JCI Standard MCI.19.4 – Patient Clinical Record, the “quality oversight mechanism“

It is a common sight in hospitals as doctors and nurses make their rounds assessing patient needs and providing care. It is not uncommon as managers, support staff like HIM/MR professionals, and others in a hospital also make their rounds around their tasks assessing processes and resources and exercise set professional standards to their daily work, thereby understanding how processes can be more efficient, how resources can be used more wisely, and physical risks(safety) to the patients and staff can be reduced.

Thus, quality and safety is entrenched in the needs and care of patients as individual health care professionals and other staff execute their daily work.

As these individual health care professionals and other staff go about their daily work, the organisation continuously plans, designs, measures, analyses, and improves clinical and managerial processes to achieve maximum benefit from its quality and safety efforts.

It is no doubt to my mind that all these efforts to get quality and safety measures well organised requires no less clear leadership, needs some kind of mechanism and an organisational framework to oversee and improve those processes. As most clinical care processes, managerial processes and quality issues are interrelated and involve more than one department or unit and may involve many individual jobs, accentuates the need for clear leadership, a mechanism to work around with the help of an organisational framework for quality and safety.

This framework will develop greater leadership support for an organisation wide 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 organisations, nationally and internationally.

The framework and the mechanism to guide quality improvement and patient safety efforts in a hospital rest with a quality improvement and patient safety oversight group or committee.

All of the above explains  the “quality oversight mechanism“ I talked about in the post JCI Standard MCI.19.4 – Patient Clinical Record.

Abridged, and adapted from Quality Improvement and Patient Safety (QPS), Governance, Leadership, and Direction (GLD), and Management of Communication and Information (MCI) chapters of the JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 4th Edition

Nightingale rose graph

Going back to the post 8 Ways You Can Visualise Proportions,  I provided a WAY 8 using the Nightingale rose graph – or the polar area diagram to visualise proportions, and this is a follow-up on WAY 8 from that post.

The Nightingale rose graph was a diagram by Florence Nightingale (1820 – 1910). Nightingale, an Anglican English nurse became famous for tending to the wounded soldiers during the Crimean War, she loved doing night rounds and was dubbed “The Lady with the Lamp”, she laid the foundation of professional nursing and established her nursing school at St Thomas’ Hospital, London in 1860, new nurses take the Nightingale Pledge, and nurses celebrate the annual International Nurses Day on her birthday. Florence Nightingale was also a writer and an accomplished statistician  who in 1858, became the first female fellow of the Statistical Society of London (now Royal Statistical Society).

Florence Nightingale met William Farr, the Compiler of Abstracts in the General Registry Office and an innovative statistician at a dinner party in 1856. Both cared deeply about improving the world through sanitation; both understood the importance of meticulous records in providing the evidence needed to bring about change.

Now let’s move on and look at the original diagram drawn by Nightingale as below, “Diagram of the causes of mortality in the army in the East”  dated 1858 was published in Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army and sent to Queen Victoria in 1858.

You can view a 1280p X 804p of this graphic from the post 8 Ways You Can Visualise Proportions

The legend of this graphic above displays the causes of the deaths of soldiers during the Crimean war. The legend explains that each wedge is divided into three categories.:

  • “Preventible or Mitigable Zymotic Diseases” (infectious diseases, including cholera and dysenter), in blue
  • those that were the results of wounds, in red
  • those due to all other causes, in black.

The legend also explains that:

  • the black line across the red triangle in Nov. 1854 marks the boundary of the deaths from all other causes during the month.
  • in October 1854, & April 1855, the black area coincides with the red,
  • in January & February 1856, the blue coincides with the black.

Note that the graphic on the right starts from April 1854 and ends March 1855, while the the graphic on the left April 1855 starts from April 1855 and ends March 1856.

In November 1854, the number if wounds was very high as compared to other months, so it must be a period of heavy fighting, as far more soldiers died from infection than from wounds.

Now, I like to compare Nightingale’s diagram as compared to pie charts we draw today.

As a simple example, here is a frequency distribution table showing the distribution of “marital status” from a counseling center survey.

Status        Frequency(f)    Percentage (%)
Single

10

50

Married

7

35

Divorced

3

15

N=

20

100

To construct a pie chart,  the percentage of all cases that fall into each category(single, married, divorced) of the variable(marital status) is computed. A circle (the pie) is divided into segments (slices) proportional to the percentage distribution. Since a circle’s circumference is 360°, 180° (or 50%) is apportioned for the first category, 126° (35%) for the second, and 54° (15%) for the last category.

The pie chart displays like this:

 

From the graphic of Nightingale’s diagram which resembles a pie chart, it can be seen that each wedge is drawn from the common centre. As I have described above, in pie charts, we draw the area of each wedge proportional to the figure it stands for.

Thus her diagram is different from the common pie chart we know as follows:

  • the data is plotted by month in 30-degree wedges. In each month, red represents deaths by injury, blue death by disease, and black death by other causes
  • the radius of each slice (the distance from the common centre to the outer edge) is altered to achieve the area for each category; she measured each proportion along the linear radius distance
  • the red, black and blue wedges are all measured from the centre, so some areas mask parts of others unlike the wedges which appear distinct and separate like in the pie chart above
  • the areas of the wedges are not proportional; I tend to agree with Henry Woodbury that Nightingale used the word area in the generic sense of section or range as she made in her annotation, but the data actually maps to the radius of each wedge
  • the numbers of deaths from the various causes are not stated but shows their relative size

Nightingale’s diagram, often referred to as Nightingale’s Rose or Nightingale’s Coxcomb –  although she did not refer to them as such, is so visually interesting and so iconic (a rose, a coxcomb) like when I first saw her diagram in Randy Krum’s blog , I tend to agree to Henry, so beware the inherent risks in visual explanation, as more often that not we assume its conclusions without examining its data(Henry, W. 2008)..

