Professional Training Notes: Intent of IMS & Standards Summary (NABH 6th Edition)

These training notes detail the intent behind the Information Management System (IMS) standards outlined in the NABH 6th Edition, emphasizing their practical application within a hospital setting.

I. Intent of Information Management System (IMS)

The IMS standards aim to establish a robust framework for managing information across all facets of a hospital, ensuring effective communication, patient safety, and regulatory compliance. The core intent can be broken down into the following key areas:

A. Defining IMS and Scope:

• Detail: The IMS encompasses all systems and modalities related to information management within the hospital.

• Management Information System (MIS): Focuses on the broader managerial and operational data required for decision-making, resource allocation, and performance monitoring. This includes data like bed occupancy rates, financial reports, incident analysis, and employee demographics.

• Hospital Information System (HIS): Concentrates on patient-specific clinical data, including electronic medical records (EMRs), lab results, medication orders, and consultation notes.

• All Modalities: This explicitly widens the scope beyond digital systems to encompass all forms of communication and data exchange, including paper records, verbal instructions, notices, circulars, and signage. This holistic view acknowledges the reality that most hospitals operate with a combination of electronic and paper-based systems.

• Practical Application: Training should emphasize the integration of these systems and the consistent application of information management principles across all departments and communication channels. It's vital to move towards more integrated systems wherever possible.

B. Right Information, Right Person, Right Time:

• Detail: This is the fundamental guiding principle of the IMS. Information needs to be accessible and readily available to those who need it, when they need it, to perform their duties effectively and safely.

• Practical Application:

  • Workflow Analysis: Identify critical information flows within the hospital. Map out who needs what information at each step in patient care, administration, and other processes.

  • Accessibility: Implement systems that allow authorized personnel to quickly access relevant information, whether through EMRs, designated information boards, or efficient communication protocols.

  • Timeliness: Emphasize the importance of promptly updating and disseminating information. Delays can lead to errors, inefficiencies, and compromised patient safety.

  • Examples: Nurses should have immediate access to patient medication schedules, physicians should have up-to-date lab results, and administrators should have real-time bed occupancy data.

C. Authenticity, Security, and Accuracy:

• Detail: Information integrity is paramount. It must be verifiable, protected from unauthorized access or modification, and consistently accurate.

• Practical Application:

  • Authentication: Implement robust user authentication protocols (passwords, biometric scans, multi-factor authentication) to control access to sensitive data.

  • Security: Employ data encryption, firewalls, and other security measures to protect electronic information from cyber threats. Secure physical storage for paper records.

  • Accuracy: Establish procedures for data verification and validation. Regularly audit data for errors and inconsistencies. Implement standardized data entry protocols.

  • Training is Crucial: Staff must be trained on data security protocols, including proper password management, recognizing phishing attempts, and reporting security breaches.

• Examples: Implementing 2-Factor Authentication, Anti-Virus/Malware Software, Conducting internal and external audits, Data Encryption

D. Confidentiality, Integrity, and Security of Records:

• Detail: Patient information is highly sensitive and legally protected. Hospitals must uphold the highest standards of confidentiality, ensuring that access is restricted to authorized personnel and that data is protected from unauthorized disclosure. Integrity ensures information remains unaltered without authorization.

• Practical Application:

  • Access Controls: Implement granular access controls within EMRs, restricting access to specific patient records based on roles and responsibilities.

  • Confidentiality Agreements: Require all staff members to sign confidentiality agreements, emphasizing their legal and ethical obligations to protect patient information.

  • Data Breach Response Plan: Develop a comprehensive plan for responding to data breaches, including procedures for containment, notification, and remediation.

  • Policies: Establish and consistently enforce clear policies regarding the handling and disclosure of patient information.

  • Regular Audits: Conduct periodic audits to monitor compliance with confidentiality policies and identify potential vulnerabilities.

E. Complete and Accurate Medical Records & Review Processes:

• Detail: A comprehensive and accurate medical record is the foundation of safe and effective patient care. Medical records must provide a complete account of the patient's history, diagnosis, treatment, and progress. Review processes ensure quality and identify areas for improvement.

• Practical Application:

  • Standardized Documentation Templates: Implement standardized templates for documenting patient encounters, ensuring that all essential information is captured consistently.

  • Training on Documentation Standards: Provide ongoing training to staff on proper documentation practices, emphasizing the importance of completeness, legibility, and accuracy.

  • Medical Record Review Committee: Establish a committee responsible for reviewing medical records on a regular basis, identifying deficiencies, and implementing corrective actions.

  • Feedback Mechanisms: Create channels for staff to report documentation errors or concerns.

II. Summary of Standards (6th vs. 5th Edition Objective Elements)

This section provides a high-level overview of the standards themselves, focusing on the changes (if any) in the number of Objective Elements (OEs) between the 5th and 6th Editions of the NABH standards.

Standard 6th Edition OEs 5th Edition OEs Notes

Information needs met 8 7 Increase indicates a more granular and comprehensive approach to meeting information needs.

Management and control of data 5 5 No change suggests the core principles remain consistent.

Complete and accurate medical record 7 7 No change suggests the core principles remain consistent.

Reflects the continuity of care 8 8 No change suggests the core principles remain consistent.

Confidentiality, integrity, and security 6 6 No change suggests the core principles remain consistent.

Retention of documents 4 4 No change suggests the core principles remain consistent.

Review of medical records 7 7 No change suggests the core principles remain consistent.

Important Considerations for Training:

• Focus on practical implementation: Training should not only cover the theoretical aspects of the standards but also provide concrete examples and practical guidance on how to implement them effectively in the hospital.

• Involve all stakeholders: Include representatives from different departments and professional disciplines in the training sessions to foster a shared understanding of the IMS and its importance.

• Use interactive methods: Incorporate case studies, simulations, and group discussions to engage participants and encourage active learning.

• Provide ongoing support: Offer ongoing support and resources to staff members to help them implement the IMS standards and address any challenges they may encounter.

• Document Compliance: Clearly document compliance efforts. This may be a checklist, training records or even updated policies and procedures.

• Address Organizational Culture: An effective IMS requires a culture of information sharing, transparency, and accountability. Training should promote these values and encourage staff members to actively participate in improving the hospital's information management practices.

• New Technologies: Emphasize new standards and their implementation on software and technology to align efforts.

  • IMS1h: Use of AI to improve Operational Efficiency.

By understanding the intent behind the IMS standards and by systematically implementing them, hospitals can ensure that they are effectively managing information to enhance patient care, improve operational efficiency, and maintain regulatory compliance.

IMS1 - Meeting Information Needs of Stakeholders

This section details the requirements of NABH 6th Edition Standard IMS1, which focuses on ensuring that the information needs of all key stakeholders (patients, visitors, staff, management, and external agencies) are identified and met. Effective implementation of this standard is crucial for patient satisfaction, efficient operations, and regulatory compliance.

I. Standard Statement:

"Information needs of the patients, visitors, staff, management, and external agencies are met."

II. Understanding the Standard:

This standard is not just about passively providing information; it requires a proactive and systematic approach to:

• Identification: Actively determining the specific information needs of each stakeholder group.

• Provision: Delivering the right information through appropriate channels.

• Maintenance: Ensuring the information is current, accurate, and accessible.

III. Key Objective Elements and Professional Training Guidance:

A. IMS1a: The organization identifies the information needs of patients, visitors, staff, management, external agencies, and the community. * (CO)

• Type: Commitment - Core OE

• Training Objective: To equip participants with the knowledge and tools to effectively identify the diverse information needs of each stakeholder group.

• Practical Considerations:

  • Stakeholder Segmentation: Clearly define each stakeholder group and recognize the diverse needs within each. For example, patients have varying needs based on their condition, language, and health literacy.

  • Identification Methods:

    • Feedback Forms: Implement feedback mechanisms to solicit input from patients, visitors, and staff. This includes both traditional paper forms and digital surveys.

    • Patient Calls: Conduct regular phone calls to patients post-discharge to gather feedback on their experience, including their access to information.

    • Focus Group Interviews: Organize focus groups with representatives from each stakeholder group to delve deeper into their specific information needs.

    • Benchmarking: Research best practices from other hospitals regarding information provision.

    • Review Complaints: Analyze existing complaints and feedback to pinpoint areas where information dissemination is lacking.

• • Documentation is Crucial: Maintain detailed records of the identified information needs. This documentation should be regularly reviewed and updated.

  • Prioritization: Given resource constraints, prioritize information needs based on their impact on patient safety, operational efficiency, and regulatory compliance.

  • Consider the Community: Include the community in information need assessments, particularly regarding public health issues, preventive care, and hospital services.

  • Examples:

    • Patients: OPD timings, pre-operative instructions, post-discharge care guidelines, information on medication side effects.

    • Visitors: Visiting hours, directions within the hospital, parking regulations, infection control protocols.

    • Staff: Changes to policies and procedures, training opportunities, performance metrics, resource availability.

    • Management: Key performance indicators (KPIs), financial reports, incident data, patient satisfaction scores.

    • External Agencies: Data on vital statistics (birth/death rates), reporting of notifiable diseases, compliance with accreditation standards.

• Training Exercises:

  • Role-playing: Participants take on the role of different stakeholders and identify their information needs in a simulated scenario.

  • Brainstorming: Conduct a brainstorming session to generate a comprehensive list of information needs for each stakeholder group.

B. IMS1b: Identified information needs are captured and/or disseminated. (C)

• Type: Commitment

• Training Objective: To ensure participants understand how to translate identified information needs into actionable strategies for capturing and disseminating that information.

• Practical Considerations:

  • Written Guidance is Essential: Develop clear and concise written guidance (policies, procedures, protocols) for capturing and disseminating information. This guidance should specify:

    • Data Collection Methods: How the information will be collected (e.g., feedback forms, surveys, EMR data extraction).

    • Dissemination Channels: How the information will be distributed to the relevant stakeholders (e.g., website, intranet, bulletin boards, staff meetings).

    • Frequency of Data Collection: How often the data will be collected (e.g., daily, weekly, monthly).

    • Responsible Person: The individual or department responsible for overseeing the data collection and dissemination process.

• • Appropriate Dissemination Channels: Select the most appropriate channels for reaching each stakeholder group. For example:

    • Patients: Website, information booklets, discharge summaries, patient portals.

    • Visitors: Signage, brochures, website.

    • Staff: Intranet, email, staff meetings, training sessions.

    • Management: Reports, dashboards, presentations.

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  • Consider Language and Literacy: Information should be presented in a clear, concise, and culturally sensitive manner. Consider providing information in multiple languages and using visual aids to enhance understanding.

• Training Exercises:

  • Develop a Communication Plan: Participants develop a communication plan for disseminating a specific piece of information to a particular stakeholder group, outlining the message, channel, frequency, and responsible party.

C. IMS1c: Information management and technology acquisitions are commensurate with the identified information needs. (C)

• Type: Commitment

• Training Objective: To educate participants on aligning technology investments with identified information needs to avoid unnecessary expenses and ensure optimal functionality.

• Practical Considerations:

  • Needs Assessment Before Acquisition: Conduct a thorough needs assessment before acquiring any new information management technology (software, hardware, or services).

  • Define Requirements: Clearly define the functional and technical requirements for the technology based on the identified information needs.

  • Evaluate Alternatives: Evaluate different technology options based on their ability to meet the defined requirements.

  • Ensure Licensing Compliance: Verify that all software licenses are valid and compliant with vendor terms.

  • Consider Interoperability: Select technologies that can seamlessly integrate with existing systems to avoid data silos and ensure efficient information sharing.

  • Examples: Deciding to implement an EMR system requires careful consideration of the hospital's specific needs for patient record management, data analysis, and reporting.

• Training Exercises:

  • Technology Evaluation: Participants evaluate different technology options based on a set of defined information needs, considering factors such as cost, functionality, and interoperability.

D. IMS1d: A maintenance plan for information technology and communication network is implemented. (C)

• Type: Commitment

• Training Objective: To stress the importance of a proactive maintenance plan for IT infrastructure to ensure reliable access to information.

• Practical Considerations:

  • Comprehensive Maintenance Plan: Develop and implement a comprehensive maintenance plan that covers all aspects of the hospital's IT and communication network.

  • Key Elements of the Plan:

    • Preventive Maintenance: Scheduled maintenance activities to prevent equipment failures and ensure optimal performance.

    • Regular Backups: Implement a robust data backup and recovery system to protect against data loss.

    • Security Updates: Regularly install security updates and patches to protect against cyber threats.

    • Disaster Recovery: Develop a plan for restoring IT systems in the event of a disaster.

    • Vendor Support: Establish service level agreements (SLAs) with vendors for timely support and maintenance.

• • Include Fire Protection: Add specific fire protection plans for IT network and servers.

  • Manufacturer recommendations: Adhere to Manufacturer recommendation and regular inspections.

  • Documentation and Record-Keeping: Maintain detailed records of all maintenance activities.

• Training Exercises:

  • Maintenance Plan Simulation: Participants develop a maintenance plan for a specific IT system, outlining the preventive maintenance activities, backup procedures, and disaster recovery strategies.

E. IMS1e: Contingency plan ensures continuity of information capture, integration, and dissemination. (A)

• Type: Achievement

• Training Objective: To ensure participants can develop and implement contingency plans that guarantee continued information flow during system downtimes.

• Practical Considerations:

  • Downtime Scenarios: Identify potential downtime scenarios (e.g., power outages, network failures, system crashes).

  • Manual Backup Procedures: Develop manual backup procedures for capturing, integrating, and disseminating critical information during downtime.

  • Alternative Communication Channels: Identify alternative communication channels (e.g., paper-based forms, telephone calls, radio communication) to be used during downtime.

  • Prioritize Essential Information: Identify the most essential information that must be captured and disseminated during downtime.

  • Staff Training on Downtime Procedures: Train staff on how to use the backup procedures and alternative communication channels.

  • Regular Testing of Contingency Plan: Conduct regular drills to test the effectiveness of the contingency plan and identify areas for improvement.

  • Downtime Monitoring: Monitor downtime to improve future contingency planning.

• Training Exercises:

  • Downtime Simulation: Participants simulate a system downtime and practice using the backup procedures and alternative communication channels to capture and disseminate essential information.

F. IMS1f: The organization ensures that information resources are accurate and meet stakeholder requirements. (C)

• Type: Commitment

• Training Objective: To emphasize the importance of verifying the accuracy of all information resources and aligning them with the specific needs of the stakeholders.

• Practical Considerations:

  • Defined Review Process: Implement a defined process for regularly reviewing and updating all information resources (e.g., policies, procedures, forms, brochures, website content).

  • Subject Matter Experts: Involve subject matter experts in the review process to ensure accuracy and technical correctness.

  • Stakeholder Feedback: Solicit feedback from stakeholders on the usefulness and accuracy of information resources.

  • Regular Updates: Update information resources whenever there are changes in policies, procedures, regulations, or best practices.

  • Version Control: Implement version control to ensure that staff are using the most current versions of information resources.

  • Eliminate Outdated Information: Remove outdated or inaccurate information resources from circulation.

• Training Exercises:

  • Information Resource Audit: Participants audit a sample of information resources, checking for accuracy, completeness, and alignment with stakeholder requirements.

G. IMS1g: The organization contributes to external databases in accordance with the law and regulations. (C)

• Type: Commitment

• Training Objective: To ensure participants are aware of legal and regulatory requirements for contributing data to external databases and can comply with those requirements.

• Practical Considerations:

  • Identify Legal and Regulatory Requirements: Identify all legal and regulatory requirements for reporting data to external databases (e.g., reporting of notifiable diseases, adverse drug reactions, medical device malfunctions).

  • Standardized Reporting Procedures: Develop standardized procedures for collecting and reporting the required data.

  • Train Staff on Reporting Requirements: Train staff on the reporting requirements and procedures.

  • Ensure Data Accuracy and Completeness: Implement quality control measures to ensure that the data being reported is accurate and complete.

  • Examples: reporting adverse drug reactions to (Pharmacovigilance Programme of India) PvPI, reporting adverse events following immunization to the (Adverse Events Following Immunization) AEFI, or contributing to national disease registries.

• Training Exercises:

  • Reporting Simulation: Participants practice completing and submitting required data to a simulated external database.

H. IMS1h: The organization shall make efforts to use digital Health technology to improve Operational efficiency, patient safety and patient Experience (E)

• Type: Excellence

• Training Objective: To encourage the use of digital health technology for operational efficiency and to showcase how it can improve patient safety and experience.

• Practical Considerations:

  • Assess Opportunities: Actively evaluate areas where digital health technologies can improve operations and patient outcomes.

  • Consider AI: Consider how artificial intelligence can improve healthcare.

  • Test and Validate: Ensure that digital health technologies are tested and validated before implementation.

  • Data Analytics: Implement data analytics to monitor the effectiveness of digital health technologies and identify areas for improvement.

  • Implement Patient Safety Features: Consider features such as clinical decision support systems, bar-code medication administration, and electronic incident reporting to enhance patient safety.

  • Examples: Examples: Electronic sign out/Hand off tools, Computerized Physician order entry, Telemedicine Visits.

• Training Exercises:

  • Brainstorm the use of existing and new technology

IV. Training Delivery Methods:

• Interactive Workshops: Combine presentations with hands-on activities, group discussions, and case studies.

• Real-Life Scenarios: Use realistic hospital scenarios to illustrate the practical application of the IMS1 standards.

• Technology Demonstrations: Demonstrate the functionality of relevant information management systems and technologies.

• Checklists and Templates: Provide participants with checklists and templates to guide their implementation efforts.

V. Evaluation and Follow-up:

• Pre- and Post-Training Assessments: Use assessments to measure participants' knowledge and understanding of the IMS1 standards before and after the training.

• Practical Application Exercises: Observe participants' performance during practical application exercises to assess their ability to implement the standards.

• Follow-Up Support: Provide ongoing support and resources to staff members to help them sustain their implementation efforts.

By providing comprehensive training on IMS1, hospitals can empower their staff to effectively manage information, enhance patient care, and achieve accreditation success.

IMS2 - Processes for Management and Control of Data and Information

This section provides a comprehensive breakdown of NABH 6th Edition Standard IMS2, focusing on the establishment and maintenance of robust processes for the management and control of data and information within the hospital. This standard is crucial for ensuring data integrity, consistency, and usability, ultimately leading to better decision-making and improved patient outcomes.

I. Standard Statement:

"The organisation has processes in place for management and control of data and information."

II. Understanding the Standard:

This standard underscores the importance of having documented and consistently followed processes to manage the entire lifecycle of data and information, from collection to storage, analysis, and dissemination. The underlying goal is to transform raw data into actionable insights that support clinical and administrative functions.

III. Key Objective Elements and Professional Training Guidance:

A. IMS2a: Processes for data collection are standardised. (C)

• Type: Commitment

• Training Objective: To ensure that data collection is carried out consistently across the organization, reducing variability and improving data quality.

• Practical Considerations:

  • Standardized Forms: Develop and implement standardized forms for data collection, both physical and electronic.

  • Clear Data Definitions: Establish clear and unambiguous definitions for all data elements to ensure consistent interpretation.

  • Defined Processes: Create and document standardized processes for data collection, outlining who is responsible, when data should be collected, and how data should be entered.

  • Examples:

    • Use a standard form for collecting patient demographics at registration.

    • Define clear criteria for classifying patients based on their disease severity.

  • Key Areas to Standardize:

    • Formats: Standardize the format of data collection instruments (e.g., paper forms, electronic templates). This includes specifying required fields, data types (e.g., text, numeric, date), and validation rules.

    • Frequency: Establish a consistent schedule for data collection (e.g., daily, weekly, monthly, quarterly). The frequency should align with the purpose of the data and the needs of the users.

    • Documentation: Develop and maintain comprehensive documentation of the standardized data collection processes. This documentation should be accessible to all staff members involved in data collection.

  • Training is Essential: Conduct comprehensive training for staff involved in data collection to ensure they understand the standardized processes and can apply them consistently.

• Training Exercises:

  • Form Design: Participants design a standardized data collection form for a specific purpose, considering data elements, formats, and validation rules.

  • Process Mapping: Participants map out the steps involved in a standardized data collection process, identifying potential areas for improvement.

B. IMS2b: Data is analysed to meet the information needs. (C)

• Type: Commitment

• Training Objective: To ensure that collected data is transformed into meaningful information that supports decision-making and improvement initiatives.

• Practical Considerations:

  • Define Information Needs: Start by clearly defining the information needs of the hospital and its various stakeholders.

  • Appropriate Analysis Techniques: Select the most appropriate data analysis techniques based on the information needs.

  • Ensure availability of resources:

    • Men: Trained personnel to analyse data.

    • Material: Proper Software and Data Tools to analyse data.

    • Space: Proper area where tools are available to analyse the data.

    • Budget: Budget allocation for purchasing software/tools.

  • Examples:

    • Use statistical analysis to identify trends in patient satisfaction scores.

    • Use data visualization techniques to present information on key performance indicators.

  • Essential Aspects of Data Analysis:

    • Data Cleaning: Data cleaning involves identifying and correcting errors and inconsistencies in the data. This is a crucial step to ensure the accuracy and reliability of the analysis results.

    • Data Summarization: Data summarization involves condensing large amounts of data into more manageable and meaningful summaries. This can be done using descriptive statistics (e.g., mean, median, standard deviation) or data visualization techniques (e.g., charts, graphs).

    • Trend Analysis: Trend analysis involves identifying patterns and changes in data over time. This can be used to identify areas where performance is improving or declining, or to forecast future trends.

    • Root Cause Analysis: Root cause analysis involves identifying the underlying causes of problems or issues. This can be used to develop targeted interventions to address the root causes and prevent future occurrences.

• Training Exercises:

  • Data Analysis Simulation: Participants analyze a set of data using various techniques to answer specific questions and generate insights.

  • Reporting: Participants identify key resources for the process.

C. IMS2c: The organisation disseminates the information in a timely and accurate manner. (C)

• Type: Commitment

• Training Objective: To ensure that analyzed data is effectively communicated to the right people at the right time to support informed decision-making and action.

• Practical Considerations:

  • Decide Modalities of Sharing:

    • Which information needs to be shared with whom.

    • How information should be communicated: For example: Memos, Circulars, and Webpage.

  • Right Stakeholders: Identify the specific stakeholders who need to receive the information.

  • Timely Dissemination: Establish a clear timeframe for disseminating information to ensure that it reaches stakeholders in a timely manner.

  • Appropriate Channels: Select the most appropriate communication channels based on the audience and the nature of the information.

    • Example: Email, Reports, Presentation

  • Clear and Concise Communication: Present the information in a clear, concise, and easily understandable manner.

  • Examples:

    • Share monthly performance reports with department heads.

    • Communicate patient satisfaction scores to staff members.

  • Effective Information Dissemination Strategies:

    • Visual Aids: Use visual aids (e.g., charts, graphs) to present information in a more engaging and understandable way.

    • Brief and Concise Reports: Create brief and concise reports that highlight the key findings and recommendations.

    • Targeted Communication: Tailor the communication style and content to the specific audience.

• Training Exercises:

  • Communication Planning: Participants develop a communication plan for disseminating a specific set of findings, outlining the audience, message, channel, and timeline.

  • Presentation Skills: Participants practice presenting data findings to different audiences, using clear and concise language and visual aids.

D. IMS2d: The organisation stores and retrieves data according to its information needs. * (C)

• Type: Commitment - Asterisk (Requires System Documentation)

• Training Objective: To ensure that data is stored securely and can be retrieved efficiently when needed.

• Practical Considerations:

  • Secure Storage: Implement secure storage systems to protect data from unauthorized access, loss, or damage.

  • Efficient Retrieval: Establish efficient retrieval processes to ensure that data can be accessed quickly and easily when needed.

  • Examples:

    • Implement a secure EMR system with role-based access control.

    • Use a document management system to store and retrieve policies and procedures.

  • Strategic Data Storage and Retrieval:

    • Data Classification: Classify data based on its sensitivity and importance. This will help to determine the appropriate storage and retrieval methods.

    • Data Archiving: Establish a process for archiving data that is no longer actively used but needs to be retained for legal or regulatory reasons.

    • Data Indexing: Implement data indexing to improve the speed and efficiency of data retrieval.

  • Facilitate Access to Data

    • Patient Care: Make sure data is available to provide the best patient care.

    • Education: Make sure the data can be used to improve current education.

    • Research: Data is available to conduct research and improve current operations.

    • Management of Services: Managing overall organization.

• Training Exercises:

  • Data Security Assessment: Participants conduct a data security assessment to identify potential vulnerabilities in the hospital's data storage systems.

  • Data Retrieval Exercise: Participants practice retrieving specific data elements from different storage systems using various search techniques.

E. IMS2e: Clinical and managerial staff participate in selecting, integrating and using data for meeting the information needs. (C)

• Type: Commitment

• Training Objective: To promote a collaborative approach to data management, ensuring that both clinical and managerial perspectives are considered.

• Practical Considerations:

  • Cross-Functional Teams: Establish cross-functional teams that include clinical and managerial staff to oversee data management initiatives.

  • Data-Driven Decision-Making: Encourage clinical and managerial staff to use data to inform their decision-making.

  • Examples:

    • Involve both physicians and administrators in selecting KPIs for monitoring patient outcomes.

    • Encourage nurses and IT staff to collaborate on designing user-friendly EMR interfaces.

• • Collaboration:

    • Multidisciplinary committees: Appropriate clinical and managerial staff

    • Selection of relevant indicators.

    • Measurement of trends.

    • Initiation of actions.

• Training Exercises:

  • Data Analysis Workshop: Participants from different departments work together to analyze a data set and develop recommendations for improvement.

  • Stakeholder Communication: Participants practice communicating data findings to colleagues from different professional backgrounds.

IV. Training Delivery Methods:

• Interactive Workshops: Combine presentations with group discussions, case studies, and hands-on activities.

• Real-Life Scenarios: Use realistic hospital scenarios to illustrate the practical application of the IMS2 standards.

• Technology Demonstrations: Demonstrate the functionality of relevant data management systems and tools.

• Checklists and Templates: Provide participants with checklists and templates to guide their implementation efforts.

V. Evaluation and Follow-up:

• Pre- and Post-Training Assessments: Use assessments to measure participants' knowledge and understanding of the IMS2 standards before and after the training.

• Practical Application Exercises: Observe participants' performance during practical application exercises to assess their ability to implement the standards.

• Follow-Up Support: Provide ongoing support and resources to staff members to help them sustain their implementation efforts.

• Review Implementation: Regular check and audits.

By providing comprehensive training on IMS2, hospitals can empower their staff to effectively manage and control data and information, improving operational efficiency, clinical decision-making, and patient outcomes.

IMS3 - Complete and Accurate Medical Records

This section delivers a comprehensive training overview of NABH 6th Edition Standard IMS3, which mandates that patients cared for by the organization must have a complete and accurate medical record. This standard is foundational to patient safety, continuity of care, and medico-legal defensibility.

I. Standard Statement:

"The patients cared for by the organisation have a complete and accurate medical record."

II. Understanding the Standard:

This standard isn't solely about documentation. It encompasses the processes and systems ensuring that the medical record provides a comprehensive, up-to-date, and reliable account of each patient's journey, from admission to discharge. This includes capturing essential clinical data, adhering to documentation standards, and maintaining the integrity of the record.

III. Key Objective Elements and Professional Training Guidance:

A. IMS3a: The unique identifier is assigned to the medical record. (CO)

• Type: Commitment - Core OE

• Training Objective: To instill the importance of a unique identifier in preventing patient identification errors and ensuring proper record linkage.

• Practical Considerations:

  • Clearly Defined Identifier: Develop a clear and consistent system for assigning unique identifiers to each patient's medical record. This could be a medical record number (MRN), a unique patient identifier (UPI), or a combination of factors.

  • Electronic vs. Physical Records: Ensure the unique identifier is consistently applied to both electronic and physical records.

  • Placement of Identifier: Ensure that the unique identifier is prominently displayed on every page or screen of the medical record, for easy identification.

  • Verification Process: Implement a process for verifying the patient's identity before assigning or accessing the medical record.

  • Centralized Registry: Consider a centralized patient registry to ensure that each patient has only one unique identifier.

  • Electronic Record
    * All entries for one unique identifier should be available in one place and/or traceable to the number

  • Medical Record

    • Every sheet should have unique identifier number.

• Training Exercises:

  • Record Audit: Participants review a set of medical records to check for the presence and accuracy of unique identifiers.

  • Error Simulation: Participants simulate a patient identification error and discuss the steps that can be taken to prevent such errors from occurring.

B. IMS3b: The contents of the medical record are identified and documented. * (C)

• Type: Commitment - Asterisk (Requires System Documentation)

• Training Objective: To ensure that all essential documents and data elements are included in the medical record, providing a complete picture of the patient's care.

• Practical Considerations:

  • Defined Contents List: Develop a checklist of the essential documents and data elements that should be included in every medical record. This list should be tailored to the specific services provided by the hospital.

  • Policy and Procedure: Create a policy outlining what is kept in a patient's records.

  • Examples of Essential Documents:

    • Admission orders

    • Face sheet

    • IP sheet

    • Referrals transfer

    • Lab result

    • Imaging results

    • Discharge summary

    • Doctor's order sheet

    • TPR chart

    • Consent form

    • Nursing assessment

    • Nursing care plans

    • Dietary assessments and plans

    • Physiotherapy assessments

  • Standardized Templates: Implement standardized templates for documenting patient encounters, ensuring that all essential data elements are captured consistently.

  • Electronic Medical Record (EMR) Customization: If using an EMR, customize the system to ensure that all required fields are present and that staff are prompted to enter the necessary information.

  • Physical v. Electronic:

    • Define the documents that are being maintained in physical.

    • The goal is appropriate linkages shall be available between them.

• Training Exercises:

  • Contents Audit: Participants review a set of medical records to check for the presence of all essential documents and data elements.

  • Template Development: Participants develop a standardized template for documenting a specific type of patient encounter.

C. IMS3c: The medical record provides a complete, up-to-date and chronological account of patient care. (CO)

• Type: Commitment - Core OE

• Training Objective: To emphasize the importance of maintaining the medical record in a timely and organized manner, providing a clear timeline of the patient's care.

• Practical Considerations:

  • Timely Documentation: Encourage staff to document patient encounters promptly, ideally at the point of care.

  • Chronological Order: Ensure that all documents and entries are filed in chronological order, making it easy to follow the patient's care timeline.

  • Dated and Timed Entries: Require that all entries be dated and timed to provide a precise record of events.

  • Avoid Gaps: Minimize gaps in documentation. If there are any missing notes or documents, clearly indicate the reason for the omission.

  • Numbering: It is preferable to write pages in the medical record as numbered.

  • Organization: File identified sheets in sequential order.

  • Chronology: File entries in components in chronological order.

  • Missing Information: Place a missing note in case a sheet is missing.

• Training Exercises:

  • Chronological Sequencing: Participants review a set of medical records and identify any inconsistencies in the chronological order of documents and entries.

  • Documentation Simulation: Participants simulate a patient encounter and practice documenting the events in a timely and organized manner.

D. IMS3d: Authorised staff make the entry in the medical record. * (C)

• Type: Commitment - Asterisk (Requires System Documentation)

• Training Objective: To prevent unauthorized alterations and ensure accountability for the information contained in the record.

• Practical Considerations:

  • Defined Authorization Policy: Develop a policy that clearly defines which staff members are authorized to make entries in the medical record. This policy should be based on their roles and responsibilities.

  • Unique Usernames and Passwords: Assign unique usernames and passwords to all authorized staff members to track their entries in the electronic medical record.

  • "Master Signature List": Maintain a 'master signature list' in medical record with name of the person and their signature/employee code number.

  • Access Controls: Implement access controls in the EMR to restrict access to specific sections of the record based on user roles.

  • Different Entries: This could be different category of staff for different entries. But, it should be uniform throughout the organisation.
    * Doctors should write medication orders.
    * Nurses should write medication administration chart.
    * Dietician should write nutritional assessment.

• Training Exercises:

  • Access Control Audit: Participants review the access controls in the EMR to ensure that they are appropriate for their roles and responsibilities.

  • Authorization Simulation: Participants simulate a scenario where they are asked to make an entry in a medical record for which they are not authorized and discuss the steps they would take.

E. IMS3e: Entry in the medical record is signed, dated and timed. (C)

• Type: Commitment

• Training Objective: To establish accountability for entries and provide a clear timeline for documentation.

• Practical Considerations:

  • Require Signatures: Mandate that all entries be signed, dated, and timed by the authorized staff member.

  • Electronic Signatures: If using an EMR, implement electronic signature functionality to streamline the signing process.

  • Time Frame:
    * All entries immediately
    * By one hour of completion of assessment/procedure.

  • Automatic Timestamping: Consider implementing automatic timestamping features to record the date and time of entries in the EMR.

• Training Exercises:

  • Signature Audit: Participants review a set of medical records to check for the presence of signatures, dates, and times on all entries.

  • Documentation Practice: Participants practice signing, dating, and timing their entries in a simulated medical record.

F. IMS3f: The author of the entry can be identified. (C)

• Type: Commitment

• Training Objective: To ensure that each entry in the medical record can be traced back to the individual who made it.

• Practical Considerations:

  • Full Name or Employee Code: Require that all entries include the author's full name or employee code.

  • Master Signature List: Maintain a "master signature list" with the names and signatures of all authorized staff members.

  • Electronic Audit Trails: If using an EMR, utilize the audit trail functionality to track all changes made to the medical record.

  • Write Full Name: Write full name/employee code number/affix stamp.

  • Authorized E-Signature: Provide authorized e-signature as per statutory requirements.

• Training Exercises:

  • Author Identification Exercise: Participants review a set of medical records and practice identifying the authors of different entries based on their signatures and employee codes.

  • Audit Trail Analysis: Participants analyze an audit trail from the EMR to track changes made to a specific patient record.

G. IMS3g: The medical record has only authorised abbreviations. (C)

• Type: Commitment

• Training Objective: To minimize the risk of misinterpretation and medication errors by using only approved abbreviations.

• Practical Considerations:

  • Standardized Abbreviation List: Develop a standardized list of approved abbreviations to be used in the medical record. This list should be readily accessible to all staff members.

  • Prohibit Unapproved Abbreviations: Prohibit the use of unapproved abbreviations in the medical record.

  • Do use Standardized List: Do use a standardised list of approved abbreviations.

  • Do not use Error-Prone: Do not use error-prone abbreviations for medications.

• Training Exercises:

  • Abbreviation Audit: Participants review a set of medical records and identify any instances of unapproved abbreviations.

  • Scenario-Based Exercise: Participants practice using approved abbreviations in a simulated patient encounter.

IV. Training Delivery Methods:

• Interactive Workshops: Combine presentations with group discussions, case studies, and hands-on activities.

• Real-Life Scenarios: Use realistic hospital scenarios to illustrate the practical application of the IMS3 standards.

• Medical Record Review: Conduct a practical review of medical records and documentation.

V. Evaluation and Follow-up:

• Pre- and Post-Training Assessments: Use assessments to measure participants' knowledge and understanding of the IMS3 standards before and after the training.

• Documentation Audits: Conduct periodic audits of medical records to assess compliance with the documentation standards.

• Feedback Mechanisms: Establish feedback mechanisms for staff to report concerns or suggestions related to medical record documentation.

By providing comprehensive training on IMS3, hospitals can empower their staff to create and maintain complete and accurate medical records, improving patient safety, continuity of care, and medico-legal defensibility.

IMS4 - Medical Record Reflecting Continuity of Care

This section presents detailed professional training notes on NABH 6th Edition Standard IMS4, which emphasizes the critical role of the medical record in demonstrating continuity of care. This standard focuses on ensuring that the medical record provides a clear and comprehensive account of the patient's journey, enabling healthcare providers to make informed decisions and deliver seamless care.

I. Standard Statement:

"The Medical Record reflects continuity of care."

II. Understanding the Standard:

This standard goes beyond simply documenting events; it mandates that the medical record acts as a cohesive narrative, highlighting the logical progression of care, the rationale behind treatment decisions, and the coordination between different healthcare providers. This standard ensures everyone involved in a patient's care can easily understand the patient's clinical history, current status, and future plan, even across different departments and encounters.

III. Key Objective Elements and Professional Training Guidance:

A. IMS4a: The medical record contains information regarding reasons for admission, diagnosis, and care plan. (C)

• Type: Commitment

• Training Objective: To emphasize the foundational elements that set the stage for patient care and treatment within the medical record.

• Practical Considerations:

  • Reasons for Admission: Document the patient's presenting symptoms, the primary reason for seeking medical attention, and any relevant history that led to the admission. Be specific and avoid vague language.

  • Diagnosis: Clearly state the working diagnosis (if applicable) and the confirmed diagnosis. Include the diagnostic criteria used to reach the conclusion. Codify as per the ICD/SNOMED CT

  • Care Plan: Outline the initial care plan, including planned interventions, investigations, medications, consultations, and anticipated outcomes.

  • Responsibility: The treating doctor/doctor member of the treatment team, the treating team are responsible to document the above.

  • Documentations: Make sure documentation of diagnosis of IP, MRD.

• Training Exercises:

  • Case Study Analysis: Participants review a case study and identify the key elements that should be included in the medical record to meet the requirements of this objective element.

  • Template Review: Participants review and revise existing admission templates to ensure they capture all necessary information.

B. IMS4b: The medical record contains the details of assessments, re-assessments, and consultations. (C)

• Type: Commitment

• Training Objective: To ensure that all assessments, re-assessments, and consultations are documented comprehensively, providing a longitudinal view of the patient's condition and response to treatment.

• Practical Considerations:

  • Initial Assessments: Document the findings of the initial assessments conducted by various healthcare providers, including physicians, nurses, and other specialists (e.g., physical therapists, dietitians).

  • Re-Assessments: Document all re-assessments conducted throughout the patient's stay, noting any changes in their condition or response to treatment.

  • Consultation Notes: Include copies of all consultation notes from specialists, summarizing their findings and recommendations.

  • Physical v. Electronic: These records can be maintained physical/electronic form.

  • Assessments: Examples are Medical, Nursing, Rehabilitation, Physiotherapy, Nutrition

• Training Exercises:

  • Documentation Simulation: Participants simulate a patient encounter and practice documenting the findings of an assessment, re-assessment, or consultation.

  • Chart Review: Participants review medical records to identify any gaps in documentation related to assessments, re-assessments, or consultations.

C. IMS4c: The medical record contains the results of investigations and the details of the care provided. (C)

• Type: Commitment

• Training Objective: To ensure that all investigations and care activities are thoroughly documented, providing a comprehensive record of the patient's treatment.

• Practical Considerations:

  • Investigation Results: Include copies of all investigation reports (e.g., laboratory results, imaging reports, pathology reports).

  • Care Details: Document all care activities provided to the patient, including medications administered, procedures performed, therapies provided, and education given.

  • Physical v. Electronic: These records can be maintained physical/electronic form.

• Training Exercises:

  • Chart Audit: Participants review medical records to ensure that all investigation results and care details are properly documented.

  • Scenario Simulation: Participants simulate a complex patient scenario and practice documenting the investigations and care provided in a clear and concise manner.

D. IMS4d: Operative and other procedures performed are incorporated in the medical record. (C)

• Type: Commitment

• Training Objective: To ensure that all operative and other procedures performed on the patient are thoroughly documented, providing a clear account of the interventions.

• Practical Considerations:

  • Procedure Name and Details: The name of the procedure and the date on which it was performed.

  • Procedure report: Document the indications for the procedure, the technique used, the findings, and any complications that occurred. Include pre-operative and post-operative diagnoses

  • Informed Consent: Include a copy of the informed consent form, indicating that the patient understood the risks and benefits of the procedure.

  • Physical v. Electronic: This record can be maintained physical/electronic form.

• Training Exercises:

  • Operative Note Review: Participants review operative notes to ensure that they contain all essential information.

  • Procedure Documentation Practice: Participants practice documenting a simulated procedure, including the indications, technique, findings, and complications.

E. IMS4e: When a patient is transferred to another organisation, the medical record contains the details of the transfer. (C)

• Type: Commitment

• Training Objective: To ensure that the receiving organization has all the necessary information to continue the patient's care seamlessly.

• Practical Considerations:

  • Key Transfer Details:

    • Date of transfer

    • Reason for transfer

    • Name of receiving organization

    • Clinical condition of patient before transfer

  • Transfer Summary: Prepare a transfer summary that includes:

    • Pertinent medical history

    • Current medications

    • Allergies

    • Recent investigations

    • Treatment plan

    • A note mentioning transfer as per request of patient.

  • Communication with Receiving Organization: Communicate with the receiving organization to ensure they are aware of the transfer and have all the necessary information.

• Training Exercises:

  • Transfer Summary Development: Participants develop a transfer summary for a simulated patient, including all the essential information.

  • Communication Scenario: Participants simulate a phone call with a receiving organization to discuss a patient transfer.

F. IMS4f: The medical record contains a copy of the discharge summary. (C)

• Type: Commitment

• Training Objective: To ensure that the patient and subsequent caregivers have a comprehensive summary of the patient's stay, enabling informed decision-making and continued care.

• Practical Considerations:

  • Discharge Summary Elements: A discharge summary will includes:

    • Final diagnosis

    • Significant findings

    • Procedures performed

    • Medications at discharge

    • Follow-up instructions

    • Contact information for healthcare providers.

    • Discharge summary shall be signed by a doctor member of the treating member.

• Training Exercises:

  • Discharge Summary Review: Participants review discharge summaries to ensure that they contain all essential information.

  • Discharge Planning Simulation: Participants simulate a discharge planning meeting with a patient and their family, providing them with a comprehensive discharge summary and instructions.

G. IMS4g: In case of death, the medical record contains a copy of the medical certificate of the cause of death. (C)

• Type: Commitment

• Training Objective: To ensure proper documentation for legal and statistical purposes.

• Practical Considerations:

  • Death Certificate inclusion: Include the death report, cause of death, date of death, and time of death.

  • International Form of Medical Certificate of Cause of Death : Provide the death certificate based on the above.

  • Note: Medical Certificate of the cause of death as per the international classification of the cause of Death (WHO) shall be part of medical record.Cardiac and respiratory arrest is an event of death and not the cause of death.

• Training Exercises:

  • Participants practice completing a mock death certificate.

H. IMS4h: Care providers have access to current and past medical record. (C)

• Type: Commitment

• Training Objective: To ensure timely access to information and emphasize continuity of care.

• Practical Considerations:

  • Access:
    * If the MRD is open 24/7, then provide access to medical records to designated healthcare providers (those involved in patient care).
    * If the MRD is NOT open 24/7, then ensure that the authorised personnel can open MRD and retrieve record.

  • Provide Continuity of Care: Patient Records available 24/7 so that care providers have continuity of care.

  • Retrievable Data: Medical Records retrievable for existing patients who come to emergency room.

• Training Exercises:

  • Participants practice how to pull charts or access data from EHR in mock emergency situation.

IV. Training Delivery Methods:

• Interactive Workshops: Use case studies, role-playing, and group discussions to engage participants.

• Chart Audits: Conduct hands-on chart audits to identify gaps in documentation.

• Technology Demonstrations: Show how electronic medical record systems can facilitate continuity of care.

V. Evaluation and Follow-up:

• Documentation Audits: Regularly audit medical records to assess compliance.

• Feedback Mechanisms: Establish channels for staff to report concerns or suggestions related to documentation.

By providing thorough training on IMS4, hospitals can empower their staff to create and maintain medical records that effectively reflect continuity of care, leading to improved patient outcomes and enhanced safety.

IMS5 - Confidentiality, Integrity, and Security of Records, Data, and Information

This section provides in-depth professional training notes on NABH 6th Edition Standard IMS5. This crucial standard focuses on establishing and maintaining a robust framework to safeguard the confidentiality, integrity, and security of all records, data, and information within the hospital, protecting sensitive patient information and ensuring compliance with ethical and legal obligations.

I. Standard Statement:

"The organisation maintains confidentiality, integrity and security of records, data and information."

II. Understanding the Standard:

This standard emphasizes the holistic protection of information throughout its lifecycle, encompassing physical and electronic records. It goes beyond simply having security measures in place; it requires a proactive approach that includes policies, procedures, training, monitoring, and continuous improvement. This ensures that sensitive patient information is protected from unauthorized access, disclosure, alteration, or destruction.

III. Key Objective Elements and Professional Training Guidance:

A. IMS5a: The organization maintains the confidentiality of records, data, and information. (CO)*

• Type: Commitment - Core OE - Asterisk (Requires System Documentation)

• Training Objective: To instill an understanding of patient privacy rights and to equip participants with the skills to protect confidential information.

• Practical Considerations:

  • Access Control:

    • Access control: Control accessibility to MRD and HIS.

    • Electronic system: Provide different access to different personnel and specific for that user.

    • Physical records: Use tracer card to trace movement of files in and out of MRD.

  • Confidentiality Policies:

    • Develop and implement comprehensive confidentiality policies that define what constitutes confidential information, who is authorized to access it, and how it should be handled. These policies should comply with all applicable legal and ethical guidelines.

  • Training and Awareness:

    • Provide regular training to all staff members on confidentiality policies and best practices. This training should cover topics such as patient privacy rights, proper handling of medical records, data security protocols, and the importance of reporting security breaches.

  • Data Minimization:

    • Collect only the minimum amount of data necessary for the specific purpose. Avoid collecting or storing sensitive information that is not essential.

  • Workplace Privacy:

    • Design the physical workspace to protect patient privacy. Ensure that conversations about patients cannot be overheard by unauthorized individuals.

  • Ensure data Privacy

    • Ensure authentication, access control and automatic log off features.

    • Ideally, only clinical care providers should have access rights to a person's clinical records.

• Training Exercises:

  • Scenario-Based Discussion: Participants analyze realistic scenarios involving confidential information and discuss the appropriate course of action.

  • Policy Review: Participants review the hospital's confidentiality policies and identify any areas for improvement.

B. IMS5b: The organisation maintains the integrity of records, data and information. * (CO)

• Type: Commitment - Core OE - Asterisk (Requires System Documentation)

• Training Objective: To prevent unauthorized alterations or deletions of information and to ensure that data remains accurate and reliable.

• Practical Considerations:

  • Access Controls: Implement strong access controls to restrict who can modify or delete data. Use role-based access controls to ensure that staff members only have access to the data they need to perform their jobs.

  • Audit Trails: Enable audit trails to track all changes made to data, including who made the changes, when they were made, and what was changed. This helps to identify and investigate unauthorized modifications.

  • Data Validation: Implement data validation rules to ensure that data is entered correctly. This can include format checks, range checks, and consistency checks.

  • Backup and Recovery: Implement a robust backup and recovery system to protect against data loss or corruption.

  • Version Control: Implement version control for documents and data to ensure that the most recent version is always available.

  • Corrections:

    • Adhere to written guidance and ensure written documentation.

    • Keep track of changes made in records/data.

• Training Exercises:

  • Audit Trail Analysis: Participants analyze an audit trail to identify any suspicious activity or unauthorized modifications.

  • Data Validation Exercise: Participants practice entering data into a system and identify the data validation rules that are in place.

C. IMS5c: The organisation maintains the security of records, data and information. (CO)*

• Type: Commitment - Core OE - Asterisk (Requires System Documentation)

• Training Objective: To protect information from unauthorized access, disclosure, alteration, or destruction, using both physical and electronic safeguards.

• Practical Considerations:

  • Physical Security:

    • Implement physical security measures such as locked doors, security cameras, and access control systems to protect physical records from unauthorized access.

    • Adequate pest and rodent control measures.

    • Fire-safe cabinets.

  • Network Security:

    • Implement firewalls, intrusion detection systems, and other network security measures to protect electronic data from unauthorized access.

  • Data Encryption:

    • Encrypt sensitive data at rest and in transit to protect it from unauthorized disclosure. Use strong encryption algorithms and key management practices.

  • Access Control:

    • Implement strong access controls to restrict who can access electronic data.

  • Malware Protection:

    • Install and maintain antivirus and anti-malware software on all computers and devices.

  • Data Backups:

    • Regular Backups of all important data.

  • Incident Response:

    • Preventive measures against cyber attack on electronic medical records and data.

  • Ensure Secure Messaging

    • The organisation shall ensure that patients confidential data for example Lab reports etc is communicated through secure messaging platform

• Training Exercises:

  • Security Audit: Participants conduct a security audit of their department or area to identify potential vulnerabilities.

  • Phishing Simulation: Participants participate in a phishing simulation to test their ability to identify and avoid phishing scams.

D. IMS5d: The organisation uses developments in appropriate technology for improving confidentiality, integrity and security. (A)

• Type: Achievement

• Training Objective: To encourage the adoption of new technologies that enhance data protection and to foster a culture of continuous improvement in data security.

• Practical Considerations:

  • Stay Informed: Keep abreast of the latest developments in information security technology.

  • Assess New Technologies: Regularly evaluate new technologies for their potential to improve confidentiality, integrity, and security.

  • Implementation and Training: Implement new technologies effectively and provide staff with the necessary training to use them properly.

  • Review and update:

    • Review and update helps in improving:

    • Confidentiality, integrity and security of information.

• • Examples:

    • There is a mechanism to safe guard patient data generated from medical equipment & its access to authorised people.

    • This includes disabling USB Ports of Medical Devices

    • Restricting remote access & Downloading of patient data regular updating of Anti virus installed in Medical equipment

    • The Patient data back up from medical equipment are done in timely basis
      *This can be also be based on findings of risk assessment.

• Training Exercises:

  • Technology Review: Participants research and present on a new information security technology.

  • Implementation Plan: Participants develop an implementation plan for a new technology, considering factors such as cost, benefits, and potential risks.

E. IMS5e: The organisation discloses privileged health information as authorised by the patient and/or as required by law. (C)

• Type: Commitment

• Training Objective: To ensure that staff understand the circumstances under which privileged health information can be disclosed and that they follow the proper procedures for doing so.

• Practical Considerations:

  • Define Privileged Information: Train staff on what constitutes privileged health information. This includes information furnished by a patient to facilitate diagnosis and treatment that is legally protected from disclosure.

  • Authorization Requirements: Require that patients provide written authorization before their privileged health information is disclosed, except as required by law.

  • Legal Exceptions: Understand the legal exceptions to the confidentiality rule, such as mandatory reporting requirements (e.g., reporting of abuse, neglect, or communicable diseases).

  • Take special care in medico-legal cases:Take special care in medico-legal cases and other special situations identified by Government and organisation.

• Training Exercises:

  • Consent Form Review: Participants review a sample consent form to ensure that it meets all legal requirements.

  • Ethical Dilemma Discussion: Participants discuss ethical dilemmas related to the disclosure of privileged health information and how to resolve them.

F. IMS5f: Request for access to information in the medical records by patients/physicians and other public agencies are addressed consistently. (C)*

• Type: Commitment - Asterisk (Requires System Documentation)

• Training Objective: To ensure that all requests for access to medical records are handled in a fair, consistent, and timely manner, while protecting patient privacy.

• Practical Considerations:

  • Defined Access Procedures: Develop clearly defined procedures for handling requests for access to medical records from patients, physicians, and other public agencies.

  • Release of Information Forms: Require requesters to complete a release of information form.

  • Legal Review: Have legal counsel review requests from public agencies to ensure that they are legally valid.

  • Denial of Information: Information can be denied only if a licensed healthcare professional considers the release of information would endanger life/safety of patients and others.

  • Address RTI Grievances: It should be addressed by Government and other applicable bodies as per written guidance.

• Training Exercises:

  • Request Processing Simulation: Participants simulate the process of handling a request for access to medical records, from receiving the request to providing the information.

  • Legal Consultation: Participants consult with legal counsel on a hypothetical request for access to medical records.

IV. Training Delivery Methods:

• Interactive Workshops: Use case studies, role-playing, and group discussions to engage participants.

• Policy Review: Review the hospital's information security policies and procedures.

• Technology Demonstrations: Show how security technologies can be used to protect data.

V. Evaluation and Follow-up:

• Security Audits: Regularly conduct security audits to assess the effectiveness of security measures.

• Incident Reporting: Encourage staff to report security breaches or suspicious activity.

• Policy Updates: Regularly review and update information security policies and procedures.

By providing thorough training on IMS5, hospitals can empower their staff to protect sensitive patient information, maintain data integrity, and comply with ethical and legal obligations, fostering a culture of security and trust.

IMS6 - Availability, Currency, and Retention of Documents, Records, Data, and Information

This section offers comprehensive professional training notes on NABH 6th Edition Standard IMS6. This standard is vital for ensuring that the organization not only has the right information available when needed but also manages that information effectively over its lifecycle, from creation to secure disposal. Effective implementation of this standard directly impacts operational efficiency, legal compliance, and the quality of patient care.

I. Standard Statement:

"The organisation ensures availability of current and relevant documents, records, data and information and provides for retention of the same."

II. Understanding the Standard:

This standard focuses on two primary aspects of information management:

1. Availability and Currency: This involves having processes to ensure that staff can easily access up-to-date and relevant documents, records, and data necessary for their roles.

2. Retention: This encompasses developing and implementing a systematic approach to retain these resources for the legally and clinically required periods, while also ensuring confidentiality and secure disposal.

III. Key Objective Elements and Professional Training Guidance:

A. IMS6a: The organisation has an effective process for document control. * (CO)

• Type: Commitment - Core OE - Asterisk (Requires System Documentation)

• Training Objective: To equip participants with the knowledge and tools to implement and maintain a robust document control system that ensures the currency and relevance of documents used within the hospital.

• Practical Considerations:

  • Defined Documents: Clearly identify the types of documents that fall under the document control system (Forms, formats, policies and procedures.)

  • Authorization Process: Establish a process for authorizing and releasing new or revised documents. This typically involves review and approval by designated individuals or committees.

  • Current and Relevant: Ensure documentation is created for adequacy and is current and relevant.

  • Document Review and Update: Implement a system for regularly reviewing and updating documents to ensure that they remain accurate and relevant. This should include defined intervals for review, as per policy.

  • Version Control: Use a version control system to track changes to documents and to ensure that staff are using the most current version.

  • Accessibility: Make current documents readily accessible to staff, either electronically or in print. Consider a centralized document repository.

  • Obsolete Documents: Develop a process for removing and archiving obsolete documents. Ensure that obsolete documents are clearly marked as such to prevent accidental use. Only Current valid versions of the documents are available for use

• Training Exercises:

  • Document Control Audit: Participants conduct an audit of the hospital's document control system to identify any weaknesses.

  • Document Revision Exercise: Participants practice revising a document, using version control and following the hospital's document control procedures.

B. IMS6b: The organisation retains patient's clinical records, data and information according to its requirements. * (CO)

• Type: Commitment - Core OE - Asterisk (Requires System Documentation)

• Training Objective: To ensure that the hospital complies with legal and clinical requirements for retaining patient records.

• Practical Considerations:

  • Legal and Regulatory Requirements: Research and document all applicable legal and regulatory requirements for retaining patient records (both state and federal).

  • Defined Retention Schedule: Based on the legal and regulatory requirements, develop a detailed retention schedule that specifies how long different types of patient records must be retained.

  • Types of Clinical Records: Define for each category of medical record, data and formats used to capture data.

    • Medical

    • Surgical

    • Pediatric

    • Out-patient

    • In-patient

    • MLC

  • Formats of Clinical Records:

    • Registers

    • Forms

  • Retention Policy Compliance: In consonance with: Rules laid down by NMC and respective state authority.

• Training Exercises:

  • Retention Schedule Development: Participants work together to develop a retention schedule for different types of patient records.

  • Legal Compliance Simulation: Participants simulate a scenario where they are required to produce a patient record for a legal proceeding.

C. IMS6c: The retention process provides expected confidentiality and security. (C)

• Type: Commitment

• Training Objective: To ensure that retained records are protected from unauthorized access and disclosure, even after they are no longer actively used.

• Practical Considerations:

  • Secure Storage: Store retained records in a secure location with limited access. This could be a locked room, a secure off-site storage facility, or an encrypted electronic archive.

  • Access Controls: Implement strict access controls to restrict who can access retained records.

  • Confidentiality: This should be applicable for both manual and electronic system to maintain confidentiality.

  • Employee Training: Provide training to staff members who handle retained records on confidentiality requirements and security procedures.

• Training Exercises:

  • Security Assessment: Participants conduct a security assessment of the hospital's record retention area to identify potential vulnerabilities.

  • Access Control Simulation: Participants simulate a scenario where they are attempting to access a retained record and identify the controls that are in place to prevent unauthorized access.

D. IMS6d: The destruction of medical records, data and information are in accordance with the written guidance. (C)*

• Type: Commitment - Asterisk (Requires System Documentation)

• Training Objective: To ensure that medical records are destroyed securely and in compliance with all applicable laws and regulations, as per the policy written.

• Practical Considerations:

  • Destruction Methods: Define acceptable methods for destroying medical records. This could include shredding, incineration, or degaussing electronic media.

  • Legal Compliance: Destruction shall be conducted in accordance with the written guidance.

  • Documentation and Recordkeeping: Document all record destruction activities, including the date of destruction, the method of destruction, and the types of records that were destroyed.

  • Obtain Approval: Take approval of concerned authority (internal/external).

  • Destroy Medical Records: Destroy medical records, data and information.

• Training Exercises:

  • Destruction Procedure Simulation: Participants simulate the process of destroying medical records, following the hospital's policies and procedures.

  • Legal Review: Participants consult with legal counsel on the hospital's record destruction policies.

IV. Training Delivery Methods:

• Interactive Workshops: Combine presentations with group discussions, case studies, and hands-on activities.

• Real-Life Scenarios: Use realistic hospital scenarios to illustrate the practical application of the IMS6 standards.

• Document Management System Demonstrations: Demonstrate how document management systems can facilitate document control and record retention.

V. Evaluation and Follow-up:

• Pre- and Post-Training Assessments: Use assessments to measure participants' knowledge and understanding of the IMS6 standards before and after the training.

• Policy Review and Updates: Implement an ongoing process for reviewing and updating policies and procedures related to availability, currency, and retention.

• Audit and Feedback Loops: Implement regular audits of all relevant procedures and solicit employee input and feedback.

By providing comprehensive training on IMS6, hospitals can empower their staff to effectively manage the lifecycle of information, ensure compliance with legal and regulatory requirements, and improve operational efficiency.

IMS7 - Review of Medical Records

This section presents detailed professional training notes on NABH 6th Edition Standard IMS7. This essential standard emphasizes the importance of a systematic and ongoing review of medical records to ensure quality, completeness, accuracy, and compliance with established standards. Effective implementation of this standard is crucial for improving patient care, mitigating risks, and demonstrating a commitment to quality improvement.

I. Standard Statement:

"The organisation carries out a review of medical records."

II. Understanding the Standard:

This standard is not simply about checking for missing signatures. It requires a structured and regular evaluation of medical records against predefined parameters to identify areas for improvement in documentation practices, patient care delivery, and overall clinical performance. The key goals of this review process are to:

1. Identify Deficiencies: To identify gaps, errors, or inconsistencies in the medical record.

2. Improve Documentation: To promote consistent and accurate documentation practices among healthcare providers.

3. Enhance Patient Care: To identify opportunities to improve the quality and safety of patient care.

4. Promote Learning: To provide feedback to healthcare providers on their documentation practices and identify areas where they can improve their skills.

III. Key Objective Elements and Professional Training Guidance:

A. IMS7a: The medical records are reviewed periodically. (CO)

• Type: Commitment - Core OE

• Training Objective: To establish a regular schedule for medical record reviews to ensure ongoing quality assurance.

• Practical Considerations:

  • Define Periodicity: Establish a defined periodicity for conducting medical record reviews (e.g., monthly, quarterly, annually). The periodicity should be based on the volume of records, the complexity of patient care, and the risk factors involved.

  • Consider Electronic v. Physical Record: The organisation should define the periodicity of review of medical records. The review shall be carried out for physical and/or electronic medical records.

  • Documented Schedule: Document the review schedule in a policy or procedure.

  • Regular Reviews: Adhere to the established review schedule.

  • checklist: Use a checklist.

• Training Exercises:

  • Schedule Development: Participants work together to develop a medical record review schedule, considering the hospital's specific needs and resources.

  • Timeline Simulation: Participants simulate the process of conducting a medical record review within the defined periodicity.

B. IMS7b: The review uses a representative sample based on statistical principles. (C)

• Type: Commitment

• Training Objective: To ensure that the review process is efficient and effective by focusing on a statistically valid sample of medical records.

• Practical Considerations:

  • Sampling Methods: Select a sampling method that is appropriate for the size and complexity of the hospital's patient population. Common sampling methods include:

    • Simple random sampling

    • Systematic random sampling

    • Stratified sampling

  • Define Sample Size: Determine the appropriate sample size based on the desired level of confidence and the expected rate of errors.

  • Sampling for Total Discharge: Base on total discharges (including deaths and total indoor patients).

• Training Exercises:

  • Sample Size Calculation: Participants calculate the appropriate sample size for a medical record review, using different sampling methods and confidence levels.

  • Sampling Technique Simulation: Participants practice selecting a random sample of medical records using a specific sampling technique.

C. IMS7c: The review is conducted by identified individuals. (C)

• Type: Commitment

• Training Objective: To ensure that the review process is conducted by qualified and trained individuals who understand the relevant standards and guidelines.

• Practical Considerations:

  • Qualifications and Training: Identify individuals who have the necessary qualifications and training to conduct medical record reviews. This could include physicians, nurses, medical record specialists, or other healthcare professionals.

  • Authority: An individual who is identified and authorised by the organisation.

  • Competency Assessment: Implement a process for assessing the competency of individuals who conduct medical record reviews.

  • Training Materials: Provide reviewers with access to relevant standards, guidelines, and training materials.

• Training Exercises:

  • Competency Assessment Simulation: Participants simulate a competency assessment for a medical record reviewer.

  • Standards and Guidelines Review: Participants review and discuss the relevant standards and guidelines for conducting medical record reviews.

D. IMS7d: The review of records is based on identified parameters. (C)

• Type: Commitment

• Training Objective: To ensure that the review process is focused and objective by using predefined parameters to assess the quality and completeness of medical records.

• Practical Considerations:

  • Parameter Selection: Select parameters that are relevant to the hospital's goals and objectives. Parameters might include:

    • Timeliness.

    • Legibility.

    • Completeness of consent forms.

    • Availability of operation/procedure notes.

    • Eg: Final Diagnosis not mentioned

    • Incomplete OT notes in an Operated Patient

    • Incomplete Consent Missing

    • Signature name date time for all entries.

  • Checklist Utilization: Check list could be used for this purpose

• Training Exercises:

  • Parameter Development: Participants work together to develop a set of parameters for conducting a medical record review.

  • Checklist Creation: Participants create a checklist based on the defined parameters.

E. IMS7e: The review process includes records of both active and discharged patients. (C)

• Type: Commitment

• Training Objective: To provide a comprehensive assessment of documentation practices across the continuum of care.

• Practical Considerations:

  • Active Patients: Include medical records of patients who are currently receiving care at the hospital.

  • Discharged Patients: Include medical records of patients who have been discharged from the hospital.

  • Define adequate mix: The organisation should ensure an adequate mix of both sets of medical records.

• Training Exercises:

  • Record Selection Simulation: Participants practice selecting a sample of medical records that includes both active and discharged patients.

F. IMS7f: The review points out and documents any deficiencies in records. (C)

• Type: Commitment

• Training Objective: To ensure that identified deficiencies are systematically documented for analysis and corrective action.

• Practical Considerations:

  • Define deficiencies: Ensure deficiencies in records are Highlight

    • Documented

    • Final diagnosis not being documented.

    • Absence of OT notes in an operated patient.

• Training Exercises:

  • Audit Simulation: Participants review medical records and practice identifying and documenting any deficiencies that they find.

  • Deficiency Tracking Tool: Participants create a tool for tracking identified deficiencies.

G. IMS7g: Appropriate corrective and preventive measures are undertaken. (C)

• Type: Commitment

• Training Objective: To close the loop by implementing corrective and preventive actions to address the identified deficiencies and prevent future occurrences.

• Practical Considerations:

  • Document Deficiencies: Record deficiencies.

  • Take CAPA: Take CAPA in a defined time.

  • Document Action: Document actions taken.

  • Disseminate Information: The organisation should disseminate preventive actions to the relevant staff.

• Training Exercises:

  • Corrective Action Planning: Participants develop a corrective action plan to address a specific deficiency identified in a medical record.

  • Preventive Action Development: Participants develop preventive actions to prevent similar deficiencies from occurring in the future.

IV. Training Delivery Methods:

• Interactive Workshops: Use case studies, role-playing, and group discussions to engage participants.

• Chart Audits: Conduct hands-on chart audits to provide practical experience.

• Data Analysis Demonstrations: Demonstrate how data analysis can be used to identify trends and patterns in medical record deficiencies.

V. Evaluation and Follow-up:

• Competency Assessments: Assess the competency of medical record reviewers.

• Performance Monitoring: Monitor the performance of the medical record review process.

• Process Improvements: Implement changes to the medical record review process based on data analysis and feedback from reviewers.

By providing comprehensive training on IMS7, hospitals can empower their staff to effectively review medical records, identify areas for improvement, and implement corrective and preventive actions, leading to enhanced patient care and improved clinical outcomes.

List of the policies and procedures that are explicitly required by the discussed IMS standards:

IMS1: Information Needs

• Written Guidance: Policy and Procedure for capturing and disseminating information (Specifying Data Collection Methods, Dissemination Channels, Frequency of Data Collection, Responsible Person)

• Downtime policy in case of electronic recording

IMS2: Management & Control of Data

• Policy for standardized forms, clearly defined data definitions, and processes for data collection.

• Policy for when information should be communicated

IMS3: Complete & Accurate Medical Record

• Policy outlining the components/contents for what is kept in a patient's medical records and what is on the checklist.

• Authorization policy for who can make entries in the medical record.

• Policy for how the medical records are dated and timed.

• Approved Abbreviations list (Can be part of the overall policy or a separate document).

IMS4: Continuity of Care:

• Procedures on the specific contents in regards to investigations performed and details of what care was provided.

• Procedures to maintain records of data of individuals.

• Policies on procedures and access

IMS5: Confidentiality, Integrity & Security

• Confidentiality policies to define confidential information, access rights, and handling procedures.

• Procedures for Audit Trails.

• Policies for data encryption.

• Policy for releasing the information requested and any related fees.

IMS6: Availability and Retention

• Policy for document control.

• Detailed retention schedule specifying how long different record types must be retained.

• Policy and procedures for destruction of records.

IMS7: Review of Medical Records

• Schedule for medical record reviews.

• Check list procedures.

• Authority of who can review.

Important Considerations:

• Holistic Approach: While these are explicitly required, remember that having well-defined policies in related areas can further support these standards and improve overall performance.

• Accessibility: Policies and procedures must be readily available and accessible to relevant staff.

• Training & Communication: Simply having policies isn't enough. Staff must be trained on the policies and understand their responsibilities.

• Regular Review & Update: These policies and procedures need to be regularly reviewed and updated to ensure they remain effective and compliant with changes in regulations and best practices.

Disclaimer: Please note that this list is based on the information provided in the training notes. A full review of the NABH 6th Edition standards is always recommended to ensure complete compliance.