Category Archives: Hospital Accreditation

Risks, benefits, and alternatives of anaesthesia

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When devising a plan of anaesthesia care, the anaesthesia planning process includes educating the patient, his or her family, or decision maker on the risks, benefits, and alternatives related to the planned anaesthesia and postoperative analgesia.

Educating the patient, his or her family, or decision maker on the risks include the following factors to consider when formulating a planned anaesthetic,  usually hampered by individual patient variability:

  1. persuading patients who may express a fear of dying during anesthesia that anaesthesia is very safe (Ronald & Manuel, 2011)
  2. certain prescription drugs (antihypertensive, tranquilisers, steroids, and diuretics) and over-the-counter (OTC) medications and herbal preparations, can increase (Sue & Patricia, 2011) the patient’s anaesthesia risks. Surgical patients with chronic diseases at risk taking numerous medications can cause complications during the perioperative period and also increase the patient’s anaesthesia risks. The anaesthesiologist will advise the patient, family, and decision makers which medication(s) must be stopped at least 2 weeks prior to surgery, or the surgery may be canceled.
  3. the patient’s co-morbid conditions i.e coexisting diseases
  4. other risks include peripheral nerve damage, brain damage, airway trauma (most often caused by difficult tracheal intubation), intraoperative awareness, eye injury, fetal/newborn injury, and aspiration.

The use of regional anaesthesia has significant benefits for patients and facilities. For example, regional anaesthesia  for patients undergoing orthopedic procedures decreases (Ronald & Manuel, 2011) overall anaesthesia when compared to general anaesthesia and postanaesthesia care unit (PACU) discharge time can be shortened and the immediate postoperative period made more pleasant for the patient.

The patient, his or her family, or decision maker  will be educated on the choice of anaesthesia, whether it is to be either general, or regional or sedation and will be influenced by (Ronald & Manuel, 2011):

  1. site of the surgery
  2. position of the patient during surgery
  3. risk of aspiration
  4. age of the patient
  5. patient cooperation
  6. anticipated ease of airway management
  7. coagulation status
  8. previous response to anaesthesia
  9. preference of the patient

This discussion on the risks, benefits, and alternatives related to the planned anaesthesia and postoperative analgesia occurs as part of the process to obtain consent for anaesthesia (including moderate and deep sedation) as required in PFR.6.4, ME 2, which I have already blogged about 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 link of your current window).

An anaesthesiologist or a qualified individual provides this education.

If a hospital has been accredited for Joint Commission International (JCI) accreditation status or already enjoying JCI accreditation status or because a hospital is going for a re-survey by JCI surveyors for another new term of JCI accredited status, then a Health Information Management (HIM) / Medical Records (MR) practitioner is likely to be part of a team using the Medical Records Review Tool form during any one Medical Records Review session which contains the JCI Standard ASC.5.1 to test for conformance to its requirement which states that “The risks, benefits, and alternatives are discussed with the patient, his or her family, or those who make decisions for the patient.”

Although this standard does not require any form of documentation in the medical record, HIM/MR practitioners must take note that risks, benefits, and alternatives that are discussed with the patient, his or her family, or those who make decisions for the patient are normally recorded by the surgeon or anaesthetist in the Preanaesthesia Evaluation Note.

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

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

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

When others can grant consent

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Image credit : http://www.ophthalmologymanagement.com/

Previous posts about patient informed consent on this blog provided insight into required documentation in a medical record, and they were built upon requirements on:

  1. how a process defined by the hospital and carried out by trained staff in a language the patient can understand, facilitates acquiring patient informed consent
  2. how patients and families can make care decisions after they receive adequate information about the illness, proposed treatment(s), and about health care practitioners who have primary responsibility for the patient’s care or who is authorised to perform procedures or treatment(s)
  3. informed consent which is obtained before surgery, anaesthesia, use of blood and blood products, and other high-risk treatments and procedures

Image credit : http://www.eidohealthcare.com/

In this post I shall discuss about a hospital process within the context of existing law, culture, and custom when others can grant informed consent as the last required documentation in the medical record for patient informed consent.

Informed consent is based (Michelle & Mary, 2011) upon the principle of autonomy which refers to an individual’s right to choose and the ability to act on that choice. The individuality of a patient as an individual with a right to decide for them is respected when autonomy is maintained.

A frequently occurring ethical dilemma confronting autonomy is when informed consent for care sometimes requires that people other than (or in addition to) the patient be involved in decisions about the patient’s care. This is especially true when the patient does not have the mental or physical capacity to make care decisions, when culture or custom requires that others make care decisions, or when the patient is a child. It should not be surprising that the process of seeking informed consent when informed consent for care sometimes requires that people other than (or in addition to) the patient be involved in decisions about the patient’s care presents doctors and other health professionals with difficult ethical issues.

When the patient is a child, parental or guardian consent should be obtained before treatment is initiated on a minor. If a patient is a minor and the parents or legal guardian deny a lifesaving treatment, a court may be obtained by the hospital authorities to overrule the decision.

When a patient is either comatose or near death, there is usually knowledgeable concurrence by the prescribing doctor who writes a do not resuscitate (DNR) order and the patient’s family or guardian about actions to prolong the patient’s life. The principles of informed consent must be respected by the prescribing doctor. A hospital will have policies in place that provide a mechanism (process) that respects local law, culture, and custom for reaching a DNR decision as well as for resolving conflicts in decision-making.

At a later time, if a patient with dementia is unable to give informed consent for procedures and thus unable to make decisions competently, responsibility for decision-making often falls on the family. The family can make decisions on behalf of the patient, using the patient’s expressed preferences from an advance directive stating the his or hers preferences for caregiver procedures, treatments, and life-sustaining measures, completed while he or she was still mentally competent to understand and make health decisions.

Parents and guardians will be required to provide informed consent to disclose to those who need to know a minor’s human immunodeficiency virus (HIV) status to provide medical care and services care. Such confidential HIV related information will indicate that the minor had an HIV-related test; or has HIV infection, HIV-related illness, or Acquired Immunodeficiency Syndrome (AIDS) or any information that could indicate that the minor has been potentially exposed to HIV.

The Joint Commission International (JCI) requires that a hospital “establishes a process, within the context of existing law and culture, for when others can grant consent” and “individuals, other than the patient, granting consent are noted in the patient’s record” through its Standard PFR.6.2 (JCI, 2011).

In all circumstances irrespective if the hospital is JCI accredited or not, Health Information Management (HIM) / Medical Records (MR) practitioners must look out for relevant informed consent form documentation that must be available in the medical record for a (i) minor, (ii) mentally incompetent patients, (iii) DNR patients, (iv) patients with dementia, and (v) minors diagnosed or suspected as HIV infected.

HIM/MR practitioners must be aware that informed consent will not be present in the medical record for patients in certain extreme emergencies such as when an unconscious patient is admitted to an emergency room and procedures may be performed without specific written or verbal consent, as no one may be available to give consent. HIM/MR p can update their awareness by checking out specific protocols in documentation maintained for example from their hospital Quality Department  that must be followed for example, (i) that allow for two doctors to sign an emergency consent, and (ii) a court order to administer treatment is obtained for cases of extreme emergencies.

A hospital policy usually contains clauses to the above exceptions for informed consent when others can grant consent within the context of existing law and culture. I like to advise HIM/MR practitioners to also check out relevant hospital policy to reference and formulate a section on informed consent HIM/MR best practices including circumstances when other can give consent on behalf of patients, in the Medical Records Policy.

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

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

Data must be aggregated, analysed, and transformed into useful information by expert individuals

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A hospital’s primary purpose is to provide patient care and to work to improve patient care outcomes over time by applying quality improvement principles. To reach conclusions and to make decisions on how to work to improve patient care outcomes over time, requires access to a wide range of information from varying sources.

Each time patients receive health care, a record is generated to document the patient’s current symptoms,medical history, results of examination, treatments rendered along with outcomes, ancillary report results (e.g., laboratory), diagnoses, and plans for treatment. This patient data is organised, analysed, and maintained by Health Information Management (HIM) / Medical Records (MR) practitioners working in hospital settings to ensure the delivery of quality health care.

Data collection and analysis processes entail combining patient care data from various sources and transformed into useful information.  But the ability to collect and analyse data within and across hospitals is hampered by different information systems and processes, and by the highly complex and fragmented nature of health care systems.

Converting data into meaningful information for decision making calls for the expertise of trained and qualified professionals. The data analysis process involves individuals who will be among medical, nursing, and other departmental heads who participate in relevant quality improvement and patient safety processes. These indivuals must understand information management, have skills in data aggregation methods, and know how to use various statistical tools and techniques when suitable, and participate in the process.

Understanding statistical techniques is helpful in data analysis, especially in interpreting variation and deciding where improvement needs to occur. Every system has variation; some of this is due to the system itself, known as common cause variation; some of it is due to singular incidents or special situations; this is special cause variation. 94 percent of problems (or possibilities for improvement) lie with the system as common-cause variation; 6 percent are special causes (Deming, 1982). In understanding trends and variation in health care, statistical tools for example run charts, control charts, histograms, and Pareto charts can prove to be useful statistical tools to know. Examining data over a period of time and making decisions based on trends or other patterns, will save time, energy, and other resources.

HIM/MR practitioners are trained in managing patient health information and medical records, administering computer information systems, and coding diagnoses and procedures for health care services provided to patients, and have an understanding of statistical techniques as part of their training and education.  I believe their unique knowledge and expertise in hospital management information systems will enable strong partnerships beween them and with clinical and management teams to advance the quality and safety of patient care delivery.

Image credit : http://www.dashboardinsight.com/

Data analysis must provide continuous feedback of quality management information to help those individuals make decisions and providing continuous quality improvement, and allocating limited resources to optimise quality and effectiveness. Thus, results of data analysis need to be reported to those individuals responsible for the process or outcome being measured  and who are accountable for taking action of the results.

Hospitals which have adopted the Joint Commission International (JCI) hospital accreditation program, and who are already JCI acredited or hospitals seeking JCI accreditation status or hospitals that are seeking for a re-survey for JCI accreditation status, have to comply with JCI Standard QPS.4, which specifically requires that individuals in  a hospital with appropriate experience, knowledge, and skills systematically aggregate and analyze data using statistical tools and techniques when suitable and transform the data into useful information. This standard also requires that  “Results of analysis are reported to those accountable for taking action.”

It is imperative from the above that HIM/MR practitioners practicing in hosptitals with a quality improvement and patient safety program such as hospital accreditation are likely individuals who will be among medical, nursing, and other departmental heads who participate in relevant quality improvement and patient safety processes. HIM/MR practitioners as trained individuals to understand healthcare information management, have skills in data aggregation methods, and know how to use various statistical tools and techniques, and thus I believe they will be best suited for this role.

References :
American Health Information Management Association (AHIMA) 2011, HIM Functions in Healthcare Quality and Patient Safety, Viewed 15 September 2012 < http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049122.hcsp?dDocName=bok1_049122>

Deming, WE 1982, Out of the Crisis, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA

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

The assessment findings from patient’s and family’s ability to learn and willingness to learn are documented in the patient’s record

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A patient education plan should be among the contents of a medical record. Health Information Management (HIM) / Medical Records (MR) practitioners need to know that assessment findings of patients and their family of their knowledge and skill strengths and deficits documented in the patient’s medical records, are used to plan the education.

I think HIM/MR practitioners also need to know and understand why this documentation forms part of a medical record.

HIM/MR practitioners must understand  that patient and family education is an integral part of patient care. Caregivers at a hospital must assist the patient to identify the learning needs and resources to help restore and maintain an optimal level of functioning. A knowledge deficit about the course of illness and self-care practices hinders a patient’s recovering from illness or engaging in health-promoting behaviors.

To help bridge the gap between what a patient knows and what a patient needs to know in order to achieve optimum health, a plan must be formulated to determine if the patient and family are willing and capable to learn. The patient and family ability to learn and willingness to learn are then assessed

Thus, the HIM/MR practitioners will find documentation of the assessment findings based on many patient variables that determine if the patient and family are willing and capable to learn. Therefore, to plan the education, the hospital assesses:

  1. the patient’s and family’s beliefs and values since different people attach different values to different types of risk. and patients of different cultures react to illness with their own ingrained broader health belief systems encompassing just about everything seen, heard or felt since their birth; this is especially so as the world becomes borderless and with the new wave of medical tourists searching for the cutting-edge medical expertise and technology, it is common in hospital settings to receive an increasing number of incoming medical tourism patients and immigrant patients from various ethnic and cultural backgrounds
  2. their literacy, educational level, and language as health care teaching involves the use of printed materials, involves reading, comprehension, basic mathematical abilities, and the ability to make health care decisions
  3. emotional barriers – anxiety, fear, anger, depression and inability to comprehend and motivations – frequent reinforcement of learning through immediate feedback and continual reassessment of effectiveness enhances the value of the learning
  4. physical limitations – affecting learning that involves physical application of knowledge for example when a patient learns to give himself or herself an injection, and cognitive limitations – affecting learning that involves the acquisition of facts and data often used in problem solving and decision-making
  5. the patient’s willingness to receive information

HIM/MR practitioners working in a hospital setting that has acquired the Joint Commission International (JCI) accreditation status or is planning to be accredited or been re-surveyed by JCI, must know that JCI mandates that medical records should contain documentation on patient teaching and learning. The JCI Standard PFE.2.1 requires that “The patient’s and family’s ability to learn and willingness to learn are assessed.” and also requires that “The assessment findings are documented in the patient’s record.”

However, HIM/MR practitioners need to realise that patient education is a standard and essential component of medical and nursing practice, teaching interventions and the patient’s response must be documented in all practice settings. Elements of a patient education plan include:

  1. content taught
  2. teaching methods used
  3. who was taught (e.g., patient, which family member, other caretaker)
  4. patient and family response to teaching activities

One approach of documentation for patient and family teaching is by using codes that helps nurses, doctors and other health care providers to document and track patient education in a Patient and Family Education Record. Nurses, doctors and other health care providers make an assessment of need, provide education and then document the encounter using codes found in the form. The codes allow the educator a quick method of documenting that education took place during a given patient visit or stay. The form informs everyone using the form that a given patient received education on specific topics and encourage subsequent health professionals to do the appropriate follow-up.

Click here (this link opens in a new tab of your current window browser) for an example of a Patient and Family Education Record.

Such documentation promotes (Sue and Patricia, 201) continuity of care and facilitates accurate communication to other health care providers.

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

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

University of Connecticut Health Center USA, PATIENT AND FAMILY TEACHING RECORD – Family Education of the Hospitalized Infant, viewed 12 September 2012 <http://nursing.uchc.edu/unit_manuals/ccmc_nicu/FORMS/FORM%20-%20Family%20Education%20of%20the%20Hospitalized%20Infant%20(9-1-11).pdf>

Plan of posts on Quality Improvement and Patient Safety (QPS) standards

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I first introduced an approach to make real improvements that help patients and reduce risks through international accreditation standards in my post An overview of quality indicators under the JCI QPS approach (this link will open in a new tab of your current browser window).

In that post I prepared the ground for future posts on patient safety in the accreditation process of the Joint Commission International  (JCI) from the chapter “Quality Improvement and Patient Safety (QPS)”. In promoting the quality agenda in hospitals, this QPS chapter from the  JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 4TH EDITION manual describes a comprehensive approach to quality improvement and patient safety.

In this post, I shall present my plan to discuss how best I think Health Information Management (HIM) / Medical Records (MR) practitioners can contribute and benefit by applying the QPS standards to their daily work to understand how processes can be more efficient, resources can be used more wisely, and physical risks can be reduced.

The QPS chapter presents the standards into five (5) sections (as I shall refer the layout of the standards from this chapter ) of standards as follows :

  1. Section 1 : Leadership and Planning
  2. Section 2 : Design of Clinical and Managerial Processes
  3. Section 3 : Measure Selection and Data Collection (Data Collection for Quality Measurement)
  4. Section 4 : Validation and Analysis of Measurement Data (Analysis of Measurement Data)
  5. Section 5 : Gaining and Sustaining Improvement (Improvement)

Section 1 is about hospital management (leaders) collaboration to carry out a quality improvement and patient safety program.

Design of new and modified systems and processes according to quality improvement principles is covered in standards from Section 2.

Selection and data collection of key measures for each of the hospital’s clinical and managerial structures, processes, and outcomes are requirements for standards under Section 3.

Section 4 has several standards that outlines what, when, who and how on validation and analysis stages of data collected from identified key measures in Section 3.

Knowledge gained from data analysis of Section 4 is gainfully used (acheieved) to identify potential improvements or to reduce (or prevent) adverse events and sustained through an ongoing program of risk management. Data collected is also used to identify improvement and safety activities for the priority areas identified. An ongoing program of risk management is used to identify and to reduce unanticipated adverse events and other safety risks to patients and staff. These are improvement and safety activities covered under the standards from Section 5.

I believe that HIM/MR practitioners will be involved from the initial stage of collaboration with hospital management and other departmental leaders to carry out a quality improvement and patient safety program to the period when risk management activities continue to sustain the hospital’s Quality Improvement and Patient Safety program.

My next post on QPS standards for quality improvement and safety activities will begin with standards found under Section 4. I plan to walk through these standards first as I think they will involve health information contained in medical records, directly involving HIM/MR practitioners in data collection and analysis of clinical structures, processes, and outcomes.

However, I shall be paying visits to the other standards in the QPS chapter and cross-referencing them or making separate posts for any QPS standard apart from those from Section 4. I believe there is no one right way to approach quality improvement and safety activities by using the framework enshrined in the JCI QPS chapter but I plan to approach the way I feel the best way I can do in benefit of HIM/MR practitioners.

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