Vital Statistics Commission of Jamaica - Planning Institute of Jamaica

Vital Statistics Commission 

of 

Jamaica 

Audit of Vital Registration 

and Vital Statistics Systems 

Report of Findings and 

Recommendations 

August 31, 2005 

Mortality Statistics Branch, National Center for Health Statistics, 

Centers for Disease Control and Prevention 

Pan American Risk Management Associates LLC 

Ernst & Young LLP, Health Sciences Advisory Services

Audit of Vital Registration and Vital Statistics Systems: Jamaica 

Table of Contents 

PREFACE.................................................................................................................................1 

OVERVIEW OF FINDINGS AND RECOMMENDATIONS ............................................2 

FINDINGS............................................................................................................................... 3 

DATA COLLECTION ....................................................................................................... 3 

Reporting of Births and Deaths....................................................................................... 3 

Vital Events Occurring Outside of Public Hospitals ...................................................... 4 

Forms................................................................................................................................4 

Information Flow to RGD ............................................................................................... 5 

Data Entry and Coding at RGD ...................................................................................... 5 

Registration (Birth and Death) Databases...................................................................... 6 

Regional Health Authority and Ministry of Health........................................................ 6 

Suspicious (Violent, Unnatural) or Sudden Deaths ....................................................... 7 

HUMAN RESOURCES...................................................................................................... 9 

MOH and Hospital Staff.................................................................................................. 9 

RGD .................................................................................................................................. 9 

MOJ/Coroners................................................................................................................ 10 

STATIN and PIOJ ......................................................................................................... 10 

MANAGEMENT AND ORGANIZATIONAL STRUCTURE AND LINKAGES .... 10 

HIS policy....................................................................................................................... 10 

Information Management and Accountability ............................................................. 11 

Interagency-Collaboration and Communication.......................................................... 12 

DATA DISSEMINATION ............................................................................................... 12 

RECOMMENDATIONS.......................................................................................................14 

RECOMMENDATIONS IMPLEMENTATION WORK PLAN .....................................19 

EXHIBIT A – Cross-Reference of Recommendations to Findings .....................................38 

EXHIBIT B – Flows of Data .................................................................................................47 

EXHIBIT C – Meetings and Attendees .................................................................................55


PREFACE 

At the request of the Vital Statistics Commission of Jamaica, in collaboration with the Pan 

American Health Organization (PAHO) and CARICOM, a multi-disciplinary team consisting 

of representatives from the Mortality Statistics Branch, National Center for Health Statistics, 

Centers for Disease Control and Prevention; Pan American Risk Management Associates 

LLC; and, Ernst & Young LLP performed an assessment or audit of the processes utilized to 

collect, process, and disseminate national vital statistics data. The audit included the review 

of pertinent laws, rules, regulations, and policies; interviews; and, on-site observations. 

The audit team worked under the guidelines of a Terms of Reference issued by the Vital 

Statistics Commission for the project. The overriding objective of having the audit 

performed was to identify points in the data collection process where data was not being 

correctly or adequately collected. The implications of not having data correctly or 

adequately collected include misleading assumptions for planning purposes and potential loss 

of funding for programs to address socioeconomic factors contributing to high mortality 

rates. 

The audit team approached the project first from a high level perspective to gain insight as to 

interagency data flow, then at the department level to identify breakdowns in process or lack 

of defined process. The team assessed responsibility, authority, and accountability. 

Additionally, flows of data within and between agencies were evaluated to identify ways to 

improve efficiencies. 

Outputs of the audit, included herein, include a written report of findings and 

recommendations, and a written work plan to implement the recommendations. 

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OVERVIEW OF FINDINGS AND RECOMMENDATIONS 

The findings of this study are arranged in four key categories: data collection; human 

resources; management and organizational structure and linkages; and, data dissemination. 

Overall, the findings point to a lack of coherent and coordinated government policies with 

regard to vital statistics, a lack of effective and efficient communication and collaboration 

between and within agencies and ministries, and the absence of a standard definition of vital 

statistics. These deficiencies serve as significant obstacles to the production of valid and 

reliable national vital statistics. 

Vital statistics are a critical element in health planning and the development of health 

programs. They involve the planning, summarizing, and interpreting of data on vital events 

and are much more than merely numbers of births and deaths. A sound national vital 

statistics system rests on the foundation of reliable and complete vital registration and, 

although inextricably interconnected, the registration of vital events and the production of 

vital statistics are substantively different activities requiring substantially different skill sets. 

Registration of vital events is largely an administrative activity requiring expertise in the 

collection, management, and storage of records. In contrast, the production of national vital 

statistics, including calculation, tabulation, analysis and publication, requires expertise in 

statistical and demographic methods. 

In order to address the obstacles to the production of valid and reliable national vital 

statistics, the duties and responsibilities of each agency must be clarified. A separation of the 

registration and statistical functions is recommended given the current legal framework and 

the distribution of human resources. The Registrar General’s Department (RGD) should 

focus it’s efforts on registration activities and the production of standard vital statistics data 

sets for both births and deaths. Publication of official national vital statistics should be done 

by the Statistical Institute of Jamaica using the vital statistics data sets produced by RGD. 

All other government entities producing and/or publishing vital statistics should use the same 

data sets, methodologies, and definitions to ensure consistency government-wide. In 

addition, because the registration and statistical functions are so closely tied, effective 

methods of communication and formal data sharing agreements must be developed between 

all agencies involved. 

Successful implementation of the recommendations contained in this document is contingent 

on the absolute commitment and support from Cabinet level executives. With accountability 

demanded at the highest levels it will be possible to obtain commitments from Ministry 

executives, managers, and employees. 