I think too that it better sense using a stacked bar chart that introduces a scale, more readable labels, and a single chart for the entire 1854-1856 period. These changes provide context and continuity, and make clear the two campaigns of the war as can be viewed below:

Source : dd.dynamicdiagrams.com

or like this:

Source : dd.dynamicdiagrams.com

Lesson learned:

Because of her novel methods of communicating data by creating graphs as we have seen above to highlight the death toll from diseases above the death toll from wounds in the Crimean War, Nightingale returned to Great Britain and continued to fight for better conditions in hospitals, and this made her a pioneer in establishing the importance of sanitation in hospitals.

Abridged, and adapted from the following sources:

  1. Coolinfographics, Randy Krum’s blog
  2. Charts, Worth a thousand words, Dec 19, 2007, The Economist
  3. Nightingale’s Rose, By Henry Woodbury, Jan 9, 2008, dd.dynamicdiagrams.com
  4. Nightingale’s ‘Coxcombs’, May 11, 2008, understandinguncertainty.org
  5. Statistics: A Tool for Social Research, Eighth Edition Joseph F. Healey, 2009, Wadsworth Cengage Learning, Belmont, CA, USA
  6. Wikipedia

JCI Standard MCI.19.4 – Patient Clinical Record

With this post, it is the finish line for the relevant standards that apply to the Patient Clinical Record expounded from the JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 4th Edition.

But the finish line is not quite over.

This last standard that applies to the Patient Clinical Record (PCR), Standard MCI.19.4 states that “As part of its performance improvement activities, the organization regularly assesses patient clinical record content and the completeness of patient clinical records”.

Here I present a Q&A format to review this standard.

  How often does a hospital assess its PCRs?
  PCRs are to be reviewed on a regular basis, measureable by ME 1.
  Do you review all PCRs in the hospital?
  NO, the review  “uses a representative sample”, measureable by ME2. It is important to ensure that this representative sample includes “records of active and discharged patients” as will be accessed for compliance by ME6. In my next post for this standard, I shall elaborate more on this process, for example on how I conducted the selection of the representative sample.
  Who conducts this review?
  “The review is conducted by physicians, nurses, and others authorized to make entries in patient records or to manage patient records”, measureable by ME 3.
  What is the objective of this review?
  “The review focuses on the timeliness, legibility, and completeness of the clinical record” ”, measureable by ME 4. You would have read the post regarding “the timeliness, legibility, and completeness of the clinical record “from the post JCI Standard MCI.19.2 & MCI19.3 – Patient Clinical Record
  Is anything else checked in the review process?
  “Record contents required by laws or regulations are included in the review process”, measureable by ME 5. In Malaysia, neither specific laws nor regulations govern records contents. Guideline exist, I did post about the MMC guideline for medical records contents from the post Malaysian Medical Council (MMC) – acceptable contents of a patient’s medical record
  How are the results of this review process utilised by a hospital?
  “The results of the review process are incorporated into the organization’s quality oversight mechanism”, measureable by ME 7. 

More on the “quality oversight mechanism“, and also on a future post, how as the JCI MCI Champion1, I prepared the results of the review in a comprehensive report for management.

1A staff selected by management to spearhead all related activities to a specific chapter or chapters from the JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS.

Patient data breaches in the BYOD and BYOC era

Health information is becoming increasingly vulnerable to data breaches as hospital employees turn up for work with mobile devices such as smartphones and tablets and use consumer-friendly and easy-to-use cloud storage services.

This proliferation of mobile devices in the workplace and hooking up onto cloud storage services is among the factors most likely to cause a data breach at hospitals in the US(a worldwide phenomenon, I must add), as indicated by 31 percent of healthcare organisation respondents from the 2012 HIMSS Analytics Report: Security of Patient Data*.

Bringing your own device and using cloud storage services has led to the new digital lifestyle era at the workplace, and two new acronyms, BYOD(Bring Your Own Device) and BYOC(Bring Your Own Cloud)!

You know your own devices well, so what then is this cloud storage service?

Image credit: https://www.marconet.com/blog/what-is-the-cloud-and-how-should-you-use-it-infographic

Now that the graphic would have given to those others who prefer inspiration, but maybe “just an introduction” to the tech-savvy, I think it was enough to arouse leaders in workplaces that manage patient data to think about the possibilities of anyone who could use such free and easy cloud services for criminal uses, thus beware it’s highly probable that mobiles devices and the cloud could be used to breach health information security at any HIM/MR Department.

In a future blog, I shall take you further to discuss some best practices for hospital data security.

*The 2012 HIMSS Analytics Report: Security of Patient Data, the third installment of the bi-annual survey of healthcare providers nationwide, shows a steady rise in data breaches over the last six years, despite increasingly stringent regulatory activity surrounding reporting and auditing procedures, and heightened levels of compliance –  a report as commissioned by the information security practice of Kroll Advisory Solutions