JCAHO Ongoing Record Review

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JCAHOOngoing Record Review Patient Tracers

• Jean S. Clark RHIA
• January 19, 2006

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Objectives

• Clarify IM changes for 2006
• Discuss preparing for the first year of
  unannounced surveys
• Discuss hot topics for 2006
• Discuss critical safety goals for 2006

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Objectives (cont)

• Discuss ongoing record reviews and tracers
• Structuring the process
• What should be the sample size
• Using tracers to identify documentation issues
• Reporting ongoing record reviews
• A success story
• Q A

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2006 Changes for IM

• UNANNOUNCED SURVEYS
• Yikes!

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2006 Changes for IM

• IM.6.20 Records contain patient-specific
  information, as appropriate to the care,
  treatment, and services provided
• EP 2 Added the patients language and
  communication needs

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2006 Changes for IM

• INFORMATION MANAGEMENT - reviewed with some
  editorial changes for clarity
• IM.6.30 now contains what should be in an
  operative report
• Exception Note Timeframe for written or
  dictated full report can be determined by
  organization when postoperative progress note is
  written immediately after the procedure

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2006 Changes for IM

• Patient Language Communication Needs
• Steps to Compliance
• Develop a standardized approach to obtaining the
  information - Policy
• Who will collect, and document -
  Registration/Access, Nursing Assessment
• Implement the process - Part of ORR to see if it
  works

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2006 National Patient Safety Goals

• Implement a standardized approach to hand off
  communications, including an opportunity to ask
  and respond to questions.
• Label all medications, medication containers
  (e.g., syringes, medicine cups, basins), or other
  solutions on and off the sterile field in
  perioperative and other procedural settings.
• Reconciliation of medications implemented January
  1, 2006

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2006 National Patient Safety Goals

• Implement a standardized approach to hand off
  communications, including an opportunity to ask
  and respond to questions.
• Examples
• nurse to nurse MD to MD nurse to MD OR to
  PACU ED to receiving facility

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2006 National Patient Safety Goals

• Implement a standardized approach to hand off
  communications, including an opportunity to ask
  and respond to questions.
• Compliance Steps
• Identify where this applies
• Who is involved
• What information should be communicated
• Asking and responding to questions
• Repeat-back situations
• Information to be available

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2006 National Patient Safety Goals

• Accurately and completely reconcile medication
  across the continuum of care
• Examples
• Referring or transferring a patient to another
  setting, service, practitioner, or level of care
  within or outside the facility
• When the facility requires that orders be
  rewritten
• When the patient changes service, setting,
  provider or level of care and new meds are
  ordered
• All patients in and out AND all medications

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2006 National Patient Safety Goals

• Accurately and completely reconcile medication
  across the continuum of care
• Compliance Steps
• List of meds when patient enters facility
• Compare with new orders for meds
• Update list as orders change
• Communicate to the next provider

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2005 Problematic Standards

• Assisted Living
• IM.4.5 - Each resident record contains
  documentation about services provided to the
  resident
• Ambulatory Care
• IM.3.10 - The organization has processes in place
  to effectively manage information, including the
  capturing, reporting, processing, storing,
  retrieving, disseminating, and displaying of
  clinical/service and nonclinical data and
  information.

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2005 Problematic Standards

• Behavioral Health Care
• IM.3.10 See previous slide
• IM.6.50 Designated qualified personnel accept
  and transcribe verbal orders from authorized
  individuals.
• IM.6.10 The behavioral health care organization
  ahs a complete and accurate clinical/case record
  for every client assessed, cared for, treated, or
  served.

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Problematic Standards

• Critical Access Hospital
• IM.3.10
• IM.6.50
• Preferred Provider Organizations
• IM.2.20 Information,security, including data
  integrity, is maintained

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Problematic Standards

• Laboratory
• IM.6.230 Current reference intervals approved
  by the clinical laboratory director are provided
  in the clinical record when test results are
  reported.
• IM.6.220 Required records and reports are
  maintained and, as appropriate, filed in the
  clinical record of the patient and with the
  pathology and clinical laboratory services.
• IM.6.260 The laboratory has current written
  descriptions of and instructions for analytical
  methods and procedures

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Problematic Standards

• Office-Based Surgery
• IM.6.
• IM.2.20 Information security, including data
  integrity is maintained.
• Long Term Care
• IM.3.10
• IM.6.50

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Problematic Standards

• Medicare/Medicaid Certification-Based long Term
  Care
• IM.3.10
• IM.6.50
• Managed Care Organizations
• IM.4.10 The information management system
  provides information for use in decision making.
• Home Care
• IM.3.10

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Problematic Standards - Hospitals

• IM.3.10 (44) Prohibited abbreviations
• IM.6.50 (15) Verbal/telephone orders including
  read back and verify
• IM.6.10 (15) Complete and accurate record

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Problematic Standards - Hospitals

• New Frequently Asked Question (FAQ)
• Contract with after hours cleaning service when
  medical records are stored in an unlocked area.
  Cleaning staff sign confidentiality statements
• Answer Record not considered secured

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Problematic Standards - Hospitals

• IM.3.10 (44) Process to effectively manage
  information
• This is specifically related to the use of
  prohibited abbreviations in the medical record.
• Compliance Requirements
• Pre-printed forms 100
• Paper forms 90
• Computerized forms Exception, except for free
  text entries

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Problematic Standards - Hospitals

• IM.6.50 (14) Verbal orders including read back
  of critical test results
• This is specifically related to process for
  reading back and verifying v/t orders and in
  particular critical test values and results
• Steps to Compliance
• Identify which are critical test results/values
  that fall into this category
• Develop electronic process to measure
• Keep data on the units
• Observation, patient tracers

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Problematic Standards - Hospitals

• IM.6.10 (15) Hospital has a complete and
  accurate medical record for every individual
  assessed, cared for, treated, or served
• 18 EPs in this standard
• Main Issues
• HPs
• Operative Reports

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Problematic Standards Hospitals IM.6.10 (15)

• Main Issues
• History and Physical Update (PC.2.120, EP7)
• An update to the patients condition since it was
  last assess is required at the time of admission
  when using an HP that was performed before
  admission and before outpatient surgery.

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Problematic Standards HospitalsIM.6.10 (15)

• Compliance
• Update can be within 24 hours of the inpatient
  admission or at the time of the outpatient
  procedures for which the medical staff has
  determined require an HP
• Method used to evaluate the patient to identify
  the type and extent of the update to the
  condition is defined by the facility

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Problematic Standards HospitalsIM.6.10 (15)

• Compliance
• Detail and location of the documentation of the
  update defined by the organization
• Update and preanesthesia assessment could be
  combined activity where the patient is going to
  surgery within the first 24 hours of admission
• No requirement for another update to HP within
  24 hours of inpatient surgery.

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Problematic Standards HospitalsIM.6.10 (15)

• Other EPs to watch for
• Define which entries require countersignatures
  for nonindependent practitioners
• Every entry dated (not to include signatures if
  they occur in real time, or required by state or
  federal law)
• Delinquent medical records

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Ongoing Record Reviews

• IM.6.10, EPs 12,13
• No changes for 2006
• Facility can define the process
• If record is accurate, complete, timely at the
  time of tracers, then ongoing record reviews have
  been successful
• Incorporate review of NPSGs, problematic
  standards, your own findings into tracers and
  report as ongoing record reviews

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Ongoing Record Reviews

• IM.6.10, EPs 12,13
• Structuring your reviews
• HIM or PI as facilitator, or combination of the
  two!
• Require monthly point of care reviews
• Provide tools
• Require reporting to HIM or PI to compile data
  and
• prepare reports

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Ongoing Record Reviews

• IM.6.10, EPs 12,13
• Using tracers as part of ongoing record reviews
• One tool does not fit all
• Problematic Standards
• National Patient Safety Goals
• IM and POC chapters

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Ongoing Record Reviews

• IM.6.10, EPs 12,13
• Sample sizes one size does not fit all reviews
• Category C EPs
• 30 cases, sample ALL
• 31 100, sample 30
• 101 to 500, sample 50
• gt 500, sample 70

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Ongoing Record Reviews

• IM.6.10, EPs 12,13
• Sample sizes one size does not fit all reviews
• Specific direction to units/departments i.e.
• 4 tracers per month cover all staff
• Focus on NPSGs quarterly
• Sample (use Category C sample sizes) after
  discharge
• for selected topics such as content of DS

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Ongoing Record Reviews

• IM.6.10, EPs 12,13
• Tools
• NPSGs (see attached)
• JCAHO tool how to use it
• Tracer tool (see attached)

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Ongoing Record Reviews

• IM.6.10, EPs 12,13
• Reporting
• Must require accountability to correct
• Who made the documentation error?
• Consider requiring correcting the error
• Must have TEETH to succeed

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Ongoing Record Reviews

• IM.6.10, EPs 12,13
• Success Stories
• Process is outlined
• Expectations are clear
• Data is entered electronic
• Reports are provided back to the unit/dept

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Ongoing Record Reviews

• IM.6.10, EPs 12,13
• Success Stories
• Prohibited abbreviations
• Correct errors
• Tied to evaluations
• Next step MD reappointments

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References

• 2006 JCAHO Hospital Accreditation Manual
• Executive Briefings
• www.jcaho.org

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Questions/Comments

• Barbara.Millas_at_va.gov