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FINDINGS 

DATA COLLECTION 

Reporting of Births and Deaths 

During discussions with staff of Kingston Public Hospital, Spanish Town Hospital, Victoria 

Jubilee Hospital, the Ministry of Health (MOH) and the Registrar General’s Department 

(RGD), we identified six major concerns with regard to the completeness of reporting of 

hospital births: 

1. Weekend staffing – On the weekends, because staffing levels are lower, there is often 

no ward secretary on duty. As a result, the birth notification form is sometimes not 

completed. 

2. C-sections – C-section delivery is a surgical procedure and surgical recovery typically 

takes place outside of the maternal ward. Staff outside the maternal ward are 

generally not familiar with the procedures involving completion of the birth 

notification form and, as a result, may not collect this information. 

3. Bed availability – If no bed is available postpartum in the maternal ward, the mother 

may be admitted to a bed outside the maternal ward. As noted with regard to c- 

sections, staff outside the maternal ward are generally not familiar with birth 

notification. 

4. Births en route to the hospital – For births occurring en route to the hospital, there is 

inconsistency in the procedures applied with regard to birth notification. Some told 

us that the hospital would be responsible for birth notification. Others stated that 

these births would be treated as out-of-hospital births and notification would be the 

responsibility of the mother. 

5. Perinatal deaths – When neonates die in the nursery, if the cause of death is not 

known, a postmortem is performed. If the postmortem takes a long time, the mother 

will often not return to claim the body. In these cases, the body is often disposed of 

with no birth (or death) notification. Staff at Victoria Jubilee stated as a matter of 

policy that if the mother did not claim the body within 30 days, the body would be 

disposed of with no notification. 

6. Hospital billing practices – Although we were unable to confirm this first hand, we 

noted multiple instances in which the medical records department of some hospitals 

(Spanish Town Hospital, in particular) were alleged to require payment of hospital 

bills prior to birth notification. This was alleged to account for the relatively high rate 

(15%) of delayed registration in Spanish Town. 

Because the law requires registration of a death to obtain a burial permit, death registration 

for deaths occurring post-infancy is likely complete or nearly so. With regard to deaths, the 

main concern is with the completeness of reporting of perinatal deaths (both fetal and 

neonatal) as noted above and the accuracy of the cause-of-death statement reported on the 

medical certificate of cause of death. The cause of death statement is a source of error in 

mortality statistics in the U.S. and most other countries. Training of physicians in proper 

cause of death certification is and should be an ongoing effort. We found that some efforts 

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are underway to address this in Jamaica. The RGD does some querying of physicians in 

cases of incomplete cause of death certification or where the cause of death is poorly 

specified. However, they do not do this using a standard set of parameters or procedures. In 

addition, we reviewed a draft handbook for medical and nursing personnel by Professor 

Affette McCaw-Binns of the University of the West Indies (UWI) that contains a very nice 

set of instructions on proper cause of death certification. 

In part, the problems noted above are the result of the lack of a robust, computerized hospital 

information system. Births, deaths, and fetal deaths are not reconciled with admissions. 

Monthly census summaries of vital events are compiled manually and are prone to errors. 

There is no verification process between the summaries and actual data from medical 

records. As a result, it is likely that the information sent to the Regional Health Authority 

(RHA) and MOH on the number of vital events occurring in hospitals is inaccurate. This is 

of particular concern as these figures are often used as a benchmark for assessing the 

completeness of registration data produced by the RGD. 

In addition, there is no network that allows electronic interfacing of data across agencies. 

The transfer of mortality and morbidity information from the hospitals to the RHA’s and the 

MOH is paper-based. The Patient Admission System (PAS) currently in use by public 

hospitals has very limited capabilities in terms of the type of information collected and its 

reporting ability. 

Vital Events Occurring Outside of Public Hospitals 

We are concerned that births attended by certified midwifes, uncertified attendants, and 

physicians outside of the public hospitals may not be reported completely because no formal 

notification is required, except from the certified midwifes. In these cases, the mother is 

generally responsible for notifying the RGD and registering her child. The RGD has initiated 

education campaigns targeted to parents emphasizing the importance and benefits of birth 

registration. 

We are also concerned that there is a lack of information concerning births and deaths 

occurring in private hospitals and clinics. No one we talked with seemed to know much 

about this. In addition, births in prisons may not be reported completely. Deaths in custody 

are handled by the coroner and, as a result, are subject to the same procedures as other 

coroners cases (see “violent deaths” below), but we could not get a satisfactory answer 

regarding how births are handled. 

Forms 

The forms used for reporting and registering births and deaths are designed to be handwritten 

and provide for free-form information entry rather than forced fields entry. As currently 

formatted, they are not suitable for computer generation. In addition, some important 

information is not currently being collected on the forms. For example, information about 

the birth outcome (e.g., birth weight, gestational age) is not collected on the birth notification 

or registration forms. The death notification and registration forms are also missing some 

important information, e.g., birth date and whether the deceased was pregnant at the time of 

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death. That being said, some work has been done by Professor McCaw-Binns to address 

these gaps. However, progress toward making these changes has apparently stalled. 

The Registration (Births and Deaths) Act specifies in the First Schedule the format of the 

forms to be used in registering births, deaths, and stillbirths (see also Section 71). Section 72 

(first paragraph) of the Act, however, states that “[i]t shall be lawful for the Minister [of 

Health] or the Registrar-General with the sanction of the Minister, by order to alter from time 

to time all or any of the forms contained in the First Schedule…” Paragraph 3 of the same 

section states further that “[e]very form when altered in pursuance of this section shall have 

the same effect as if it had been contained in a Schedule…” Thus, we assert that changes to 

registration forms A, B, and C do not require first a change to the law. The birth notification 

form and the cause-of-death certification form (death notification) are not specified in the 

Schedule of the Registration Act and may be altered at the discretion of the Registrar General 

with the sanction of the Minister of Health. 

