Category Archives: Quality

JCI Standard MCI.19.4 – Patient Clinical Record, Medical Records Review, Committee & TOR

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Once a leader is appointed to champion MCI Standards, one of the first steps leading this challenge is to gather a team to define a terms of reference (ToR) document.for a Medical Records Review Committee (MRRC) which will oversee the mechanism to conduct the Medical Records Review.

In this post, I shall propose a ToR for a MRRC.

But before that a little about what this ToR document is all about. It defines all aspects of how a MRRC will conduct a regular assessment of “patient clinical record content and the completeness of patient clinical records” as part of a hospital’s performance improvement activities, as required by JCI Standard MCI.19.4

The ToR also defines the objective and the scope of the evaluation, outlines the responsibilities of the MRRC and provides a clear description of the resources available to conduct the study, in this case the hospital’s multidisciplinary professionals and authorised groups enable this through a process of regular review and evaluation of patient care records,

The ToR document includes the definition and function – when is one needed, and what are its objectives, what should be included in the review(content),  what needs to be in place(preparation) for a member of the MRRC to facilitate the completion of a high quality evaluation, what steps (process) should be taken to develop an effective ToR, and the roles and responsibilities of designated members.

Now, below is one sample of a ToR for a MRRC I like to propose.

MEDICAL RECORDS REVIEW COMMITTEE (MRRC)

TERMS OF REFERENCE(ToR)

INTRODUCTION

Medical records form the basis for patient care planning, support diagnoses and treatment. They also provide the basis to evaluation of the patient’s condition, treatment as well as continuity of care. It is therefore pertinent that every doctor, nurse, allied health practitioner and those authorised to make entries in the patient records ensure that the content and timeframes of clinical documentation conform to the highest professional standards, to meet patient, legal and accrediting bodies’ requirements.

OBJECTIVE

The MRRC is established as part of the hospital’s quality improvement activities to ensure standards of patient care documentation are maintained in conformance to legal and regulatory bodies, including professional and accrediting agency standards. The hospital’s multidisciplinary professionals and authorised groups enable this through a process of regular review and evaluation of patient care records.

KEY FUNCTIONS

The Committee shall on a regular basis, review and evaluate medical records to ensure:

  1. that they are maintained in a complete, legible and timely manner and with pertinent and useful clinical information and overall adequacy to provide the highest standard of patient care.
  2. that the records are adequately completed at all times so as to facilitate continuity of care and communication among all those providing patient care services as well as allowing quality improvement activities to be performed.
  3. 1that the review and evaluation includes records of patients currently receiving care (active patients) as well as records of discharged patients, and covers inpatient areas, outpatient clinics and emergency room and is based on a sample representing the practitioners providing care and the types of care provided
  4. that record contents required by laws or regulations are included in the review process
  5. that the patient record review is carried out by conducted by the medical staff, nursing staff, and other relevant clinical professionals who are authorized to make entries in the medical record or to manage medical records

MEMBERSHIP

Chairman : Clinican or Doctor, Hospital Administration
Co-Chair : Manager or Head of Department(HOD), Health Information Department / Medical Records Department
Members : Manager, Customer Services or Public Relations or or designate
HOD Nursing Services or designate
HOD Rehabilation Services or designate
HOD Pharmacy Services or designate
Nutritionist or Dietitician
Secretarial Support : Health Information Department / Medical Records Department designate or Hospital Administration designate
Facilitator : Senior Manage or Manager, Quality Management
Note : Clinicians and  Medical Affairs representative attend on ad-hoc basis

ROLES AND RESPONSIBITIES

Chairman

  1. He / she shall lead the team and be responsible for setting directions, goals and objectives.
  2. He / she shall provide and update to the 2JCI Management Committee and relevant regulatory / accrediting bodies concerning patient care standards documentation and quality of clinical records keeping in the hospital.
  3. He / she shall lead the team during the JCI MCI – Medical Records Interview

Co-Chair

  1. He / she shall assist the team in achieving set directions, goals and objectives.
  2. He / she shall chair the meeting in the absence of the Chairman.

Members

  1. He / she shall be familiar with the key 3Licensing & Accreditation requirements including Joint Commission International Accreditation Standards and document control procedures pertaining to medical records.
  2. He /she shall review identifies problems relating to patient care standards documentation and document control.
  3. He /she shall initiate, recommend or provide solutions to non-conforming standards and deficient clinical records, through designated channels; verify the implementation of preventive measures and monitor its effectiveness.

MEETING

  1. The Committee shall meet at least once a month.
  2. Ad-hoc meeting may be convened to discuss urgent matters.
  3. The members shall serve for a minimum of a 2-year period and may be re-appointed to another term.
  4. The quorum shall be seventy-five present (75%) of membership.

1 The TOR must specifiy what type of medical records will be reviewed and evaluated, example the MRRC may review and evaluate inpatient medical records only

2Main committee overseeing quality improvements

3Example, International Standards Organisation(ISO)

Once the ToR document is ready, it is time for discussion and approval by the MRRC and then forwarded to the MCI Committee for its endorsement.

Next, I shall be presenting a ToR for the MCI Committee and followed by the methodolgy to conduct a review and last, some discussion on presenting the results to senior leaders in quality.

References:

  • Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th Edition, USA, JCI
  • Dawn,R., Nidhi, K., and Arianne, W., 2011, Writing Terms Of Reference For An Evalaution: A  How-To Guide, Independent Evaluation Group(IEG), The World Bank, Washington, USA

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

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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

JCI Standard MCI.19.4 – Patient Clinical Record

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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.

Malaysian Medical Council (MMC) – acceptable contents of a patient’s medical record

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Further to the acceptable norm for medical record contents, and qualified by the JCI Standard MCI.19.1 which states that “The patient 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”, HIM/MR practitioners in Malaysia need to take note that the Malaysian Medical Council (MMC) recommends  the following items which may make up the contents of a patient’s medical record – perhaps other countries also have similar guidelines :

  • Doctor’s clinical notes
  • Recording of discussion with patient/next of kin regarding
    disease/management/possible use of tape recording for such discussions
  • Referral notes to other specialists for consultation/co-management
  • Laboratory reports
  • Imaging records and reports
  • Clinical photographs
  • Drug prescriptions
  • Nurses’ reports
  • Consent forms
  • Operation notes/anaesthetic notes
  • Video recordings
  • Printouts from monitoring equipment
  • Correspondence with other healthcare professionals
  • Computerised/electronic records
  • Recordings of telephone consultations.

Source: mmc.gov.my/v1/

JCI Standard MCI.19.2 & MCI19.3 – Patient Clinical Record

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Its been 7 days since I last posted on quality standards for patient clinical records.

To continue on JCI hospital accreditation standards, this Thursday morning I am posting away this post drafted over the last 4 days, sharing with you my experiences on the JCI Standard MCI.19.2 and JCI Standard MCI.19.3. These 2 standards relate to the quality of patient clinical records.

JCI Standard MCI.19.2 states that “organization policy identifies those authorized to make entries in the patient clinical record and determines the record’s content and format”.

Thus, the person(s) who have the authority and right to document in a patient clinical record must be as defined by the hospital’s policy. This would mean all writers who document in a patient clinical record – doctors especially, must be trained in and/or briefed and follow their hospital’s standards and policies for documentation.

A hospital policy for patient record documentation must define by job title and function, including students in academic settings as those authorised to make entries in the patient clinical record The policy must determine the format and location of entries, contain a process to ensure that only authorised individuals make entries in patient clinical records, contain a process that addresses how entries in the patient record are corrected or overwritten, provides identities of those authorised to have access to the patient clinical record and thereby have the obligation to keep the information confidential, and also contains a process to ensure that only authorised individuals have access to the patient clinical record and if information is compromised then it also contains a  process to be followed when confidentiality and security are violated. If your hospital policy satisfies these provisions, then the MEs of MCI19.2 surely be in full compliance (graphic below gives a summary of the policy, double-click on graphic for a larger view of this graphic in a new tab, of the same window of your browser).

In Malaysia, training and awareness on the right to document in patient clinical records by doctors begins during their internship. “A Guidebook for House Officers”, published 23 April 2008 by the Malaysian Medical Council, clearly states that “in Malaysia, pursuant to the Medical Act 1971, internship is only imposed upon after graduation. The two-year internship combines service and training roles. It is formulated in such a way to ensure medical practitioners like you gain appropriate knowledge, skill and experience as well as correct attitude rather than merely employment and provision of services”. This training roles includes that regarding documentation in the patient clinical record as in section 4.4, page 32 of this guidebook.

If the author, the date and the time for each patient clinical record entry especially for timed treatments or medication orders can all be identified successfully, then you patient record satisfies the Standard MCI.19.3 which states that “every patient clinical record entry identifies its author and when the entry was made in the record”.

However the requirement that the author, the date and the time for each patient clinical record entry especially for timed treatments or medication orders, must be stipulated in the hospital policy.

I think it is also wise to include in the policy that the authors should sign with their legal signature (your last name and legal first name or initials), no nicknames should be used, and initials should follow their name indicating their status as a specific caregiver, depending on local statutes and regulations which I think is lacking in Malaysia, but take note that this is not required(no mention) by JCI Standard MCI.19.3

I did not cover in this post about counter-signatures, telephone order (T.O.), voice order (V.O.), Fax Signatures, Electronic Signatures, and Signature Stamps, but of course all these other modes of documentation entries can be included in the policy.

Here I remember the familiar ISO 9001 cliché “say what you do and do what you say”, is to document everything that everyone does. You also must have heard the “wasn’t documented, wasn’t done” motto which is a common one in healthcare settings.