The hospital you work at will have many data-driven processes in place to assess ways to improve patient care. Data is collected and analysed, data analysed is usually used to evaluate its current performance and also to be able to compare your hospital’s performance with other similar hospitals, all of which is to find the opportunity to improve in four ways:

1. analysis of its past historical data with itself over time , such as month to month, or one year to the next or last year’s value to the current year, or a time series of several years, provides an initial baseline for examining trends and allows judgment on the direction of the measure;
2. making competitor and industry comparisons what other similar hospitals are achieving provides crude guidelines. Competitor and industry comparisons has direct bearing on the hospital’s profitability, especially the privately owned hospital;
3. (a) with standards, such as those set by accrediting and professional bodies such as through reference databases collected and analysed from data on hospital performance frequently made available through publicly available hospital quality comparison Web sites aimed at patients for example, data that can be viewed from Hospital Compare from the Centers for Medicare and Medicaid Services, Quality Check from the Joint Commission on Accreditation of Healthcare Organizations and the Leapfrog Group’s Hospital Quality and Safety Survey Results; comparing standards set for example by the Joint Commission International (JCI) also enables a hospital to improve its desirable practices; also, (b) it is common knowledge that hospitals are legally responsible for ensuring the quality of medical care; as healthcare practitioners we are aware that the hospital management of a public hospital or in the case of a private hospital – the hospital board, is responsible for exercising the duty of care based on those set by laws or regulations – for example the legal requirement of the Private Healthcare Facilities And Services (Private Medical Clinics Or Private Dental Clinics) Regulations 2006, Private Healthcare Facilities And Services Act 1998 in Malaysia, on behalf of the patients and the community and on behalf of doctors who desire to participate, and the hospital as a whole is liable for damages should they fail.; and
4. with recognised desirable practices identified in the literature as best or better practices or practice guidelines, for example in determining the success or failure of medical audit assessment by monitoring actual or suspected problems through (i) sentinel cases, (ii) criterion-based audit, (iii) comparison of small groups in the same field applicable at local hospital levels, (iv) conducting surveys like patient satisfaction surveys, and (v) peer review.

These comparisons help the hospital understand the source and nature of undesirable change and help focus improvement efforts that can be achieved through re-education, retraining, facilitation in small groups, or by more active persuasion.

If your hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then it must be able to show evidence that it has a process or processes that incorporates data analysis measures to make relevant comparisons (i) over time within the hospital, (ii) with similar hospitals when possible, (iii) with standards when appropriate , and (iv) with known desirable practices, in order to satisfy the JCI QPS.4.2 Standard which states that “The analysis process includes comparisons internally, with other organizations when available, and with scientific standards and desirable practices.

How do Health Information Management (HIM) / Medical Records (MR) practitioners fit into this JCI Standard?

I can think of two ways as I come to the end of  this post.

In my opinion, HIM /MR practitioners must facilitate diagnostic excellence from rapid communication of patients’ current needs and understanding of the clinically indicated responses by ensuring that recording is made faster and more complete in medical records , include safeguards to improve accuracy, and speed transmission of patient-related information. For example, the penalty for incomplete medical records (usually a temporary loss of privileges) is quickly and routinely applied. A word of caution though about imposing the penalty. As we are fully aware, reality, however, does not always match with what is desired since I believe many doctors still enjoy the  part of their job which is talking to their patients and in this context, medical records tends to assume lesser importance. I think it is also not desirable to have a culture among doctors to be obsessive record writers who ‘spent all the time writing and didn’t even look at me’, a common complaint among patients.

HIM /MR practitioners must also exercise caution in the retrieval of medical records of the sample of patients designated as appropriate for example,a medical records audit. For example, the retrieval of medical record through diagnostic coding for Myocardial Infarction (MI) cases, after a patient’s discharge, may not enable the retrieval of a record of a patient who had a dissecting aneurysm of the aorta mismanaged as an MI for the first 12 hours of his/her care

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

Kenneth RW, and John RG 2010, The well-managed healthcare organization, 7th edn, Health Administration Press, Chicago, Illinois, USA

Srinivasan, AV 2008, Managing a modern hospital, 2nd edn, Response Books, SAGE, New Delhi, India