Information Flow to RGD 

Generally, it is the Local District Registrar (LDR) that receives notification of births and 

deaths and completes the registration forms. We visited and talked with the LDR for Spanish 

Town. The Spanish Town LDR’s office is not situated at the hospital. Although this is not 

an ideal situation, the office is nevertheless accessible to the public. It is an open air facility 

with no computers or automation. All registrations are completed on paper. Parish officers 

then pick up the paper forms for transport to the RGD. 

In discussion with the Spanish Town LDR and others at RGD and elsewhere, the problem 

most frequently mentioned with regard to birth registrations is delayed registration. The 

Registration Act (section 17) defines delayed registration as registrations occurring 12 

months or more after birth. RGD uses a three month criterion for timeliness (according to 

section 17, three months after birth is the point at which the Registrar General may require 

those with information about a birth to attend in person at the RGD and declare the fact and 

circumstances of birth for the purpose of registration). The RGD has made dramatic 

improvements in the past few years, bringing the overall percentage of delayed registrations 

(after three months) to about one percent or less for most parishes. However, delayed 

registration of birth still remains a problem in Spanish Town where the percentage of birth 

registrations that are delayed beyond three months is still about 15%, with a significant 

number still being registered one year after birth. This is consistent with the allegations of 

improper billing practices at Spanish Town Hospital described above. 

Data Entry and Coding at RGD 

Once the registration forms are received at RGD, the information reported on the forms is 

scanned, keyed in, and/or coded. We observed the data entry staff and found the data entry 

standards and procedures to be rigorous. We also observed the coders at work and found that 

they are doing competent work. Coding of the underlying cause of death is done manually, 

using the Tenth Revision of the International Classification of Diseases (ICD-10) 

promulgated by the World Health Organization (WHO). Coders indicated that they had been 

trained by PAHO staff in the ICD-10 coding rules and procedures. In addition, the coders 

use, as a reference tool, a set of printed decision tables which are part of the Automated 

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Classification of Medical Entities (ACME) software. ACME is used in automated coding to 

select the underlying cause of death. The coders seemed to be using the tables in an 

appropriate manner to determine “due to” relationships between diseases and in applying 

some of the more complicated coding rules. Overall, we believe that the quality of the coded 

output is good. Of course, good coding procedures do not mitigate problems with the input. 

As noted above, the accuracy and completeness of cause-of-death statements are 

questionable. That being said, as noted above, in some cases of incomplete cause of death 

certification or where the cause of death is poorly specified, the coders do sometimes call the 

certifying physician for clarification, but do not do this using a standard set of parameters or 

procedures. 

Registration (Birth and Death) Databases 

While at RGD, we visited with the database administrator and looked at the birth and death 

registration databases. The data resides in a SQL 2000 database. It is well organized and the 

administrator has a good grasp on the structure of the database. Whenever the administrator 

receives a request from the Vital Statistics Department at RGD, he sends a Microsoft Excel 

spreadsheet with the required data. Since the data reside in a relational database, it can be 

sorted either on the date of registration or on the date of occurrence. The database is 

organized according to the date of registration and not according to the date of occurrence. 

However, it is clear to us that vital statistics data sets with the appropriate indicators for both 

births and deaths based on occurrences for a particular year would be easy to extract from the 

registration databases. When data was last requested by the Statistics Institute of Jamaica 

(STATIN), there was no direct communication between the database administrator and the 

technical lead at STATIN, hence there were duplicates in the data (statistical data sets should 

have been requested in a particular format instead of “raw data”). 

Recently, RGD delivered a data set to STATIN and the Planning Institute of Jamaica (PIOJ). 

During our first visit to STATIN, we looked at the content of this data set. STATIN staff 

indicated that they had asked for “raw” data and the data that were delivered contained 

duplicates and had not been edited. In addition, the data were organized according to date of 

registration. Later, when talking with the RGD database administrator about this data set, it 

became clear that there was not consensus on the meaning of “raw data”. RGD assumed this 

meant pre-edited data. STATIN was merely asking for an individual-record data set. It 

became apparent to us that there was a lack of understanding on the part of STATIN in terms 

of the structure and composition of the registration data, and on the part of RGD in terms of 

what is needed by STATIN for the production of vital statistics. No formal data sharing 

agreement exists between the two agencies. 

When looking at the databases, we found that there is no linkage between birth and death 

records. Such a linkage is important from a security standpoint in order to prevent fraud. It 

is our understanding from discussions with RGD staff that the RGD intends to initiate a 

birth-death linkage and will be developing a plan in the near future. 

Regional Health Authority and Ministry of Health 

Information on births and death and other health information are collected by the RHA 

independent of the registration activities. This information is then passed on to the MOH. 

6


RHA staff indicated some concern about the accuracy and timeliness of the information 

obtained, especially from clinics. By the time RHA gets the information from the hospitals 

and clinics, it is at least one month old. When information is missing from the hospital 

reports, RHA staff indicated that they call the hospital to obtain the information. However, 

there does not appear to be a mechanism for checking the accuracy or consistency of the data 

coming in. The data are taken at face value. An important concern raised by RHA staff 

involved missing discharge summaries in the hospital medical records. To check this, we 

looked at a few randomly selected medical records during our visit to Spanish Town hospital 

to assess whether or not discharge summaries were present. In all records reviewed, 

discharge summaries were present. The RHA’s also investigate possible maternal deaths. 

