Management of Communication and Information Chapter -MCI TAIBA HOSPITAL Management of Communication and Information Chapter -MCI Healthcare Informatics. Communications. Medical Records. Medical Forms.

Overview Providing patient care is a complex endeavor that is highly dependent on the communication of information. This communication is to and with the community, patients and their families, and to other health professionals. Failures in communication are one of the most common root causes of patient safety incidents. To provide, coordinate, and integrate services, health care organizations rely on information about the science of care, individual patients, information is a resource that must be managed effectively by the organization’s leaders. Every organization seeks to obtain, manage, and use information to improve patient outcomes, as well as individual and overall organization performance.

Over time, organizations become more effective in: Identifying information needs; Designing an information management system; Defining and capturing data and information; Transmitting and reporting data and information; and Integrating and using information.

MCI Chapter Standards MCI.1 MCI.2 MCI.3 The organization communicates with its community to facilitate access to care and access to information about its patient care services. (Communication with communities) Communicated information regarding services and the process to obtain care. MCI.2 The organization informs patients and families about its care and services and how to access those services. (Patients and families need complete information on the care and services offered by the organization). MCI.3 Patient and Family communication and education are provided in an understandable format and language. (Patients can only make informed decisions and participate in the care process if they understand the information provided to them).

MCI.4 Communication is effective throughout the organization. (Effective communication within the organization is a leadership issue. Thus the organization’s leaders understand the dynamics of communication among and between different departments). (Organization’s leaders should pay attention to the accuracy and timeliness of transmission of information in the organization). MCI. 5 The leaders ensure that there is effective communication and coordination among medical, nursing, and departments responsible for providing clinical services. (To coordinate and integrate patient care, the leaders develop a culture that emphasizes cooperation and communication). (The leaders develop formal (ex. Standing Committees, Joint Teams) and informal (ex. Newsletters and posters) methods for promoting communications among services and individual staff members). MCI. 6 Information about the patient’s care and response to care is communicated among medical, nursing, and other care providers during each staffing shift, and between shifts. (Communicating and exchanging information between and among healthcare professionals is essential to a smooth care process)

MCI. 7 The patient’s record(s) is available to the care providers to facilitate the communication of essential information. (The patient’s record(s) is a primary source of information on the care process and the patient’s progress and thus is an essential communication tool). (To be useful and support continuity of patient’s care, it needs to be available during inpatient care, for outpatient visits, and at other time as needed). (Organization policy identifies those care providers who have access to the patient’s record to ensure confidentiality of patient information). MCI.8 Information related to the patient’s care is transferred with the patient. (patients are frequently transferred within the organization during their care, when the care team changes as a result of transfer, continuity of patient care requires that initial information related to the patient. Thus medications and other treatments can continue uninterrupted, and the patient’s status can appropriately monitored (ex. Reason of admission, significant findings, diagnosis, procedures performed, medications and other treatments and the patient condition at the time of transfer).

MCI. 9 The organization plans and designs information management processes to meet internal and external information needs. (information is generated and used during patient care and for managing a safe and effective organization. The ability to capture and provide information requires effective planning which incorporates input from the organization’s leaders). (Planning consider the organization’s mission, service provided, resources, access to technology and support effective communication). (planning of the organization management strategies are appropriate with the organization’s size complexity of services, availability of trained staff, and other human and technical resources).

MCI. 10 Information privacy and confidentiality are maintained. (The organization maintains the privacy and confidentiality of data and information) MCI. 11 Information security, including data integrity, is maintained. (Security procedures are addressed to allow only authorized staff to gain access to data and information. Access to different categories of information is based on need and defined by job title and function). MCI.12 The organization has a policy on retention time of records, data, and information. (The organization develops and implement a policy that guides the retention of patient clinical records and other data and information. Patient clinical records and other information are retained for sufficient periods to comply with laws and regulations and support legal documentation).

MCI.13 The organization uses standardized diagnosis codes, procedure codes, symbols, abbreviations and definitions. (Uniform use of diagnosis and procedure codes support data aggregation and analysis). (Abbreviations and symbols are also standardized and include the “Do Not Use” list. Such standardization is consistent with recognized international standards).

MCI. 14 The data and information needs of those in and outside the organization are met on a timely basis in a format that meets user expectations and with the desired frequency. (The format and methods of disseminating data and information to the intended user are tailored to meet the user’s expectations). MCI.15 Appropriate clinical and managerial staff participate in selecting, integrating, and using information management technology. (Information management technology represents a major investment of resources for healthcare organization. Technology is carefully matched to the organization’s current and future needs and its resources).

MCI. 16 Records and information are protected from loss, destruction, tampering, and unauthorized access or use. (Patient records and other data and information are secure and protected at all times. (for ex. Active patient records are kept in areas where only authorized health professional staff have access, and records are stored in locations where heat, water, fire, or other damage is not likely to occur).

MCI.17 Decision Makers and other appropriate staff members are educated and trained in the principles of information management. (Individuals in the organization who generate, collect, analyze, and use data and information are educated and trained to effectively participate in managing information) MCI. 18 A written policy or protocol defines the requirements for developing and maintaining policies and procedures. The policy outlines how the following will be carried out: Review and Approval of all policies and procedures by an authorized person before issue. The process and frequency of review and continued approval of policies and procedures. The controls for ensuring that only current, relevant versions are available wherever they are used; Identification of changes in PP. Others,……

MCI. 19 The organization initiates and maintains a clinical record for every patient assessed or treated. (Every patient assessed or treated in a healthcare organization as an inpatient, outpatient, or urgent care patient has a clinical record).

MCI. 19.1. The clinical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and result of treatment, and promote continuity of care among health care providers. MCI. 19.1.1. The clinical record of every patient receiving emergency care includes the time of arrival, the conclusions at termination of treatment, the patient’s condition at discharge, and follow-up care instructions

MCI.19.2 Organization policy identifies those authorized to make entries in the patient clinical record and determines the record’s content and format. MCI. 19.3 Every patient clinical record entry indentifies its author and when the entry was made in the record. MCI.19.4 As part of its performance improvement activities, the organization regularly assesses patient clinical record content and the completeness of patient clinical records.

MCI. 20 Aggregate data and information support patient care, organization management, and the quality management program. MCI. 20.1 The organization has a process to aggregate data and has determined what data and information are to be regularly aggregated to meet the needs of clinical and managerial staff in the organization and agencies outside the organization.

MCI. 20.2 The organization supports patient care, education, research, and management with timely information from current sources. MCI. 20.3 The organization has a process for using or participating in external databases. (The organization collects and analyzes aggregate data to support patient care and organization management, Aggregate data provides a profile that allows the comparison of the organization’s performance). (This aggregate data are an important part of the organization’s performance improvement activities that help the organization to understand its current performance and support the utilization review of different organization’s departments. In all cases, Security and confidentiality of data and information are maintained.

Thank You, Dr. Khaled Z. Al kondakly Chief Medical Officer Ph.D, MHA, MBA, CPHQ-USA MSc, MBBCh-EGY Chief Medical Officer American Board of Healthcare Quality and Utilization Review (ABHQUR-USA). Membership of American College of Healthcare Executives (ACHE-USA). Member of American National Association of Healthcare Quality (NAHQ-USA). Member of American Society of Healthcare Quality (ASQ-USA). Member of Saudi Arabian Quality Council (SAQC-KSA).