In preparing your facility for initial accreditation by Joint Commission, you are trying to improve the process of ongoing record review. All health…

The Joint Commission (TJC) standards for ongoing record review emphasize an interdisciplinary approach to evaluate the quality and appropriateness of patient care. The current process, limited to HIM personnel, primarily assesses technical compliance (e.g., completeness, timeliness) but lacks the clinical perspective necessary for a comprehensive quality review. Shifting to an interdisciplinary team of care providers—including physicians, nurses, and other relevant clinicians—aligns the review process with TJC's focus on using the health record to assess and improve clinical performance and patient outcomes. This change is fundamental to meeting the intent of TJC's Record of Care and Performance Improvement standards.

A. have more frequent committee meetings.

While frequency is important, the composition of the review team is a more critical, foundational issue for TJC compliance than the meeting schedule.

B. have the committee report to the Executive Committee.

Reporting to a Quality Management Committee is an appropriate and common governance structure; changing the reporting line is not the primary deficiency.

C. have a physician perform all the reviews.

This approach is too narrow. TJC promotes a collaborative, team-based review, and excluding non-physician clinicians overlooks their essential contributions to patient care.

1. Johns

M. L. (2015). Health Information Management Technology: An Applied Approach (4th ed.). AHIMA Press.

In Chapter 10

"Quality and Performance Improvement

" the text explains that medical record review is a key function of quality management programs. It states

"The review of patient records is a component of most quality management programs... The review is carried out by a committee of the medical staff or other professional staff" (p. 299). This highlights the necessity of involving clinical professionals

not just HIM staff

in the review process to meet accreditation standards.

2. LaTour

K. M.

Eichenwald-Maki

S.

& Oachs

P. K. (2021). Health Information Management: Concepts

Principles

and Practice (6th ed.). AHIMA Press.

Chapter 22

"Data Analytics and Decision Support

" discusses performance improvement (PI) methodologies required by accreditors like The Joint Commission. The text emphasizes that PI teams should be interdisciplinary

stating

"The team should be composed of individuals who are close to the process or system being studied... The team should be interdisciplinary" (p. 731). This principle directly applies to the record review process

which is a core PI activity.

3. The Joint Commission. (2023). Comprehensive Accreditation Manual for Hospitals.

Standard PI.01.01.01 states that the hospital collects data to monitor its performance. The elements of performance (EPs) for this standard require data collection on processes that are high-risk

high-volume

or problem-prone. The review of health records is the primary method for this data collection. The manual consistently implies that such clinical reviews are conducted by clinical staff as part of medical staff or organizational performance improvement functions

not solely by HIM personnel. The focus is on clinical content and patient outcomes

which necessitates a multidisciplinary clinical team. (Specific EPs vary

but the principle is consistent across the PI chapter).