MSQH – Introductory Post

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MSQH-SS-7MSQH short for the Malaysian Society for Quality in Health, 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.

MSQH’s standards cover all aspects of healthcare, beginning with the patient’s point of entry into the healthcare system, patient’s interphase with healthcare providers, staff ethics, training and their competencies and outcomes of care.

MSQH avails that its standards are at par with other hospital accreditation standards like the Joint Commission International (JCI) Standards after the International Society for Quality in Health Care (ISQua) had granted MSQH the highly esteemed honor that “accredits the accreditors” and provides worldwide recognition for accredited organisations like MSQH that meet approved international standards under ISQua’s International Accreditation Program (IAP).  This highly esteemed honor for the period from August 2008 to July 2012 reinforces that MSQH’s standards meet the highest international benchmark.

Effective January 2013, all MSQH accredited hospitals are surveyed once every four years, submit the 18 month and 30 month compliance reports, and will also undergo ‘Surprise Surveillance’ for continuous compliance based on the 4th Edition of the MSQH Hospital Accreditation Standards.

In this introductory post and in subsequent posts, I shall begin blogging about the MSQH SERVICE STANDARD 7 Health Information Management System based on the 4th Edition of the MSQH Hospital Accreditation Standards.

This standard is divided into 6 topics as follows:

TOPIC 7.1: ORGANISATION AND MANAGEMENT

TOPIC 7.2: HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

TOPIC 7.3: POLICIES AND PROCEDURES

TOPIC 7.4: FACILITIES AND EQUIPMENT

TOPIC 7.5: SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

TOPIC 7.6: SPECIAL REQUIREMENTS

Topic 1 to Topic 5 each have one standard, while Topic 6 has 2 standards. All the standards have a list of criteria for compliance.

I shall be writing about Topic 7.1 in my next post on MSQH SERVICE STANDARD 7.

References:
Malaysian Society for Quality in Health 2013, About, viewed 2 February 2013, <http://www.msqh.com.my/web/index.php?option=com_content&view=article&id=46&Itemid=54>

Malaysian Society for Quality in Health 2013, CEO’s Message, viewed 2 February 2013, <http://www.msqh.com.my/web/index.php?option=com_content&view=article&id=52&Itemid=61>

APDC: ICD-10 codes for 12 known and common diseases of the duodenum, gall bladder, liver, and pancreas

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ICD-10-book-cover-for-APDC-series-labelBeginning with this post, I shall commence a series called “APDC”, short for “Anatomy and Physiology Disease Coding”.

Posts will feature anatomy vectors incorporating display of diseases and conditions terms from the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10).

My aim of these posts is to share ICD-10 coding experiences on common diseases and conditions with readers  who have just embarked on a new career in Health Information Management (HIM) / Medical Records (MR) management and as a refresher for ICD-10-experienced readers.

By common, I am only highlighting the diseases and conditions that I have frequently encountered  principal diagnoses found in medical records here in Malaysia, and perhaps in your region too.

Today let us look at diseases and conditions common to the duodenum, gall bladder, liver, and pancreas. The image below shows some of the common diseases and conditions found in medical records for the duodenum, gall bladder, liver, and pancreas (click on the image to view a larger image in a new tab of your current browser window).

ICD10-codes-for-12-known-common-diseases-of-DGBLP

ICD-10 Chapter XI is the chapter that contains the ICD-10 codes for diseases of the digestive system, including those affecting the duodenum, gall bladder, liver, and pancreas.

Alcoholic liver disease usually occurs after years of drinking too much. The longer the alcohol use has occurred, and the more alcohol that was consumed, the greater the likelihood of developing liver disease, causing swelling and inflammation (hepatitis) in the liver. Over time, this can lead to scarring and then cirrhosis of the liver. Cirrhosis is the final phase of alcoholic liver disease. Code K70.3 for alcoholic liver disease is advised..

Acute cholecystitis is a sudden inflammation of the gallbladder that causes severe abdominal pain. In 90% of cases, acute cholecystitis is caused by gallstones in the gallbladder. Other causes include severe illness and (rarely) tumors of the gallbladder. If it is recorded as acute cholecystitis, then use the ICD-10 code, K81.0, but many times it is just recorded as cholecystitis, thus just use K81.

The cystic duct is the short duct that joins the gallbladder to the common bile duct. Gallstones can enter and obstruct the cystic duct, preventing the flow of bile. Have you encountered jaudice sometimes recorded in the medical record? The occurrence of jaundice due to inflammation of the gallbladder neck and adjacent hepatoduodenal ligament resulting from a stone lodged in the cystic duct could be defined as the Mirizzi syndrome, a rare complication. Inexperienced coders would just code the jaundice to R17, unspecified jaundice.

Duodenitis is inflammation of the duodenum, the first portion of the small intestine. The duodenum is a tube around a foot long. Its near end connects to the stomach; the duodenum’s far end blends into the rest of the small intestine.

Duodenitis can only be diagnosed with a tissue biopsy, which is performed using endoscopy (esophagogastroduodenoscopy). Hence, Biopsy or endoscopy are common ways of recording diagnosis, which means the Health Information Management (HIM) / Medical Records (MR) practitioner must read the contents of the medical record to derive at a more decisive ICD-10 code.  Some of you must have known the diagnosis Crohn’s disease –  an inflammatory condition that can cause duodenitis,:recorded as the principal diagnosis in medical records. If you are certain that duodenitis is the reason for the endoscopy, then use ICD-10 code K29.8, otherwise just code Crohn’s disease.

The shape of the pancreas is like a tadpole, the pancreas can be affected in its head (the rightmost portion that lies adjacent to the duodenum), body (the middle portion of the pancreas), tail (the leftmost portion of the pancreas that lies adjacent to the spleen) parts, and the ducts that lead away from the pancreas.

Most people have just one pancreatic duct. The pancreatic duct (functional), or duct of Wirsung (also referred as the Major pancreatic duct), is a duct joining the pancreas to the common bile duct to supply pancreatic juices which aid in digestion. The pancreatic duct joins the common bile duct just prior to the ampulla of Vater, after which both ducts perforate the medial side of the second portion of the duodenum. However, some people have an additional accessory pancreatic duct also called the Duct of Santorini (non-functional), which connects straight to the duodenum, bypassing the Ampulla of Vater.

Compression, obstruction or inflammation of the pancreatic duct may lead to acute pancreatitis. The most common cause for this obstruction is choledocholithiasis, or gallstones in the common hepatic duct. ICD-10 Code K80.5 is the correct code for choledocholithiasis. Obstruction can also be due to duodenal inflammation in Crohn’s Disease. A gallstone may get lodged in the constricted distal end of the ampulla of Vater, where it blocks the flow of both bile and pancreatic juice into the duodenum. Bile backing up into the pancreatic duct may initiate pancreatitis. Calculus of pancreas is the condition when a gallstone may get lodged in the pancreatic duct. ICD-10 Code K86.8 is used for this condition.

Sometimes doctors will record the discharge diagnosis as ERCP, short for Endoscopic Retrograde Cholangiopancreatography, which is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. Through the endoscope, the surgeon can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on X-rays. ERCP is used primarily to diagnose and treat conditions of the bile ducts and main pancreatic duct, including gallstones. Since procedure coding is yet to be implemented in most hospitals in Malaysia,  I like to suggest that Health Information Management (HIM) / Medical Records (MR) practitioners must read the medical record to determine the right ICD-10 to use. Is the patient suffering from acute pancreatitis or chronic pancreatitis, or a disease of biliary tract, unspecified and the ERCP done for diagnostic purposes. I think in this instance it is best to code this case as K83.9 for disease of biliary tract, unspecified.

Fibrosis of pancreas (K86.8) is a specified disease of the pancreas.caused by such processes as necrosis (a form of cell injury that results in the premature death of cells in living tissue), inflammation or duct obstruction, in this instance the accessory pancreatic duct due to chronic pancreatitis.

Malignant neoplasm (cancer) may affect the head of pancreas, acute pancreatitis may be caused by the middle pancreas, and malignant neoplasm (cancer) may also affect the tail of pancreas. ICD-10 C25.0 is used to code malignant neoplasm of the head of pancreas, ICD-10 C25.2 is used to code malignant neoplasm of the tail of pancreas, and ICD-10 K85 is used to code acute pancreatitis causes by the middle pancreas. Do remember to refer to Chapter IV (appropriate codes in this chapter, i.e. E05.8, E07.0, E16-E31, E34.-) that may be used, if desired, as additional codes to indicate either functional activity by neoplasms and ectopic endocrine tissue or hyperfunction and hypofunction of endocrine glands associated with neoplasms and other conditions classified elsewhere. For those wishing to identify the histological type of neoplasm, then provide the separate morphology codes from the section Morphology of neoplasms..

Cholangitis is an infection of the common bile duct, the tube that carries bile from the liver to the gallbladder and intestines. Bile is a liquid made by the liver that helps digest food. Cholangitis is usually caused by a bacterial infection, which can occur when the duct is blocked by something, such as a gallstone or tumor. The infection causing this condition may also spread to the liver. Use ICD-10 Code K83.0 for Cholangitis affecting the bile duct. You may need to code the infection as well.

Bile duct obstruction is a blockage in the tubes that carry bile from the liver to the gallbladder and small intestine. Either or both of the left and right hepatic ducts can be affected. If the obstruction is not due to calculus, then the ICD-10 code K83.1 must be used. The presence of gall stones in these ducts requires the use of the ICD-10 codes K80.3, K80.4 and K80.5

Do exercise caution when applying these codes (K80.3, K80.4 and K80.5) when cholelithiasis, or gallstones, a common syndrome in which hard stones composed of cholesterol or bile pigments form in the gallbladder is also reported.

References:

  1. Nicki, RC, Brian, RW & Stuart, HR 2010, Davidson’s Principles and Practice of Medicine, 21 edn, Churchill Livingstone Elsevier, Elsevier Health Sciences, Beijing, P.R. China
  2. William, DC 2010, Current clinical medicine, 2nd edn, Saunders Elsevier, Philadelphia, PA, USA
  3. World Health Organization 2011, Volume 1 Tabular list, International Statistical Classification of Diseases and Related Health Problems 10th Revision, 2010 edn, Geneva, Switzerland

Making comparisons via data analysis for improvement efforts

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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

10 Ways ICD-10 Changed Everything In Malaysian Healthcare

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I stumbled upon this chart below from AAPC, that provides education and professional certification to physician-based medical coders and to elevate the standards of medical coding (by clicking on this chart, the  chart will open in a new tab of your current window and you can then click the image again from the new tab to view a larger and clearer image).

ICD-10 will change everything

Chart credit: aapc.com/

As Malaysia had already implemented ICD-10 by 1 January 1999, I felt like doing this post based on the chart above showing the things that changed since the transition period in 1998 from ICD-9 till we switched to using ICD-10, as you can view from the presentation below (by clicking on this presentation, the presentation will open in a new tab of your current window and you can then click the image again from the new tab to view a larger and clearer image).

10-Ways-ICD-10-Changed-Everything-In-Malaysian-Healthcare

Written Discovery – Introduction

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written-discovery-logThis post is a follow-up to the subject of written discovery I talked about in the post JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” (this link will open in a new tab of your current browser window).

I am writing from common knowledge and experiences and I must confess I am no legal authority but I have used facts in this post based on matters relating to public domain circulars and proceedings I had been part of.

In Malaysia and even in your country it is increasing common when individual healthcare providers and hospitals face a real threat of becoming defendants in malpractice lawsuits.

Some common potential-litigation warning signs of an impending malpractice lawsuit may include instances when (i) the hospital administration receives an executed patient authorisation for release of medical records produced by a lawyer and usually accompanied (if not at a later date) request for copies of medical records/medical report(s), ,films and billing records, (ii) when patient and/or family that is very upset about an unexpected or dramatic outcome sends in a written compliant or even heated verbal exchanges occur in the care area(s) or when the patient and/or family present themselves at the hospital administration, and (iii) when a letter is sent to the press and is published in the newspapers or a press conference is called by the aggrieved parties. Whatever the circumstances maybe, the requests for the production of documents and tangible items already signals that there is reasonable belief that a lawsuit may be filed.

I shall not cover a spoliation action, a type of action not yet a phenomenen in Malaysia when a patient can seek damages not for negligent medical care, but for a breach of the duty to preserve medical evidence from the loss of medical information like key medical records or films,  medical devices or instruments used during the care and treatment, and even the loss of non-medical information such as phone records.

In preventing a spoliation action and in general, I think Health Information Management (HIM) / Medical Records (MR) practitioners should always maintain health information, and communication protocols for preserving health information with effective medical information maintenance policies and procedures through consistent and established policies. Your actions and practices will help control unnecessary hospital litigation losses and increase efficiency when answering inquires from legal, regulatory, or accreditation agencies.

Before I write more on my next post on written discovery, I think some knowledge on some law terms is necessary.

In a civil action like for a medical-malpractice lawsuit, a claimant (“plaintiff”) will state the defendant’s actions, or omissions, which caused the claimant’s loss and files a civil claim (“lawsuit”) against the defendant(s) who usually are individual(s) doctors, hospital(s), and doctor or medical practice group(s).

The claim is to seek recovery for injuries that the plaintiff believes were caused by the defendant’s failure to meet an established professional duty of care.