A hospital’s primary purpose is to provide patient care and to work to improve patient care outcomes over time by applying quality improvement principles. To reach conclusions and to make decisions on how to work to improve patient care outcomes over time, requires access to a wide range of information from varying sources.
Each time patients receive health care, a record is generated to document the patient’s current symptoms,medical history, results of examination, treatments rendered along with outcomes, ancillary report results (e.g., laboratory), diagnoses, and plans for treatment. This patient data is organised, analysed, and maintained by Health Information Management (HIM) / Medical Records (MR) practitioners working in hospital settings to ensure the delivery of quality health care.
Data collection and analysis processes entail combining patient care data from various sources and transformed into useful information. But the ability to collect and analyse data within and across hospitals is hampered by different information systems and processes, and by the highly complex and fragmented nature of health care systems.
Converting data into meaningful information for decision making calls for the expertise of trained and qualified professionals. The data analysis process involves individuals who will be among medical, nursing, and other departmental heads who participate in relevant quality improvement and patient safety processes. These indivuals must understand information management, have skills in data aggregation methods, and know how to use various statistical tools and techniques when suitable, and participate in the process.
Understanding statistical techniques is helpful in data analysis, especially in interpreting variation and deciding where improvement needs to occur. Every system has variation; some of this is due to the system itself, known as common cause variation; some of it is due to singular incidents or special situations; this is special cause variation. 94 percent of problems (or possibilities for improvement) lie with the system as common-cause variation; 6 percent are special causes (Deming, 1982). In understanding trends and variation in health care, statistical tools for example run charts, control charts, histograms, and Pareto charts can prove to be useful statistical tools to know. Examining data over a period of time and making decisions based on trends or other patterns, will save time, energy, and other resources.
HIM/MR practitioners are trained in managing patient health information and medical records, administering computer information systems, and coding diagnoses and procedures for health care services provided to patients, and have an understanding of statistical techniques as part of their training and education. I believe their unique knowledge and expertise in hospital management information systems will enable strong partnerships beween them and with clinical and management teams to advance the quality and safety of patient care delivery.
Data analysis must provide continuous feedback of quality management information to help those individuals make decisions and providing continuous quality improvement, and allocating limited resources to optimise quality and effectiveness. Thus, results of data analysis need to be reported to those individuals responsible for the process or outcome being measured and who are accountable for taking action of the results.
Hospitals which have adopted the Joint Commission International (JCI) hospital accreditation program, and who are already JCI acredited or hospitals seeking JCI accreditation status or hospitals that are seeking for a re-survey for JCI accreditation status, have to comply with JCI Standard QPS.4, which specifically requires that individuals in a hospital with appropriate experience, knowledge, and skills systematically aggregate and analyze data using statistical tools and techniques when suitable and transform the data into useful information. This standard also requires that “Results of analysis are reported to those accountable for taking action.”
It is imperative from the above that HIM/MR practitioners practicing in hosptitals with a quality improvement and patient safety program such as hospital accreditation are likely individuals who will be among medical, nursing, and other departmental heads who participate in relevant quality improvement and patient safety processes. HIM/MR practitioners as trained individuals to understand healthcare information management, have skills in data aggregation methods, and know how to use various statistical tools and techniques, and thus I believe they will be best suited for this role.
American Health Information Management Association (AHIMA) 2011, HIM Functions in Healthcare Quality and Patient Safety, Viewed 15 September 2012 < http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049122.hcsp?dDocName=bok1_049122>
Deming, WE 1982, Out of the Crisis, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA