Patient Medical Record Review Form – JCI Hospital Survey Process Guide, 5th Edition, Part 1

Millions of football (soccer) fans around the world have been waiting four years for the 2014 FIFA World Cup which is the 20th FIFA World Cup, an international men’s football tournament which began on Thursday, 12 June 2014 and currently taking place in Brazil.

I am sure many readers already know that football might seem pretty straightforward. You will also surely know that a match of soccer has two teams of eleven players on a field (called a pitch), both trying to put a spherical ball into the other team’s goal. They can use any part of their body besides their arms or hands to do so, except the goalie (called a keeper), who can use his hands as long as he’s within a box in front of his own net.to play one man down for the rest of the match.

A team is made up of ten defenders, midfielders, and forwards — with varying numbers of each for strategic reasons — plus one keeper. Different coaches use all sorts of different numbers and formations of the first three: currently, the 4-2-3-1 formation (four defenders, two defensive midfielders, three attacking midfielders, and a forward) is especially popular.

Readers, this post if actually about the Patient Medical Record Review Form (MRRF) found in the Joint Commission International (JCI) Hospital Survey Process Guide (HSPG), Fifth Edition manual. This form is used during a Closed Patient Medical Records session to determine whether or not relevant documentation requirements for relevant standards from the JCI Hospital Accreditation Standards (HAS), Fifth Edition have been met.

As the more burning topic of interest for the next couple of weeks is the World Cup 2014 now under way, I decided to graphically represent a total of 61 JCI HAS found in this form as an Infographic showing a football match played by two teams each consisting of not more than eleven players (standards) – one of whom is the goalkeeper, using the 4-2-3-1 formation.

Just as a match of football might seem pretty straightforward, the implementation and use of the Patient MRRF during a Closed Patient Medical Records (CPMR) session is not that straightforward.

This post is the first part of a series of posts on the Patient MRRF.

As a brief overview, a total of sixty-one (61) JCI HAS are now included in this form. Several JCI HAS have been dropped from the Patient MRRF based on the JCI HSPG, Fourth Edition.. New HAS have been included based on the JCI HAS, Fifth Edition. The Standards in the JCI HAS, Fifth Edition have been rearranged and modified; as such some JCI HAS found in the Patient MMRF based on the JCI HSPG, Fourth Edition.have been given new Standards Number(s).

For a start, below is an infographic showing some twenty-two (22) JCI HAS from the total of 61 JCI HAS found in the Patient MMRF of the JCI HSPG, Fifth Edition. Click on the image which will open a new tab of your current browser window, and to view a larger image just click on the magnifying glass which appears over the image.

MMRF-football-pitch-Team-A-vs-Team-B

The subsequent post on this series will bring you more infograhics and on the changes in the Patient MMRF found in the JCI HSPG, Fifth Edition effective 1 April 2014.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Joint Commission International, 2013, Joint Commission International Accreditation Standards For Hospitals, 5th edn, JCI, USA
  3. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4thd edn, JCI, USA
  4. Joint Commission International, 2014, Hospital Survey Process Guide (HSPG), 5th edn, JCI, USA
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JCI Hospital Accreditation Decision Rules

The Joint Commission International (JCI) had announced the updated Accreditation Decision Rules for Hospitals as was published on their webiste.on 13 March 2014.

By and large Health Information Management (HIM) / Medical Records (MR) practitioner in a hospital setting will not be briefed about everything hospital accreditation, especially matters like how the decision is made to accredit a hospital. That notwithstanding, If you are working at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for accreditation status, I think it is important to be aware on how all information from the initial or triennial full JCI and any required follow-up focused survey are used to make the decision regarding a hospital accreditation.

The hospital must meet five (5) conditions to be accredited. The conditions requires that the hospital must be able to demonstrate that there is acceptable compliance with each standard, there is acceptable compliance with the standards in each chapter, there is overall acceptable compliance,  the total number of measurable elements (MEs) found to be “Not Met” or “Partially Met” is not above the mean (three or more standard deviations) for a hospital surveyed under the hospital accreditation standards within the previous 24 months, and the ME in the International Patient Safety Goals ( IPSG) is scored “Not Met”.

Since the 5 conditions encompass the relevant standards that HIM / MR practitioners manage in the daily routine management of health information management / medical records management in a hospital setting, he or she must be made aware of by circulars or at least briefed on these 5 conditions to be accredited.

If the HIM / MR practitioners in their practice fail to comply with any relevant standard, any relevant standards in each chapter, and contribute to non-compliance of MEs found to be “Not Met” or “Partially Met” is not above the mean (3 or more standard deviations) for a hospital surveyed under the hospital accreditation standards within the previous 24 months, than he or she would be deemed to be contributing negatively to the overall performance during the hospital survey process and towards accreditation been denied!

The HIM / MR practitioner is advised to be aware of At Risk for Denial of Accreditation conditions, especially the 5 conditions regarding relevant standards and MEs.

Below is a flowchart (click on the flowchart below and it will open in a new tab of your current window; click on the resulting image in this new tab for a larger view of the flowchart image – zoom to see bigger fonts or simply print to read) showing all the decision rules that will be taken by the JCI Accreditation Committee to validate if your hospital meets the criteria for accreditation. From the chart, there are two potential outcomes. The outcomes may be that the hospital meets the criteria for accreditation or does not meet the criteria and is denied accreditation. The charts also shows At Risk for Denial of Accreditation conditions.

accreditation-decision-rules

References:

  1. Joint Commission International, 2013, Joint Commission International Accreditation Standards For Hospitals, 5th edn, JCI, USA
  2. Joint Commission International, 2014, JCI Announces Updated Accreditation Decision Rules for Hospitals,  viewed 31 March 2014, <http://www.jointcommissioninternational.org/jci-announces-updated-accreditation-decision-rules-for-hospitals/>

JCI Standard GLD.3.2 – leadership role in the dynamics of communication within a hospital, Part 1

This afternoon, I am to write about the Joint Commission International (JCI) Management of Communication and Information (MCI) Standard MCI.5 which states that “The leaders ensure that there is effective communication and coordination among those individuals and departments responsible for providing clinical services.”

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Image credit: http://www.danieldecker.net/

Surely, the Health Information Management (HIM) / Medical Records (MR) practitioner’s practice is not responsible for providing clinical services, thus Standard MCI.5 will definitely not require any HIM / MR practitioner to comply with it.

However because Standard MCI.5 is included among other standards found in the MCI Chapter of the JCI manual (4th edition) that mostly apply to the practice of HIM / MR (all of which I have completed posting on this blog), I still wish to write about this standard so that HIM / MR practitioners will be aware and also that they will appreciate the ongoing communication and coordination among those individuals and departments responsible for providing clinical services in a typical hospital setting. A HIM / MR practitioner will perhaps then understand and appreciate the demand for medical records use in the dissemination of patient care information among fellow colleagues operating from different departments responsible for providing clinical services.

From the post The JCI Manuals, 5th Edition are effective 1 April 2014  (this link will open in a new tab of your current browser window), readers will now know that hospitals need to begin to focus their hospital accreditation program based on the 5th edition of the JCI international standards for hospitals.

Examining this 5th edition of the JCI international standards for hospitals, I found that there are many changes to this 5th edition of the hospital manual. Expect to find requirement changes that “raise the bar” on compliance expectations in addition to finding more clarity over and above nearly all of the text that appeared in the 4th edition.

One major change I found on further examination of the 5th edition is that you can no longer find the MCI Chapter in the 5th edition. The “Management of Communication and Information” (MCI) in the previous edition (4th edition) is now known as the “Management of Information” (MOI) chapter (5th edition).

Nonetheless, I looked for the Standard MCI.5 in the MOI chapter of the 5th edition, but it was no longer there among the rewritten MOI chapter. Delving deeper, I found that Standard MCI.5 is now moved and consolidated with similar requirements of Standards, and in this case to the “Governance, Leadership, and Direction” (GLD) chapter in the 5th edition.

The Standard MCI.5 now combines with MCI.4 (also from the 4th edition) in the GLD chapter of the 5th edition “to better align hospital leadership requirements; revises standard, intent, and MEs to clarify expectations” (JCI 2013, p.161) to form the Standard GLD.3.2 in the 5th edition which states that “Hospital leadership ensures effective communication throughout the hospital. “

I shall be writing about the Standard GLD.3.2 of the 5th edition in the next part. What I plan to write in this next part will also relate to the Standard MCI.4 which states that “Communication is effective throughout the organization.” which I have already posted in the post JCI Standard MCI.4 – accuracy and timeliness of information in the hospital through effective communication (this link will open in a new tab of your current browser window).

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Joint Commission International, 2013, Joint Commission International Accreditation Standards For Hospitals, 5th edn, JCI, USA

The JCI Manuals, 5th Edition are effective 1 April 2014

JCIH14EBJCIHSPG14Joint Commission International (JCI) Accreditation Standards for Hospitals, 5th Edition and The Joint Commission International Accreditation Hospital Survey Process Guide, 5th Edition are both now effective starting 1 April 2014.

JCI claims that the Accreditation Standards for Hospitals, 5th Edition is trimmed to contain lesser standards, has better structure and logical flow between standards requirements, and now incorporates two new chapters to cater for Academic Medical Center Hospitals

The JCI Accreditation Hospital Survey Process Guide, 5th Edition manual like the previous edition is designed to help hospitals learn about and be better prepared for the JCI survey process. However, it now contains help for Academic Medical Center Hospitals prepare for their surveys.

References:

  1. Joint Commission International, 2014, viewed 30 March 2014, <http://www.jointcommissioninternational.org/>

Never miss out an adverse event in the medical record!

JCI Standard MMU.7 imageA hospital will normally have a policy that identifies all adverse effects that are to be documented in a medical record and those that must be reported to the hospital’s authorities within a specified time frame. An adverse event is defined as “an unanticipated, undesirable, or potentially dangerous adverse effect occurrence” in a hospital (JCI ASH p.246).

Patients are reassessed to determine their response to treatment on medications since they may suffer adverse effects like allergic responses, unanticipated drug/drug interactions, or a change in their equilibrium raising their risk of falls. Therefore, patients are constantly monitored for medication effects including adverse effects through the collaborative efforts between patients themselves, their doctors, nurses, and other health care practitioners (i) to evaluate the medication’s effect on the patient’s symptoms or illness, as well as blood count, renal function, liver function, and other monitoring with select medications, (ii) to observe the patient for adverse effects, and (iii) to record in the patient’s medical record any adverse effect(s).

This monitoring process is normally a proactive approach to risk management of a hospital with a formalised program of risk management to investigate and to reduce identified, unanticipated adverse events and other safety risks to patients and staff.

The accreditation process is well known as an effective quality evaluation and management tool designed to create a culture of safety and quality within a hospital. One of the benefits of accreditation is it strives to continually improve patient care processes and results.

If your hospital is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then the basics of data gathering and preparation includes selection of measures, data collection and aggregation, data analysis and interpretation, dissemination/transmission of findings, taking action, monitoring performance/improvement are all integral to improving safety and quality of care at your hospital. Medication management data collection issues are either addressed during the System Tracer (Data Use) as a shorter survey or during the full System Tracer – Medication Management survey.

I like to draw your attention when individuals like you as a Health Information Management (HIM) / Medical Records (MR) practitioner may be roped in as part of the hospital’s group of participants during the System Tracer (Data Use) survey since you could be considered as “Individuals who are knowledgeable about the information systems available for data collection, analysis, and reporting” (JCI HSPG p.74) or excluded if a shorter survey just for medication management data collection issues are to addressed.

Do take note too that if you are at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, the Medical Record Review Tool (MMRT).will now check for compliance of the JCI Standard MMU.7 which states that “Medication effects on patients are monitored.”, which this post is all about.

Readers, this post on the JCI Standard MMU.7 and all the rest of the standards I have posted using the JCI Hospital Accreditation Standards 4th Edition, concludes all of the necessary and mandatory documentation standards that must be included in a complete medical record. For hospitals not yet on the JCI journey, I think applying all the standards that are mandatory documentation standards using the JCI Hospital Accreditation Standards 4th Edition augurs for high quality medical records documentation standards at any hospital.

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals (ASH), 4th edn, JCI, USA
  2. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA