performance relating to nutrition care given by the JCI Standard AOP.1.6, when there is evidence in the medical record of patients screened for nutritional status and functional needs.

References:

  1. Jacqueline, CM, 2011, Detitian’s guide to assessment and documentation, Jones and Bartlett Publishers, Sudbury, MA, USA
  2. Janet, W, & Jane HK, 2010, Health assessment in nursing, 4th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, PA, USA
  3. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  4. Nutritional screening and assessment, Nursing Times.net, viewed 17 February 2013, < http://www.nursingtimes.net/nutritional-screening-and-assessment/199381.article >
  5. Using nutritional screening tools to identify malnourished patients, Nursing Times.net, viewed 17 February 2013, < http://www.nursingtimes.net/nursing-practice/clinical-zones/nutrition/using-nutritional-screening-tools-to-identify-malnourished-patients/1958881.article >
  6. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
  7. Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA