Category Archives: Hospital Accreditation

MSQH – SERVICE STANDARD 7, Organisation and Management for STANDARD 7.1.1

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MSQH-Book-SS7-HMISOrganisation and Management is the first topic among six (6) topics which make up the standards under SERVICE STANDARD 7 for Health Information Management System (HIMS) based on the 4th Edition of the Malaysian Society for Quality in Health (MSQH) Hospital Accreditation Standards effective January 2013, used by the MSQH, which is the sole Malaysian accreditation body with nationally established standards for health care facilities and services since 1997, dedicated to improving the quality of Malaysia’s health care through voluntary accreditation. You can read about the 6 topics from the post MSQH – Introductory Post (this link will open in a new tab of your current window) as well view the hierarchy of these topics (the green boxes) from the graphic below (click on the graphic to view a larger image which will open in a new tab of your current window).

MSQH Service Standard 7

Standard 7.1.1 is the first standard for Service Standard 7 and the only standard under the topic Organisation and Management (OM) which states that “The Health Information Management System (HIMS) Services shall be organised and administered to facilitate the collation, aggregation and analysis of hospital demographic data through an established system which includes safe keeping and retrieval of medical records and documents related to patient care.

Health Information Management (HIM) / Medical Records (MR) practitioners in Malaysia whose hospitals are engaged in hospital accreditation using the 4th Edition of the Malaysian Society for Quality in Health (MSQH) Hospital Accreditation Standards effective January 2013 for the Service Standard 7 HIMS must truely know that his or her hospital needs to fully satisfy fifteen (15) criteria for compliance to the OM topic for this service standard.

The criteria for compliance to the OM topic for this service standard ranges from the organisation management of the HIM / MR Department through processes planning and continued development, data management of information about major clinical services that meets Malaysian statutory requirements, reporting systems for incident reports, the formation and activities of a Medical Records Committee, and ends with the department’s involvement in quality improvement activities.

You can view the whole range of criteria listed from https://docs.google.com/file/d/0B1XnOSMJXDaqR184d1BsbHQxQWs/edit (this link will open in a new tab of your current window) from the Download List Sub-Menu under the Resources Menu.

Now I like to draw your attention to the variation or differentiation between nearly identical entities and other non-identical entities found under MSQH Service Standard 7, Standard 7.1.1 and those found under the  Joint Commission International (JCI) hospital accreditation standards,

HIM / MR practitioners will find a similarity between JCI hospital accreditation found in Standard MCI.9 (which I have not blogged on as yet) with  the MSQH Service Standard 7, Standard 7.1.1 under Criterias 7.1.1.1 to 7.1.1.10 when both of them try to cover aspects of the HIM / MR department’s mission, services provided, resources, access to affordable technology,and support for effective communication among caregivers

HIM / MR practitioners will find another similarity between JCI hospital accreditation found in Standard MCI.19.4 with the MSQH Service Standard 7, Standard 7.1.1 under Criteria 7.1.1.13 which requires regular Medical Records Review (MRR) sessions. However the MSQH Service Standard 7, Standard 7.1.1 under Criteria 7.1.1.13 does not elaborate the review process nor is there any  MMR tool to use unlike that found under JCI.

Unlike hospital accreditation for JCI accreditation status, a specific Root Cause Analysis (RCA) activity is required of HIM / MR practitioners under  the MSQH Service Standard 7, Standard 7.1.1 under Criteria 7.1.1.12 . I hope HIM / MR practitioners will not be wrongly allocated the task of conducting RCA for all incidents that occur in the hospital but rather they will only be confined to RCA for all incidents that occur for HMIS services only. as I understand from Criteria 7.1.1.11, MSQH Service Standard 7, Standard 7.1.1 which stipulates that “The Head of the HIMS Services shall ensure that the staff of HIMS Services complete incident reports which are discussed by the services with learning objectives and forwarded to the Person In Charge (PIC) of the Facility.”

There is no direct reference to “The Medical Records Committee” to be found in JCI. However, HIM / MR practitioners in Malaysia need to be aware that according to the notes found under Criteria 7.1.1.13, MSQH Service Standard 7, Standard 7.1.1 “The Medical Records Committee is a subcommittee of Medical and Dental Advisory Committee (MDAC) who advises the Governing Body on matters pertaining to HIMS.” and not as reporting directly to the Hospital’s Director or other equivalent top management official.

Quality Assurance (QA) Managers and their departments are normally assigned the duties of facilitating quality improvement (QI) activities for the hospital. I can infer that QA managers have a specialised and trained role in QI, and thus are fully qualified to be the facilitator of such QI activities, Nonetheless, Criteria 7.1.1.15, MSQH Service Standard 7, Standard 7.1.1 has assigned this role with the given and added responsibility to HIM / MR practitioners to be the “facilitator for quality improvement activities of the Facility. Areas of involvement may include:

a) compiling patient care data for clinical review/research;

b) supervising data collection and advising on analysis of data collected by personnel of other services.”

Lastly, I find that MSQH Service Standard 7, Standard 7.1.1 does not have set criteria to cover the clause “safe keeping and retrieval of medical records and documents related to patient care.” while on the contrary Standard MCI.12 of the JCI clearly states that “The organization has a policy on the retention time of records, data, and information.”

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. SERVICE STANDARD 7 Health Information Management System 2013, Malaysian Hospital Accreditation Standards, 4th edn, The Malaysian Society for Quality in Health (MSQH), Malaysia

Periodicity Of Reassessments For 13 Situations Found In Medical Records

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Here is a graphic to show a summary of the periodicity of reassessments in 13 situations which can be found in a medical record. Click the image to view a larger image in a new tab of your current window.

Periodicity-Of-Reassessments-For-13-Situations-Found-In-Medical-Records

Reassessment of all patients and results are always entered in their medical records

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Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware of the evidence of reassessment of all patients and results which are always entered in patients’ medical records. The results of these reassessments noted in the patient’s medical record is for the information and use of all those caring for the patient.

Health care practitioners  – predominately doctors and nurses are the ones who routinely conduct reassessment of patients in the following situations:

  1. to determine the patient’s response to treatment and whether the intervention remains appropriate
  2. to plan for continued treatment or discharge
  3. at intervals based on a patient’s condition and when there has been a significant change in his or her condition, plan of care, and individual needs or according to organisation policies and procedures

HIM / MR practitioners also need to be aware that a reassessment is integral to ongoing patient care i.e. it is a continuous process, and it is the key to understanding whether care decisions are appropriate and effective, and are normally carried out at intervals based on the patient’s condition and treatment to determine their response to treatment and to plan for continued treatment or discharge.

However, the periodicity of reassessment depends on the condition as well as a patient’s needs extending to the plan for continued treatment or discharge, or as defined in organisation policies and procedures as in the following situations:

  1. acute care patients are reassessed by the doctor(s) at least daily, including weekends, and when there has been a significant change in the patient’s condition
  2. non-acute patients maybe assessed less than daily and determined by a hospital policy which defines the circumstances in which, and the types of patients or patient populations for which, a doctor identifies the minimum reassessment interval for these patients
  3. nursing staff may be observed to periodically record vital signs as needed based on the patient’s condition in response to a significant change in the patient’s condition
  4. if the patient’s diagnosis has changed and the care needs require revised planning
  5. to determine if medications and other treatments have been successful and the patient can be transferred or discharged
  6. the care of patients undergoing moderate and deep sedation especially the frequency and type of patient-monitoring requirements
  7. the minimum frequency and type of monitoring during anaesthesia which is written into the patient’s anaesthesia record
  8. monitoring of physiological status during anaesthesia administration which is written into the patient’s anaesthesia record
  9. the patient’s physiological status is monitored during surgery and immediately after surgery
  10. the patient’s readiness for discharge based on the patient’s current reassessed health status and need for continuing care or services as determined by the use of relevant criteria or indications from a referral and/or discharge plan begun early in the care process and, when appropriate, which had included the family to ensure patient safety
  11. the collaborative monitoring process on medications by doctors, nurses, and other health care practitioners when they jointly evaluate the medication’s effect on the patient’s symptoms or illness and monitor and report for adverse effects like allergic responses, unanticipated drug/drug interactions, or a change in the patient’s equilibrium raising the risk of falls among others, thus in both cases to allow the dosage or type of medication to be adjusted when needed
  12. when patients are been monitored to their response to a collaborative plan among doctors, nurses, the dietetics service, and, when appropriate, the patient’s family, to provide nutrition therapy after a screening process during an initial assessment to identify those at nutritional risk
  13. dying patients and their families are assessed and reassessed according to their individualised needs by evaluating and managing their symptoms and preventing complications to the extent reasonably possible in the care of these dying patient to optimize his or her comfort and dignity

As I researched for this post, I found that this is the NOT the last in the list of medical record documentation requirements I have found as required by the Joint Commission International (JCI) standards for documentation required in a medical record.

I will still need to discuss on these other medical record documentation requirements:

  1. when a hospital policy identifies adverse effects that are to be recorded in the patient’s record and those that must be reported to the hospital
  2. when the patient’s response to nutrition therapy is recorded in his or her record
  3. when assessments and reassessments need to be individualised to meet patients’ and families’ needs when patients are at the end of life, and assessment findings are documented in the patient’s medical record

Nonetheless, any hospital’s medical record documentation, irrespective if the hospital had undergone the journey to JCI accreditation or is planning to do so, all of which will contain reassessment findings recorded in them, including that related to needs when patients are at the end of life.

So if you are practising at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then your hospital will need to fully comply with the JCI Standard AOP.2 which states that “All patients are reassessed at intervals based on their condition and treatment to determine their response to treatment and to plan for continued treatment or discharge.” Documentation of reassessment of patients in their medical records also satisfies the JCI Standard MCI.19.1, Measurement Element 5 requirement which states that “Patient clinical records contain adequate information to document the course and results of treatment.”.

References:

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

JCI Standard MCI.1 – Communication with the Community

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It is natural to think of the Public Relations (PR) department of a hospital when a hospital needs to deal with a community it serves to facilitate access to care and access to information about its patient care services. Thus, it is not surprising to pass the buck to a representative of the PR department of a hospital sitting in a Management Of Communication And Information (MCI) Committee to deal with, and in order to comply with the Joint Commission International (JCI) Standard MCI.1 which states “The organization communicates with its community to facilitate access to care and access to information about its patient care services.”

I think if you are a leader championing the JCI MCI standards, this leader must not merely delegate this MCI standard to the PR department representative to deal with, but must also nurture as teacher, mentor, colleague, and friend to guide and be responsible to coach in the implementation and compliance of this standard, thus to care for and encourage the growth or development of MCI standards for the hospital. In this scenario, it is important for this leader to be knowledgeable in PR by at least researching the subject matter and linking his or her literature reviews with this standard.

From my interactions with representatives of PR department of hospitals, they normally deal with the management of both internal and external communications. They told me they are responsible for promotions of the hospital and implementation of the hospital’s marketing programmes that are related to overall mission and vision of the hospital, also manage and improve the flow of information within the hospital and between the hospital and the community it serves. Public relations professionals also serve as liaisons to the community and work closely with other health partners in the locality in preventive health. The responsibilities of a PR person in a hospital setting includes writing and distributing news release, feature articles to the press, compiling press list, witting of newsletters, handling and maintaining a media information service, arranging press, radio and television interviews for management, preparing marketing plans for various programmes and create strategies in promotional and marketing efforts. In summary, the PR department is responsible for community relations, hospital publications, media relations special events and support for fundraising.

Since the measurable elements for this standard requires a hospital to (i) implement  a communication strategy, (ii) provide information on its services, hours of operation, and the process to obtain care through mass media interventions, such as those delivered by leaflets, booklets, posters, billboards, newspapers, radio and television, and (iii) provide information on the quality of its services, “the quality of services as is always determined by certain attributes that they have or should have. The most important attributes health services should have, are accessibility and availability,usage facility, public’s acceptance and all these always in relation to their cost.” (Athina and Andriani, 2012, p. 205) which is provided to the public and to referral sources with defined communities  and populations of interest,  I personally think that the PR department in a hospital is best suited to manage and measure this standard based on what I have already said in the preceding paragraph.

With all what I wrote above and what I intend to say in the next paragraph, let me remind you that all of us serving in the socioeconomic system of healthcare, including doctors and patients carry on our lives as person-systems within a hierarchy of multiple and overlapping systems of family, community and wider society. The internal needs of patients as person-systems, i.e. the patient is unwell, the patient’s family, workmates, employers and hospitals will tend to accept the sick role of this patient. After a defined length of time, the patient seeks the professional endorsement of a doctor for a clinical transaction, which is a subsystem of the hierarchy of systems comprising health care.  At the end of the day, the person-systems of doctor and patient constituting of the patient, members of family, community systems and professional (e.g. the doctor) or economic systems, all support a speedy and complete return to health for the patient.

Members of the MCI Committee must be aware that the approach it chooses in understanding and measuring as well as complying with this standard, is driven by the care delivery for the population served by the hospital in advising patients on how to leverage the system to ensure coordination of care across the continuum, integrated across the continuum among defined communities and populations of interest with healthcare specialists in the hospital.

So what is this “defined communities and populations of interest”,  if you are a member of  a  MCI Committee, you need to focus on?

Marie and Sandra (2011, pp. 46-47) define population of interest as “a population at risk or those with a common risk factor leading to the threat of a particular health issue. It also may be defined as a population of interest known as a healthy population who may in fact improve their health by making certain choices that will further promote health and/or protect against disease or injury. For example, an adolescent population that engages in alternative sports and chooses to wear protective gear avoids serious injury.”

I have been asked how and what does the PR department do in order to understand patterns and trends within this population of interest. First, I think it is the best interest of the PR department to be comfortable enough with information technology to collect and organise data, initiate and develop appropriate databases for their practice to better assess and serve the population of interest. I also think the PR department must design cross-sectional studies at finding out the prevalence of a phenomenon, problem, attitude or issue by taking a snap-shot or cross-section of the population. Pre-test/post-test studies could also be undertaken to measure the efficacy of a program on the same population to determine if a change has occurred.

I have also been asked how and what does the PR department do when identifying defined communities. My advice is that the PR department must be involved in gathering census data that provide the PR department with evidence about the overall health status of the population living in a particular community. The PR department could use the Internet which provides a wealth of data such as geography and history of a community as well as census track boundaries and data.

Armed with knowledge on defined communities  and populations of interest, the PR department  must surely be able to show evidence that there is (i) a communication strategy to reach the defined communities  and populations of interest , (ii) information on its services, hours of operation, and the process to obtain care, and (iii) information on the quality of its services, which is provided to the public and to referral sources with defined communities  and populations of interest, in order to fully comply with Standard MCI.1.

All this is possible when the hospital and the PR department jointly develop and revise strategic and operational plans to address community needs for a healthier community within larger geographic or political areas as reflected in the hospital’s mission and required by the JCI Standard GLD.3.1 which states that “Organization leaders plan with community leaders and leaders of other organizations to meet the community’s health care needs.”, thus recognising that they have responsibility for and can achieve an impact on the community.

References:

  1. Athina, L & Andriani, D, 2012, Quality assurance in healthcare service delivery, nursing, and personalized medicine: technologies and processes, Medical Information Science Reference, Hershey, PA, USA
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Kingsley, N & Sam, S 2009, Problems With Patients: Managing Complicated Transactions, Cambridge University Press, Cambridge, UK
  4. Louise, LI & Carolyn, LB 2008, Public Health Nursing: Leadership, Policy & Practice, Delmar Cengage Learning, New York, USA  
  5. Marie, TL & Sandra, BL (eds.) 2011, Public health nursing : practicing population-based care, Jones and Bartlett Publishers, Sudbury, MA, USA
  6. Stephan, J & Frank,  MG 2011,  Information and Communication Technologies in Healthcare, CRC Press, Boca Raton, FL, USA

The need for discharge planning and discharge planning documentation

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The attending doctor is responsible for a patient’s care and determines the patient’s readiness for discharge based on the policies and relevant criteria or indications of referral and discharge established by the hospital policy guiding the referral or discharge of patients .

Referring or discharging a patient to a health care practitioner outside the hospital, another care setting, home, or family is based on the patient’s health status and need for continuing care or services.

Continuity of care requires special preparation and considerations for some patients, such as for discharge planning.

Discharge Planning is a process which is initiated as soon as possible upon inpatient admission, that is during the initial assessment which includes determining the need for patients for whom discharge planning is critical due to age, lack of mobility, continuing medical and nursing needs, or assistance with activities of daily living, among others.

The discharge planning process includes a mechanism to identify those patients for whom discharge planning is critical. A discharge planning worksheet is generated based on a list of criteria and used as an assessment tool by a case manager or an utilisation manager (if there is one at your hospital, or in most instances initiated by a nurse), to identify patients who may require post-hospital services on discharge for inpatients once their acute phase of illness has passed. This worksheet is used to develop the Case Management Note which is a progress note documented by the case manager or an utilisation manager (if there is one at your hospital, or in most instances by a nurse),which outlines a discharge plan that includes case management/social services provided and patient education.

Discharge planning involves discussions on discharge plans with patients and their families on admission and during the hospital stay. A discharge plan is prepared to help determine home needs, assist in planning for needed medical equipment, helps in choosing a facility for care if the patient is unable to return home, and facilitates discharge to home or transfer to another facility.

The Case Management Note is not the same document as the Discharge Note which is the final progress note documented by the attending doctor, which includes details like the patient’s discharge destination (e.g., home), discharge medications, activity level allowed, and follow-up plan (e.g., office appointment).

Health Information Management (HIM) / Medical Records (MR) practitioners do take note that Health Information Management / Medical Records Management services does not include Discharge Planning. However HIM / MR practitioners can expect to find a Case Management Note included in some patients’ medical records.

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 discharge planning given to some patients as required by the Joint Commission International  (JCI) Standard AOP.1,11 which states that “The initial assessment includes determining the need for discharge planning.”, if you are working at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

I like to point out that the Medical Record Review Tool has an error that shows the JCI Standard AOP.1.8.1 (Early screening for discharge planning) as found in the JCI Hospital Survey Process Guide, 3rd Edition, Effective January 2008 instead of showing the JCI Standard AOP.1,11 with regards to compliance in discharge planning. You can find my corrected version of this JCI recommended Medical Record Review Tool from this link (the form will open in a new tab of your current window).

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA