presentation about Management of Information for Joint commission standard.

1. Management of
Information
(MOI)

2. Management of Information
(MOI)
• Formerly named Management of Communication and
Information (MCI)
• The communication is to and with patients and their
families, other health care practitioners, and the
community
• These standards have been focused to address how well
the hospital obtains, manages, and uses information to
provide, coordinate, and integrate services.
• The principles of good information management apply to
all methods, whether paper-based or electronic, and JCI
standards are equally compatible with either method.

3. Standard of MOI
Information Management
(MOI 1 – 7)
Management and Implement of Documents
(MOI 8)
Information Technology in Healthcare
(MOI 13 - 14)
Medical Record
(MOI 9 - 12)

4. Information Management
(MOI 1 – 7)

5. Standard MOI.1
The hospital plans and designs information management
processes to meet internal and external information
needs.
Measurable Elements of MOI.1
 1. The information needs of those who provide clinical services are considered
in the planning process.
 2. The information needs of those who manage the hospital are considered in
the planning process.
 3. The information needs and requirements of individuals and agencies
outside the hospital are considered in the planning process.
 4. The planning is based on the hospital’s size and complexity.

6. Standard MOI.2
Information privacy, confidentiality, and security
including data integrity are maintained.
 Careful about preserving the confidentiality of sensitive data and
information.
 Balance between data sharing and data confidentiality is addressed.
 Information contained in a database must be accurate
 Maintain data integrity during planned and unplanned downtime of data
system.
 Allow only authorized staff to gain access to data and information.
 The process to follow when confidentiality, security or data integrity are
violated.
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7. Standard MOI.2
Information privacy, confidentiality, and security
including data integrity are maintained.
Measurable Elements of MOI.2
 1. The hospital has a written process that protects the confidentiality,
security, and integrity of data and information.
 2. The process is based on and consistent with laws and regulations.
 3. The process identifies the level of confidentiality maintained for
different categories of data and information.
 4. Those persons who need or have a job position permitting access to
each category of data and information are identified.
 5. Compliance with the process is monitored.
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8. Standard MOI.3
The hospital determines the retention time of records,
data, and information.
Measurable Elements of MOI.3
 1. The hospital determines the retention time of patient clinical records
and other data and information.
 2. The retention process provides expected confidentiality and security.
 3. Records, data, and information are destroyed in a manner that does not
compromise confidentiality and security.
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9. Standard MOI.4
The hospital uses standardized diagnosis codes, procedure
codes, approved symbols and abbreviations.
Measurable Elements of MOI.4
 1. Use of Standardized diagnosis code and procedure code. (ICD 10 )
 2. Implements the uniform use of approved symbols and those not to be used
are identified.
 3. Implements the uniform use of approved abbreviation which has only one
meaning.
 4. The hospital develops and/or adopts a do-not use list of abbreviations.
 5. Abbreviations are not allowed to used on informed consent and, other
documents that patients and families received from the hospital about patient’s
care.
 6. Uniform use of codes, symbols and abbreviations across the hospital is
monitored and actions are taken to improve processes when needed.

10. Standard MOI.5
The data and information needs of those in and outside
the hospital are met on a timely basis in a format that
meets user expectations and with the desired
frequency.
Measurable Elements of MOI.5
 1. Data and information dissemination meet user needs.
 2. Users receive data and information on a timely basis.
 3. Users receive data and information in a format that aids its intended use.
 4. Staff have access to the data and information needed to carry out their
job responsibilities.

11. Standard MOI.6
Records and information are protected from loss,
destruction, tampering and unauthorized access or
use.
Measurable Elements of MOI.6
 1. Records and information are protected from loss. (Stored in a place
where heat, water , fire, or other damage is not likely to occur.)
 2. Records and information are protected from damage or destruction.
 3. Records and information are protected from tampering and
unauthorized access or use. ( implements a process to prevent
unauthorized access to electronically stored information).
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12. Standard MOI.7
Decision makers and other staff members are educated
and trained in the principles of information use and
management.
Measurable Elements of MOI.7
 1. Decision makers and others are provided education on the principles of
information use and management.
 2. The education is related to the data and information needs of the
individual and job responsibilities.
 3. Clinical and managerial data and information are integrated as needed to
support decision making.

13. Management and Implement of Documents
(MOI 8)

14. Standard MOI.8
Written documents, including policies, procedures, and
programs, are managed in a consistent and uniform
manner.
Measurable Elements of MOI.8
 1. There is a written guidance document that defines the requirements for
developing and maintaining policies, procedures, and programs, including at least
items a) through h) in the intent.
 2. There are standardized formats for all similar documents; for example, all
policies.
 3. All policies, procedures, and other written documents in circulation are
identified and tracked.
 4. The requirements of the guidance document are implemented and evident in
the policies, procedures, and programs found throughout the hospital.
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15. Standard MOI.8.1
The policies, procedures, plans, and other documents
that guide consistent and uniform clinical and
nonclinical processes and practices are fully
implemented.
Measurable Elements of MOI.8.1
 1. Required policies, procedures, and plans are available, and staff understand
how to access those documents relevant to their responsibilities.
 2. Staff are trained and understand those documents relevant to their
responsibilities.
 3. The requirements of the policies, procedures, and plans are fully
implemented and evident in the actions of individual staff members.
 4. The implementation of policies, procedures, and plans is monitored, and
the information supports full implementation.
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16. Medical Record
(MOI 9 - 12)

17. Standard MOI.9
The hospital initiates and maintains a standardized
medical record for every patient assessed or treated
and determines the record’s content, format, and
location of entries.
Standard MOI.9.1
The medical record contains sufficient information to
identify the patient, to support the diagnosis, to justify
the treatment, and to document the course and
results of treatment.
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18. Measurable Elements of MOI.9
 1. A medical record is initiated for every patient assessed or treated by the
hospital.
 2. Patient medical records are maintained through the use of an identifier
unique to the patient or some other effective method.
 3. The specific content, format, and location of entries for patient medical
records is standardized and determined by the hospital.
Measurable Elements of MOI.9.1
 1. Patient medical records contain adequate information to identify the
patient.
 2. Patient medical records contain adequate information to support the
diagnosis.
 3. Patient medical records contain adequate information to justify the care
and treatment.
 4. Patient medical records contain adequate information to document the
course and results of treatment.

19. Standard MOI.10
The medical records of patients receiving emergency
care include the time of arrival and departure, the
conclusions at termination of treatment, the patient’s
condition at discharge, and follow-up care
instructions.
Measurable Elements of MOI.10
 1. The medical records of all emergency patients include arrival and
departure times.
 2. The medical records of discharged emergency patients include
conclusions at the termination of treatment.
 3. The medical records of discharged emergency patients include the
patient’s condition at discharge.
 4. The medical records of discharged emergency patients include any
follow-up care instructions.

20. Standard MOI.11
The hospital identifies those authorized to make
entries in the patient clinical record.
Standard MOI.11.1
Every patient clinical record entry identifies its author
and when the entry was made in the record.
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21. Measurable Elements of MOI.11
 1. Those authorized to make entries in the patient medical record are
identified in hospital policy.
 2. There is a process to ensure that only authorized individuals make
entries in patient medical records.
 3. There is a process that addresses how entries in the patient record are
corrected or overwritten.
 4. Those authorized to have access to the patient medical record are
identified in hospital policy.
 5. There is a process to ensure that only authorized individuals have access
to the patient medical record.
Measurable Elements of MOI.11.1
 1. The author can be identified for each patient medical record entry.
 2. The date of each patient medical record entry can be identified.
 3. The time of each patient medical entry can be identified.

22. Standard MOI.11.1.1
The hospital has a process to address the proper use of
the copy-and-paste function when electronic medical
records are used.
Measurable Elements of MOI.8.1
 1.The hospital develops a process to address the proper use of copy-and-
paste when electronic medical records are used.
 2. The hospital provides education and training on the proper use of copy-
and-paste to all staff who document in the EMR.
 3. The hospital monitors compliance with the use of copy-and-paste
guidelines and implement corrective action as needed.
 4. The hospital develops a process to ensure that the accuracy of the EMR is
monitored.
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23. Standard MOI.12
As part of its monitoring and performance improvement activities,
the hospital regularly assesses patient medical record content
and the completeness of patient medical records.
Measurable Elements of MOI.12
 1. A representative sample of active and discharged patient’s medical records
is reviewed at least quarterly or more frequently as determined by laws and
regulations.
 2. The review is conducted by physicians, nurses, and others authorized to
make entries or manage patient records
 3. The review focuses on the timeliness, legibility, and completeness of the
medical record.
 4. Record contents required by laws or regulations are included in the review
process.
 5. The results of the review process are incorporated into the hospital’s quality
oversight mechanism.

24. Information Technology in Health Care
(MOI 13 – 14)

25. Standard MOI.13
Health information technology systems are assessed and
tested prior to implementation within the hospital and
evaluated for quality and patient safety following
implementation.
Measurable Elements of MOI.13
 1. HIT stakeholders participate in selection, implementation, and evaluation
of information technology.
 2. HIT systems are assessed and tested prior to implementation.
 3. HIT systems are evaluated following implementation for usability,
effectiveness and patient safety.

26. Standard MOI.14
The hospital develops, maintain and tests a program for response to
planned and unplanned downtime of data system.
Measurable Elements of MOI.12
 1. The hospital develops and maintains, and tests at least annually, a program
for response to planned and unplanned downtime of data systems.
 2. The hospital identifies the probable impact that planned and unplanned
downtime of data systems will have on all aspects of care and services.
 3. The program includes continuity strategies for the provision of ongoing safe,
high-quality patient care and services during planned and unplanned
downtime of data system.
 4. The hospital identifies and implements downtime recovery tactics and
ongoing data backup processes to recover and maintain data and ensure data
integrity.
 5. Staff are trained in the strategies and tactics used for planned and
unplanned downtime of data systems.
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27. Thank you for your attention