Monthly Archives: May 2012

JCI Standard MCI.1 – brochure example

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In my previous post JCI Standard MCI.1, I talked about the “Communication with the Community” and how the HIM/MR Department communicates with its community to facilitate access to care and access to information provided by the HIM/MR Department of a hospital.

I like to share with you (with expressed permission) this brochure (file will open in a new tab of your current window of your browser) from St Vincent’s Hospital Sydney Ltd, a facility of St Vincents & Mater Health Sydney, Darlinghurst, NSW, Australia. I have always admired the Aussies for a high standard in documentation!

I think it is a good brochure on communication with the community about the privacy of a patient’s health information.

JCI Standard MCI.19 Patient Clinical Record – a review

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In continuation to the post JCI Standard MCI.19 Patient Clinical Record, the first standard, its intent and the measurable elements are:

Standard MCI.19
The organization initiates and maintains a clinical record for every patient assessed or treated.

Intent of MCI.19
Every patient assessed or treated in a health care organization as an inpatient, outpatient, or urgent care patient has a clinical record. The record is assigned an identifier unique to the patient, or some other mechanism is used to link the patient with his or her clinical record. A single record and a single identifier enable the organization to easily locate patient clinical records and to document the care of patients over time.

Measurable Elements of MCI.19

  1. A clinical record is initiated for every patient assessed or treated by the organization.
  2. Patient clinical records are maintained through the use of an identifier unique to the patient or some other effective method.

Examining the intent and the measureable elements for this standard from above, I think it is important to know answers to the following questions:

Does your hospital initiate and maintain a clinical record for every patient assessed or treated?

A patient or clinical record is defined (Michelle, A.G. & Mary J.B. 2011, pg 70) “as the business record for a patient encounter, contains documentation of all health care services provided to a patient, and is a repository of information that includes  demographic data, as well as documentation to support diagnoses, justify treatment, and record treatment results.”1

1Essentials of Health Information” (Michelle, A.G. & Mary J.B. 2011, Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, New York

So since your hospital initiates and maintains a clinical record for every patient assessed or treated, who are these kinds of patient at your hospital?

Hospital patients are usually categorised as ambulatory patients (outpatients), ambulatory surgery patients(e.g., day surgery), emergency care patients, inpatients, newborn patients, observation care patients, and subacute care patients.

Now that you have identified your list of patient types/categories, how do you identify each of these identified groups of patients? State your method and how does it work?

Do you provide a single clinical record or multiple records?

Does your method use an unique identifier? If so, what is this unique identifier?
The Medical Record Number(MRN) is commonly used as this unique identifier.

How do you maintain your patient clinical records?
The above standards do not specify methods for record management,  all hospitals must implement systems to effectively manage and control records.
In addition, filing controls are established to ensure accurate filing and timely retrieval of patient records, including:

  • Chart tracking system (they could be manual or computerised)
  • File guides
  • Periodic audit of file system

It is the intent of this standard that using an unique identifier, your hospital can easily locate patient clinical records and to document the care of patients over time. How do you locate your patient clinical records using this unique identifier?

How do you link the patient with his or her clinical record?

A master patient index (MPI), sometimes called a master person index (MPI), links a patient’s medical record number with common identification data elements (e.g., patient’s complete name, date of birth, gender, mother’s maiden name, and social security number).

If your unique identifier is the MRN, then how is your MPI used to link the patient with his or her clinical record?

Your answers to the above questions must be outlined in the HIM/MR departmental policies and procedures. Your answers will provide the JCI surveryor(s) the opportunity to evaluate the compliance to this standard and chances are, he or she will give a full compliance score for this standard, if all is in order and well documented and answers answered well!

JCI Standard MCI.19 Patient Clinical Record

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I continue my tirade(certainly not trading an angry or violent speech here, but what I actually mean is trying to strongly  inform you that more than working behind the confines of the HIM/MR Department walls you work in, there exists overseeing matters that we need to pay attention at the same time) on STANDARDS for example, JCI’s standards for Management of Communications and Information (MCI) chapter.

In my earlier post on JCI Accreditation Standards for Hospitals – Introductory Post, I started off with mention of the MCI standards chapter, and subsequently dwelled on the its first standard in the JCI Standard MCI.1 post.

Here now before I discuss other standards of MCI, I like to direct you to one subject matter dearest to all of you as HIM/Medical Records professionals.

The matter is about the Patient Clinical Record, be it paper based or EMR. I think the concepts hold true for both media.

Let us look at the standard pertaining to a Patient Clinical Record, which is MCI.19

The structure of this standard is made of one main standard(MCI.19), four sub-standards(MCI.19.1, MCI.19.2, MCI.19.3  and MCI.19.4 ) and one sub-sub-standard(MCI.19.1.1), all pertaining of course to a Patient Clinical Record – this categorisation is entirely mine, just to makes things easier to understand I think (at least for me) and clearer.

The standards as quoted from JCI’s manual, page 231 goes like this:

  • MCI.19 The organization initiates and maintains a clinical record for every patient assessed or treated.
  • MCI.19.1 The clinical record contains sufficient information to identify the patient, to support the diagnosis, to justify the treatment, to document the course and results of treatment,and to promote continuity of care among health care practitioners.
  • MCI.19.1.1 The clinical record of every patient receiving emergency care includes the time of arrival, the conclusions at termination of treatment, the patient’s condition at discharge, and follow-up care instructions.
  • MCI.19.2 Organization policy identifies those authorized to make entries in the patient clinical record and determines the record’s content and format.
  • MCI.19.3 Every patient clinical record entry identifies its author and when the entry was made inthe record.
  • MCI.19.4 As part of its performance improvement activities, the organization regularly assesses patient clinical record content and the completeness of patient clinical records.

Knowing these standards will help us know if our records keeping ways do keep up with a benchmark, in this instance that set by JCI. In this way, I believe we can then excel in records keeping and maintain high standards of professionalism in our work.

Pals, I am aware I am taking you into a discourse deeper and deeper related to a techinical discussion.

I wish and I shall try to relate to these standards with a social theme, since I did profess that this website-blog would be largely a social medium, but sadly it does not seem so as I do not see any interaction of ex-colleagues nor persons actively engaged still in HIM/Medical Records. My intention is to get people talking here, so this website-blog behaves like a social media thing where people connect and exchange views and as examples, to know where each other are located and working at and for whom, how they are doing in their chosen profession etc.

Nevertheless, I shall discuss more on MCI.19 in a future post.

Eye doctor punished(fired) for peeking at records

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Before I tell you a tale of an unlucky doctor and medical records, let us for a moment know what is brewing in Malaysia with regards to privacy.

Doing some research, I know now that our Constitution of Malaysia does not specifically recognise the right to privacy (existing laws with implications for privacy include the Communications and Multimedia Act (CMA), the Anti-Corruption Act, the Companies Act, the Computer Crimes Act (CCA), modeled after the United Kingdom’s Computer Misuse Act of 1990, and section 509 of the Penal Code), but does provide for several related rights, including freedom of assembly, speech and movement(historically, the government has circumscribed all of these rights by law or practice in the name of anti-terrorism. The most controversial of these laws remains the Internal Security Act (ISA), which was originally enacted in the 1960’s in response to Communist insurgency).

However, you maybe aware that our Malaysian Ministry of Energy, Communications and Multimedia (MECM) has begun drafting a new personal data protection bill.with e-commerce concerns and the desire to comply with the adequacy provisions of the European Union Data Protection Directive (http://www.kettha.gov.my/en/content/ministry-finalising-draft-personal-data-protection-bill). I am unable to know more about this development, so I am leaving this to rest as-is basis from their official website.

The Bill aims to regulate the collection, possession, processing and use of personal data by any person/organisation (“the data user”), including the government, so as to provide protection to an individual’s (“the data subject’s”) personal data and safeguard the individual’s privacy. The legislation will also establish a set of common rules and guidelines on the handling and treatment of personal data by any person/organisation. Amongst the stated objectives of the Bill are as follows:

(i) to provide adequate security and privacy in handling personal information;
(ii) to create confidence among consumers and users of both networked and nonnetworked industries;
(iii) to accelerate uptake of e-transactions;
(iv) to promote a secure electronic environment in line with Multimedia Super Corridor
objectives.

So much for an introduction about privacy concerns in Malaysia, and now for the tale of the unlucky doctor from Stockton, CA.

Who was this doctor?
Dr. Abe Magallanez, an optometrist was employed with  Kaiser Permanente(founded in 1945, Kaiser Permanente is one of the USA’s largest not-for-profit health plans, serving more than 9 million members, with headquarters in Oakland, California) at Stockton ( the 13th largest city in the State of California, USA).

What did he do “wrong” ?
Kaiser his employer, said he looked into his wife and his two children (patients) medical records.

How does Magallanez feel about this “wrong”?
“I think it’s important not only as a (health) provider but also as a father that my family’s health and well-being are being met,” Magallanez said. “That is one of my responsibilities.”

He said even his family members gave verbal permission to review their records.

How does Kaiser view this “wrong”?
Kaiser thinks otherwise, “reviewing family records without written consent violates federal law and company policy, both of which are strictly enforced.”

Kaiser issued a statement, saying access to members’ personal health information is “strictly limited only to those situations where there is a clear clinical need.”

It further said, “Kaiser Permanente members can authorize the release of their medical records to others, but that release must be in writing, based on HIPPA (federal) or California privacy law. Employees who violate our confidentiality policies are subject to disciplinary action, including termination.”

What is Magallanez doing about this?
Magallanez is suing Kaiser in federal court. His suit also alleges his labor union abandoned him.

What does his labor union say to his allegation?
The union says it stood up for him but further efforts were futile. Karen Sawislak, executive director of Engineers and Scientists of California, Local 20, said the union stood by Magallanez through three grievance procedures.

A local optometrist’s panel and the executive board both upheld the decision not to take the case to arbitration, she said.

“The board decided that the particular conduct alleged – this case basically would not prevail,” Sawislak said.

How did it all begin?
When his son got a rash, a dermatologist prescribed a medication that didn’t work. Magallanez checked the record and discussed his son’s case with the dermatologist.

Was Magallanewz presumptuous when he had intervened in cases outside his specialty as an optometrist?

“I don’t think it was ever arrogant,” Magallanez replied. “My firm belief is that all providers, we’re all human, we make mistakes. And if someone can look at it a different way, maybe there’s some light to it.”

As Magallanez was unemployed, did he seek unemployment from Kaiser?
YES he did, but was refused, an administrative law judge even said he deserved it.

What was the court’s opinion?
Magallanez’ court papers quote the opinion: “Given that the Plaintiff had authorization from each of his family members … the Plaintiff’s actions do not constitute a deliberate violation but rather a good faith error in judgment.”

Therefore, the judge reasoned, Kaiser’s stated reasons for Magallanez’ firing must be a pretext. “The plaintiff was discharged for reasons other than misconduct in connection with his most recent work,” the judge concluded.

What is the view from HIPPA?
The state Office of HIPPA Compliance and Implementation said the Health and Safety Code (Section 123110), says patients can inspect their records. But they must submit written requests.

As for family permission, it does not need to be in writing by law, but hospitals are allowed to require it as policy. Kaiser does.

What now?
Magallanez says he has gone bankrupt.

Magallanez complained against the union to the National Labor Relations Board. The regional board dismissed his claim. Magallanez is appealing to Washington.

Magallanez admits he erred. Still, he said, a man should be able to help his family. “I don’t believe it was a fair and just decision,” Magallanez said.

Adapted from an article by By MIchael Fitzgerald, Record Columnist, Recordnet.com, posted May 13, 2012, with Q&A format of story by R. Vijayan.

An overview of quality indicators under the JCI QPS approach

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This morning I presented some pertinent questions I think Health Information Management (HIM)/Medical Records professionals face in their roles collecting and managing quality indicators in the hospital.

This evening I like to give an overview about quality indicators and how q-indicators are approached by JCI in the planning, designing, measuring, collecting, and analysing stages.

The JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS manual describes JCI’s approach to improving quality and patient safety concerns, thus reducing the risks to patients and staff. In this manual one can find the Quality Improvement and Patient Safety (QPS), which is devoted to the mainstream activities of quality improvement and patient safety that are found in both clinical processes as well as in the physical environment.

JCI’s approach advocates that the leadership of a hospital must be guided by an overall framework for quality management and improvement activities in the hospital. Thus the leadership must always have a clear vision of its role in this approach and proactively identify and reduce risk and variation by leading and planning the quality improvement and patient safety program at their hospital, with the objective to achieve maximum benefit from this approach

This leadership with the help and coordination of a quality improvement and patient safety oversight group or committee, oversees and ensures that both new clinical and managerial processes are well designed and that these processes implemented are working well through data collection methods. This data is analysed to allow the leadership to focus on priority issues to implement and sustain changes that result in improvement to both clinical processes as well as in the physical environment of the patient.

By applying the QPS standards to daily work, doctors and nurses – who assess patient needs and provide care to patients, hospital managers, support staff, and others like you, can make real improvements that help patients and reduce risks. In this way these groups I believe and conjure will understand how clinical and managerial processes can be more efficient, how to manage them wisely and efficiently, and reduce physical risks in the hospital.

It is important to take into account as most clinical and managerial quality issues involve more than one department or unit, are thus interrelated and may involve many individual job and roles.

So what are then the QPS standards?

They standards as outlined from pages 146 to 147 of the manual are as follows:

QPS.1 Those responsible for governing and managing the organization participate in planning and measuring a quality improvement and patient safety program.

  • QPS.1.1 The organization’s leaders collaborate to carry out the quality improvement and patient safety program.
  • QPS.1.2 The leaders prioritize which processes should be measured and which improvement and patient safety activities should be carried out.
  • QPS.1.3 The leaders provide technological and other support to the quality improvement and patient safety program.
  • QPS.1.4 Quality improvement and patient safety information is communicated to staff.
  • QPS.1.5 Staff are trained to participate in the program.

Design of Clinical and Managerial Processes
QPS.2 The organization designs new and modified systems and processes according to quality improvement principles.

  • QPS.2.1 Clinical practice guidelines, clinical pathways, and/or clinical protocols are used to guide clinical care.

Data Collection for Quality Measurement
QPS.3 The organization’s leaders identify key measures in the organization’s structures, processes, and outcomes to be used in the organizationwide quality improvement and patient safety plan.

  • QPS.3.1 The organization’s leaders identify key measures for each of the organization’s clinical structures, processes, and outcomes.
  • QPS.3.2 The organization’s leaders identify key measures for each of the organizations managerial structures, processes, and outcomes.
  • QPS.3.3 The organization’s leaders identify key measures for each of the International Patient Safety Goals.

Analysis of Measurement Data
QPS.4 Individuals with appropriate experience, knowledge, and skills systematically aggregate and analyze data in the organization.

  • QPS.4.1 The frequency of data analysis is appropriate to the process being studied and meets organization requirements.
  • QPS.4.2 The analysis process includes comparisons internally, with other organizations when available, and with scientific standards and desirable practices.

QPS.5 The organization uses an internal process to validate data.

  • QPS.5.1 When the organization publishes data or posts data on a public Web site, the leaders of the organization ensure the reliability of the data.

QPS.6 The organization uses a defined process for identifying and managing sentinel events.
QPS.7 Data are analyzed when undesirable trends and variation are evident from the data.
QPS.8 The organization uses a defined process for the identification and analysis of near-miss events.

Improvement
QPS.9 Improvement in quality and safety is achieved and sustained.
QPS.10 Improvement and safety activities are undertaken for the priority areas identified by the organization’s leaders.
QPS.11 An ongoing program of risk management is used to identify and to reduce unanticipated adverse events and other safety risks to patients and staff.

JCI says “the framework presented in these standards is suitable for a wide variety of structured programs and less-formal approaches to quality improvement and patient safety. This framework can also incorporate traditional measurement programs, such as those related to unanticipated events (risk management) and resource use (utilization management).”

JCI further states that “over time, organizations that follow this framework will

  • • develop greater leadership support for an organizationwide program;
  • • train and involve more staff;
  • • set clearer priorities for what to measure;
  • • base decisions on measurement data; and
  • • make improvements based on comparison to other organizations, nationally and internationally.”

In my next posts to this QPS chapter, I shall discuss the roles of Health Information Management (HIM)/Medical Records professionals, how you fit into the framework presented in these standards for a structured program and less-formal approaches at your hospital to quality improvement and patient safety, that could result in improvement to both clinical processes as well as in the physical environment of the patient. It would then be clearer on your roles managing quality indicators in the hospital in the continuous planning, designing, measuring, collecting, and analysing stages of hospital-wide quality indicators.