The results of the investigation are passed on to the MOH, but we found no evidence that this 

information was getting back to the RGD to correct death records certified in error. The 

MOH is also conducting research to assess the quality of registration data for both births and 

deaths. We talked with research staff in the Division of Health Promotion and Protection 

about some of these studies. While the studies were informative, we found no mechanism in 

place to ensure that the results were being communicated to RGD and used to improve data 

collection and reporting. 

Suspicious (Violent, Unnatural) or Sudden Deaths 

The Coroner becomes involved in the process of data collection in the case of violent, 

unnatural, or sudden deaths where the cause is unknown. When a death of this sort occurs, 

the police are responsible for notifying the coroner, for the investigation into the 

circumstances of the death, and for providing a report to the coroner of the findings of the 

investigation. In addition, all deaths occurring within custodial facilities, such as prisons and 

orphanages, are the responsibility of the coroner. The coroner upon notification of the death 

may then order a post mortem examination of the body. It is important to draw a distinction 

between the cause or mechanism of death (e.g., gunshot, suffocation, poisoning) and the 

manner of death (e.g., homicide, suicide, accident, etc.). The cause of death is often readily 

apparent and easily determined from a post mortem, whereas determination of the manner of 

death often requires more extensive and sometimes lengthy investigation. In some cases, 

because of problems in garnering cooperation with witnesses, investigations into the manner 

of deaths have taken up to five years to be completed. 

Ministry of Justice (MOJ) systems for tracking cases are all manual. As a result, there are 

limited capabilities for evaluating backlogs and systemic problems. At this time, no data 

analysis is being performed to identify problems. The MOJ is in the process of installing and 

implementing a new information system (JEMS) for tracking cases. It is hoped that this new 

system will be able to be implemented in the coroner’s offices and interface with systems in 

RGD to facilitate the registration of deaths. 

The primary interaction between the coroner and RGD involves the transmission of Form D. 

As with Forms A, B, and C in the Registration Act, Form D is specified in the Coroner’s Act. 

Changes to this form can be made at the discretion of the Minister of Justice (see Coroner’s 

Act, Section 34b). 

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Recently an amendment to the Coroner’s Act was passed that addresses some problems in the 

information collection process. Specifically addressed is the time interval in which the police 

are required to report to the Coroner. The police must now provide notification of any 

sudden or suspicious death to the Coroner within 48 hours of discovery and a report of their 

investigation within 21 days of notification (or seek an extension). In addition, a medical 

practicioner contracted to do the post mortem is given 48 hours to provide a report to the 

Coroner. This should have the effect of increasing the timeliness of the reporting of the fact 

of death and even perhaps the cause of death to the Coroner. However, the new act does not 

address the timing of the filing of Form D by the Coroner with the RGD. The Coroner’s Act, 

section 10, paragraph 1 gives the Coroner absolute discretion as to when Form D will be sent. 

The Act (Sections 10 and 15) also states explicitly that Form D is to be sent by the coroner to 

RGD, but apparently, the standard practice is for the coroner to give Form D to a family 

member to take to the LDR ostensibly because Form D does not contain much of the 

information needed for registration of the death. The problem is that Form D is often not 

picked up by the family. It is often difficult to obtain cooperation from families for 

registration information because there is no penalty for non-compliance and there is no need 

to obtain a burial permit since registration is not required for a burial permit in these cases. 

Only if there is an estate in question or a will to be probated is the family inclined to ensure 

registration procedures are completed. To address this gap, RGD parish officers present 

frequently to the coroner’s office to obtain all Form Ds not picked up by family members, 

but there is no written policy, formal expectation, or established frequency for these visits. 

Form D is manually logged at the coroner’s office in a paper logbook. There is no 

reconciliation to registrations reported by the RGD and the coroner’s office does not keep 

copies of Form D once they are sent to RGD. The coroners with whom we spoke claim that 

approximately three to four Forms D are lost per month by (or in transit to) the RGD, 

although there was no way for us to verify this claim. The current tracking and reporting 

system provides aggregate volume numbers only, and does not include the circumstances 

surrounding the causes, locations, etc. of deaths. If a juried inquest is held, the results are 

reported using Form E, Coroner’s Certificate of Finding of Jury, which is routed by the 

coroner to the RGD, but again, there is no tracking of delivery or reconciliation with RGD 

records. Form E would have the final determination as to the manner of death. 

There is some confusion as to whether RGD is allowed to make corrections to the 

information provided on Forms D and E if this information is found to be in error. We were 

told by one staff member at RGD that they could not make changes to the form and indeed, 

the coroners we talked to indicated that sometimes RGD would send a family member back 

to the coroner’s office with the form to effect changes. Another RGD staff member, 

however, indicated that changes could be made to the form by RGD staff. The Coroner’s 

Act, Section 28 states that the coroner can authorize the RGD to correct errors of fact, 

although these must be made in the margins of the Form. It is unclear whether the Act 

requires this authorization to be given in writing or whether such authorization could be 

given verbally. 

Statistical information on criminal acts, including violent deaths, is also gathered by the 

statistics divisions of district police departments. On a daily basis statistics are FAXed to the 

8


statistics divisions from the various police stations. For the two departments we visited, PCbased 

applications are used for reporting basic statistics. Kingston Police Department is 

using the MS Access application for collection and reporting; Spanish Town Police 

Department is using MS Word, but plans to implement MS Access. While this information 

is not gathered for the express purpose of death registration or statistics, RGD has recognized 

the usefulness of this information as a check on their number of registrations. This 

information is sent to RGD only on an as-requested basis, usually by download to diskette. 

HUMAN RESOURCES 

MOH and Hospital Staff 

There is no system in place to measure individual or departmental performance with respect 

to the collection of birth, stillbirth, and death information and the completion of the 

appropriate forms. Staff, including senior management, of the hospitals we visited (Kingston 

Public Hospital, Spanish Town Hospital, and Victoria Jubilee Hospital) did not seem to have 

a strong understanding of the procedures involving the reporting of births, stillbirths, and 

deaths. In several instances, we were told that hospital procedures for filling out forms are 

often not followed. The National Director for Medical Records (NDMR) indicated to us that 

a procedures manual developed by MOH exists, but that she believes few people read it. The 

NDMR suggested that we may want to recommend an orientation for the medical staff 

concerning the written medical record policy. In addition, the NDMR believes that midwifes 

need to be better trained in the gathering and reporting of birth information. 

There is no formal training of medical record staff, only on-the-job training, and no 

established competency model for these staff. Management acknowledged that people were 

hired with skills deficiencies and then provided on-the-job training to meet minimal job 

requirements. We were also told that the technical college education for medical record 

technicians supposedly does not include prerequisite courses in chemistry and physiology but 

we did not validate that issue. 

RGD 

With regard to recruitment of staff, unit managers are responsible for reviewing job 

descriptions every year and, as necessary, modifying the job descriptions to accommodate 

needed changes in requirements. The RGD has an assessment center for evaluating 

employment candidates which utilizes a psychometric analysis tool and checks references. 

We reviewed standard interview questions, job descriptions, and an orientation checklist, and 

found them to be adequate. Quarterly and annual performance reviews are conducted of all 

employees and reviews are a performance metric of managers. We reviewed several of the 

performance reviews and found them to be thorough. 

When we reviewed the competency profile of RGD staff for 2005, we discovered a listing of 

job descriptions and summaries of the skills and experiences of the incumbents in the 

position, not a catalog of the competencies for success in a given position. Nevertheless, we 

found that data entry standards and procedures are rigorous and that the data entry staff are 

held to these standards. Those data entry staff with substandard ratings and high error rates 

9


are dismissed. Coders are trained appropriately in the ICD-10 methodology. We evaluated 

the competency of one of the coders by asking her to select a record and walk us through the 

coding of the cause of death. We believe the employee is well able to perform her duties. 

The Births, Deaths, and Marriages System (BDMS) resides on a Microsoft SQL 2000 

database. The database administrator appeared diligent and skilled to perform duties 

entrusted to him. He showed us a sample of data from the underlying tables and he seemed 

to have a good handle on everything related to the data. 

The statistical training of the staff is not adequate. The RGD’s “vital statistics officers” are 

well-trained in cause-of-death coding, but have little or no training in statistics, demography, 

or demographic methods. In addition, the vital statistics department manager, tasked with 

overseeing the production of vital statistics reports, has no training in statistics or 

demography. Our finding is that RGD does not currently have the expertise to produce and 

analyze vital statistics. They do, however, have staff competent to produce a vital statistics 

data set, including data collection, data entry, cause-of-death coding, and database 

management. 

MOJ/Coroners 

The annual performance evaluation of coroner’s office personnel comes under the auspices 

of the human resources function of the MOJ. We did not review any of the evaluations or the 

system utilized. With regard to deaths, coroner’s office employees lacked clarity as to what 

information could or should be completed by the coroner’s office and what information by 

the RGD. In general, there appears to be a lack of clarity around roles and responsibilities of 

other organizations. 

The Minister of Justice indicated that a change to a Medical Examiner-type system in which 

physicians were appointed as coroners would function more effectively and efficiently. The 

MOJ is currently exploring the possibility of such a system. 

STATIN and PIOJ 

Both STATIN and PIOJ currently have several well trained demographers and statisticians 

on staff and have programming staff capable of manipulating any data provided by RGD. It 

is our assessment that either agency is capable of producing and analyzing vital statistics for 

Jamaica. 

MANAGEMENT AND ORGANIZATIONAL STRUCTURE AND LINKAGES 

HIS policy 

We find that there is no overarching health information systems policy at the highest levels 

with regard to vital registration or the production of vital statistics. There is confusion as to 

the responsibilities of each agency with respect to the production and publication of vital 

statistics. 

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Information Management and Accountability 

Current policies and procedures governing medical records and birth/death reporting in 

hospitals are contained in a manual developed and issued by the MOH. MOH’s National 

Director of Medical Records (NDMR) indicated to us that although the manual is present at 

each of the hospitals, most of the staff have not read it and do not routinely refer to it. 

According to the NDMR, the hospital administration is responsible for ensuring compliance 

with the provisions of the medical record policies. Medical record compliance inspections 

are conducted by the NDMR on a routine basis, with a goal of surveying every hospital (23) 

at least annually. The NDMR indicated that the role of an accurate hospital medical record is 

often not understood and appreciated by hospital management and staff outside of the 

medical records department and as a result, deficiencies are common. After an inspection is 

performed a report of findings is generated and sent to the hospital Chief Executive Officer 

(CEO). According to the NDMR, there is usually little correction of or follow-up on 

deficiencies noted in the inspection reports. Consequently, the same deficiencies remain 

from year to year. In the last two years, there are only two instances where hospitals even 

asked questions about the audit reports. There is apparently no system for holding the 

hospital administration accountable to the MOH for addressing the deficiencies noted during 

inspections. 

We observed that both hospital medical records and coroner records are at risk of being 

destroyed because of environmental factors, e.g., humidity, hurricanes, and vermin. This is 

troubling because medical records and coroner records are the foundation documents on 

which notification and subsequent registration of births, stillbirths, and deaths are based. 

RGD’s records management is very good. Records are kept in a climate controlled vault and 

on archival-quality paper. In addition, RGD has a plan to scan all birth, stillbirth, death, and 

marriage registrations since 1920 which will allow for electronic storage and retrieval. 

At hospitals, monthly census summaries are performed manually and are prone to errors. 

There is no verification process between these summaries and actual data from medical 

records. In addition, counts of births, deaths, and stillbirths are not reconciled with 

admissions. Lack of discharge summaries was indicated by the NDMR to be a problem, but 

our findings did not support that indication. 

At the coroner’s offices, no system is in place to measure or monitor performance so that 

improvements can be made in terms of collecting and reporting the appropriate information 

in a timely fashion (improve throughput, decrease time to completion of cases, etc.). Monthly 

and quarterly reports are generated to indicate the status of the case load. The backlog of 

coroner’s cases is monitored by manually counting outstanding cases from the diary (log), 

which may include several different ledgers. The coroner reconciles individual completed 

cases with the log prior to signing Form E. The coroner does not retain a copy of Form D or 

Form E and Form D for a given individual is not linked to Form E for the same individual. 

Thus, if a form is lost in transit to RGD, there is no simple way to reconcile or recover that 

information. The coroner’s logs do not include the date the police investigation started, so 

tracking of progress is not documented. 

11


We reviewed performance targets for RGD for fiscal year 2004-2005 and found that they are 

a combination of job descriptions and process overviews. Missing were actual processes that 

one would expect. For example, the coders call the physicians if they need clarification for 

cause of death. What should be in place would be a protocol for when a physician should be 

called and what types of questions should be asked. 

As stated earlier, birth and death records are not currently linked. Linkage of these records is 

important from a security standpoint in order to prevent fraudulent use of birth certificates. 

That being said, it is our understanding that the RGD plans to develop a birth and death 

linkage. This activity will be hampered by the fact that there is no universal, unique personal 

numbering system in Jamaica. As a result, any linkage will have to be done using a 

probabilistic matching algorithm which is inefficient compared with deterministic matching 

made possible by a unique ID. 

Interagency-Collaboration and Communication 

We find that there are no formal, written policies for methods of communication between the 

MOH and other Departments or Ministries, or within the MOH (i.e., between RGD and other 

MOH agencies). For example (as stated earlier), we noted that while data quality research 

was being performed by MOH in the Division of Health Promotion and Protection, we did 

not find any mechanisms in place to ensure the results were being used to improve data 

collection and reporting at the hospitals and the RGD. Also, maternal deaths are investigated 

by the RHA and although this information is shared with the MOH, there is no mechanism to 

provide this information to the RGD to correct death records certified in error. Transfer of 

mortality and morbidity data between hospitals and MOH is not automated (paper-based). 

Between the RGD and the coroner’s offices there is a sharing of information (forms D and E) 

but no formal agreements about how this should be done and what the timing should be. 

Between the police and RGD, there is sharing of data, but no formal agreement to do so. To 

RGD’s credit, they have made proactive efforts to gather data from the coroners and police, 

but this is not being done under formal interagency agreements. Also, there are no 

automated/electronic system linkages. 

There are no official data sharing agreements between the RGD and other agencies that are 

users of the data. It is our understanding that all requests for information or data from the 

RGD must be made through the Registrar General and that this is done on an ad hoc, asneeded 

basis. As a result, there are no means for direct clarification of data requests 

(technician to technician). 

DATA DISSEMINATION 

According to our reading of the Statistics Act (sections 7 and 8) and other relevant Acts, 

STATIN has sole legal responsibility for compiling, tabulating, and publishing national vital 

statistics. 

Some data are being shared by RGD with STATIN, PIOJ, and MOH, but there are no formal 

data sharing agreements and no official birth and death data sets. The data currently being 

12


shared are not always consistent. Often, there are multiple estimates of the same indicator 

(e.g., number of births) caused ostensibly due to data sets with different cutoff dates – data 

sets with later cutoff dates will be more complete and therefore will indicate a larger number 

of births or deaths. In addition, there were no control totals provided along with the data sets. 

Another more minor difference involves the parish and district codes. Those used by 

STATIN are different from those used by RGD. While it would be ideal if a standard set of 

geographic codes were used, conversion between coding systems is relatively simple. Of 

somewhat more concern is the fact that districts defined by STATIN do not correspond to 

registration districts defined by RGD. 

STATIN has staff with the expertise to produce national vital statistics. However, they do 

not currently demonstrate a clear understanding of the structure and format of the RGD data 

and data collection processes. STATIN also lacks a published set of technical notes detailing 

the methodologies, definitions, and procedures used to produce the vital statistics published 

in their annual report. 

Also noteworthy is the fact that PIOJ is required by the Planning Institute of Jamaica Act 

(Section 11) to publish annual reports within 3 months of the end of the year. STATIN 

publishes annual reports on this same schedule (although the Statistics Act does not mandate 

this). This will require preliminary data from RGD. At this time, there is no standard 

procedure or cutoff for designating preliminary or final data. 

13


RECOMMENDATIONS 

The findings point to core challenges which are the absence of a standard definition of vital 

statistics, ineffective inter-agency communication, a lack of accountability, and insufficient 

management control processes. 

Our fundamental recommendation is that all vital statistics produced by the Jamaican 

government and/or its respective ministries and agencies should utilize the same standard 

data sets, methodologies, and definitions. 

The collection and production of vital statistics is a process (see Exhibit A, Flow Chart “Vital 

Statistics Data Collection, Analysis, and Production, Proposed Flow of Data). The RGD 

should be responsible for producing annual “vital statistics data sets” containing information 

on births and deaths (including fetal deaths, if desired) which would be extracts from the 

current registration databases. These annual data sets should be based on the year of 

occurrence rather than the year of registration. In collaboration with STATIN and PIOJ, the 

RGD should set a cutoff date approximately two months after the end of the calendar year at 

which point a “preliminary” data set should be released in order to satisfy the publication 

requirements of STATIN and PIOJ (three months from the end of the calendar year). 

Approximately 12 months from the end of the calendar year, the RGD should release a 

“final” data set for that year. This data set should be the official source for vital statistics and 

should remain static. Recognizing that all vital events may not be captured completely at the 

12 month mark, the registration databases should be updated continuously. The RGD should 

publish annually a set of technical notes with a description of the data collection process and 

the methodologies utilized to construct the vital statistics data sets, including control totals. 

In addition, the RGD should track on an annual basis, and publish in the technical notes, the 

number of events registered after the preliminary and final cutoff dates. This will serve to 

provide a means for evaluating the completeness of the statistical data sets. 

STATIN should be responsible for producing and publishing official “vital statistic reports” 

including statistics generated from the data sets generated by the RGD. STATIN should 

publish annually a set of technical notes detailing the methodologies, definitions, and 

procedures used to produce its statistics. It is critical that these statistics be replicable by 

others (e.g., PIOJ) using the same data sets. Preliminary vital statistics should be used by 

STATIN (and PIOJ) in its annual reports as estimates of the most recent data available and 

should be prominently identified as preliminary. In subsequent annual reports, the 

preliminary statistics should be replaced by final statistics generated from the final data sets. 

Studies of vital statistics data quality and completeness carried out by or funded by 

government agencies should involve all key stakeholders in the conceptual stages. At the 

very least, research protocols and reports of findings should be subject to a clearance process 

in which each stakeholder agency has the opportunity to comment. Every effort should be 

made to ensure that the results of such studies are presented constructively with the express 

purpose of improving data quality and completeness. 

14


As referenced earlier our findings indicate that there is an issue with sudden and suspicious 

deaths being registered quickly. We recommend that policy be developed and implemented 

which would require that deaths, once reported by the police to the Coroner (within 48 hours 

according to the amended Coroner’s Act) be then reported via Form D or its equivalent by 

the Coroner to RGD and registered (even if preliminarily) within a reasonable time frame 

(e.g., 72 hours) after notification. This may require an amendment to Section 10 of the 

Coroner’s Act, which gives the Coroner absolute discretion as to when the death should be 

registered with RGD. 

To eliminate all issues associated with family members sharing the responsibility of death 

registration in the case of suspicious or sudden deaths, we recommend policy be changed 

establishing the coroner as the party solely responsible for registering deaths with RGD when 

for decedents falling within his or her jurisdiction. This should not require a change in the 

law as the law already states that the coroner is responsible for providing this information to 

RGD. 

At present a serious data bottleneck is the coroner’s court and its processes. We 

recommended a case management system that monitors current cases, including the issuance 

of preliminary registration to the RGD. 

The Coroner’s court, with or without a computerized case management system, should 

establish a team to review in great detail the case flow through the system. The team should 

be tasked with arriving at recommendations to reduce both the backlog and the time it takes 

for cases to get processed. Additionally, a feasibility study should be conducted on 

converting to a medical examiner system or medical examiner-style system. 

The new JEMS system should be evaluated for its capability in data tracking and analysis 

related to reporting deaths as well as the issue mentioned in the previous paragraph. 

Until electronic management systems are implemented, the Coroners Court should retain 

copies of all form D’s and E’s generated (we recommend the use of pre-numbered, two page 

NCR forms). 

The MOH, in conjunction with the RHA’s, should provide orientation to hospital and 

medical staff about the key points in the MOH policy regarding births, fetal deaths, and 

deaths. The MOH should hold all Hospital CEOs responsible for providing this orientation. 

Our audit determined one of the root causes of the challenges Jamaica faces with regard to 

the collection of data and reporting of vital statistics lies in the lack of universal clarity 

around definitions and responsibilities of various stakeholders. Therefore, it is essential that a 

common definition of vital statistics and its components be arrived at and universally 

communicated. Most importantly, all stakeholders must participate in a process that clarifies 

the duties and responsibilities of each agency and that develops appropriate systems and 

controls to ensure all meet their respective obligations. 

15


Once roles and responsibilities are arrived at by the various Ministries and agencies then 

communication methodologies and processes will need to be developed. We recommend 

that the RGD develop data sharing agreements with all vital statistics user agencies and/or 

ministries. These agreements should specify the structure and format of the vital statistics 

data sets, and dates when the preliminary and final versions of these data sets will be 

delivered. In addition, these agreements will eliminate the need for requests to be approved 

at executive levels and eliminate the chances of improper, incomplete or unreasonable 

requests. In all cases the agreements should be structured to allow direct communication 

between the individuals who are tasked with either preparing the data or receiving the data. 

Electronic and or manual systems within the MOH and the MOJ should be interfaced on an 

as needed basis to all for the exchange of common information. 

In the short run management systems and reporting processes should be improved upon by 

implementing PC-based applications within the Ministries and agencies. The PC-based 

systems can be installed inexpensively and quickly. In the long run a nation-wide enterprise 

data solution should be designed and implemented. A common universal system will greatly 

improve data collection speed, efficiency, and accuracy. Closely tied to these two solutions 

is clearly a need for a universal personal identification number system. 

In the absence of a universal identification system, the RGD should develop and implement a 

system that links births and deaths using probabilistic matching algorithms. 

In the long run we recommend implementing a nationwide hospital information system that 

will be interfaced with all agencies. This will improve the timeliness, accuracy, and 

completeness of registration information coming from health care institutions. 

We recommend that all vital statistics records, including but not limited to medical records at 

hospitals and data held by the coroner’s court, be safeguarded against damage. The 

protection should be against loss or degradation from humidity, hurricane, vermin, etc. 

We recommend that a team be formed to evaluate all data collection forms and ensure that 

forms are redesigned to meet the needs of all stakeholders. The forms will need such things 

as “forced fields”, pre-numbering, etc. 

The RGD can improve the timeliness, accuracy, and completeness of data by having the LDR 

networked directly to the RGD central office (database). 

The RGD should employ an electronic, automated coding system to improve the consistency 

and accuracy of cause of death coding. We recommend use of the automated system 

currently in place in the U.S. This system has successfully been adapted for other Englishspeaking 

countries. Implementation of such a system will not eliminate the need for trained 

coders. Records rejected from the automated systems will still need to be manually coded 

and some of the more rare causes (e.g., infectious diseases and maternal causes) will need 

manual review. What this system will do is give the coders already employed by RGD time 

to focus on quality control, querying of certifiers, and the more difficult cases. 

16


The RGD should establish written policies and procedures that guide coders on when and 

how they should interact with physicians. Guidance on how to structure such policies and 

procedures can be obtained at http://www.cdc.gov/nchs/data/dvs/20manual.pdf. 

The MOH policies concerning the reporting of births, fetal deaths, and neonatal deaths need 

to be firmly communicated to all public and private health care institutions. All members of 

the hospital staff and medical staff should be re-educated about key points of the MOH 

policies concerning birth and death registration. The MOH should continue to perform 

compliance audits. All audit deficiencies should have a timeline for correction. The MOH 

should institute firm financial sanctions for those institutions that are found to be out of 

compliance with MOH policies. 

The RGD should continue its efforts to communicate to the public the need and benefits of 

registering their children’s births. 

We recommend that the MOH issue a policy mandate that all hospitals be able to 

demonstrate that they have a management control system that allows for the correlation and 

checking of reported births, deaths, and fetal deaths. 

In the short run, in the absence of an electronic system, the MOH should ensure all hospitals 

have an effective manual system for tracking autopsy cases and for improving occurrence 

reporting. 

The MOH, MOJ, and the RGD should develop and implement a continuous process 

improvement program. The programs should focus employees of all levels on providing 

feedback on how to improve processes. 

All departments that are part of the vital statistics data collection and or production should 

have departmental performance management systems. Performance standards, measurement 

tools, and monitoring criteria should be developed and implemented. 

The training of medical records personnel is a vital step that needs to be addressed 

immediately. Medical records technicians should be properly trained through a standardized 

structured system, either offsite or on the job. They should either already have the 

qualifications or should be provided the structured training once employed. 

The MOH should develop and conduct training for physicians regarding proper cause of 

death certification. Successful completion of a training program (which could be self-study) 

should be integrated into Continuing Medical Education required for licensing. 

The MOH should develop and conduct training for midwifes concerning MOH birth 

reporting policies and procedures. Successful completion of a training program (which could 

be self-study) should become a requirement for licensing or certification. 

17


We recommend that a system (compatible with existing labour relations policies) be 

developed to establish competency models for all key positions related to vital statistics data 

collection and reporting. In the long run all employee evaluations should be based upon an 

objective format and be performed by the direct supervisor with input from others who have 

had regular interaction with the employee. 

18


RECOMMENDATIONS IMPLEMENTATION WORK PLAN 

PROJECT IMPLEMENTATION METHODOLOGY 

Implementing a work plan that will operationalize the recommendations presented above will 

be a considerable but far from insurmountable challenge. The work plan developed and 

following takes into consideration that financial resources are constrained, civil service 

bureaucracy is a hindrance, and that strong accountability has historically been absent in 

most of the components of the vital statistics data collection and production process. 

More than anything else, successful implementation is dependant upon the absolute 

commitment and support from cabinet level executives (CLE’s). With accountability 

demanded from CLEs it will be possible to obtain commitments from Ministry executives, 

managers, and employees. 

Change implementation is always difficult and painful. Organized and managed change is 

rarely possible without experienced and focused external guidance. Equally important, 

change cannot be sustained without the support of those who must live the changes on a daily 

basis. Therefore, with the exception of the most technical aspects of the work plan, the 

implementation will be carried out by employees deployed on “rapid results resource teams” 

(3RT). 

The 3RTs must be carefully selected, trained, and managed. The work plan under the 

“project management oversight section” details the structure for accomplishing this. 

Implementing the work plan will require assistance from objective, independent, and skilled 

external resources. Without such assistance the implementation is at risk of being derailed 

by improper focus, lack of proper accountability, and insufficient technical knowledge. 

Therefore, the work plan assumes the use of external resources as facilitators for the 

implementation processes and steps described within it. 

19


Recommendations Implementation Work Plan 

Task 

PROJECT MANAGEMENT OVERSIGHT 

Ensuring Universal Accountability & Support – below are the structure and 

process for rapid results resources teams which will implement the work steps 

detailed further down in the work plan 

1. Cabinet Level Executives (CLEs) meet / review work plan and agree on 

implementation timetable. 

2. CLEs select executive sponsors will be held accountable for 3RT success 

3. CLEs meet w/sponsors discuss their roles and agree on schedule for sponsors to report 

back in person ( at a minimum monthly) 

4. Sponsors receive training and or coaching on ensuring team success throughout the life 

span of the implementation process 

5. CEOs & Senior executives of ministries and agencies receive coaching on how to 

ensure a successful implementation throughout the life span of the process 

6. Sponsors work with external resources to identify pool of 3RT team leaders and 

members 

7. External resources provide criteria for selection 

7.1. Sponsors submit names 

7.2. Canidates interviewed and assessed 

8. External resources and sponsors meet and make final selection 

9. Process for 3RT to implement work steps 

9.1. Sponsor and meet with team and present entire workplan and the teams objectives 

9.2. Team and sponsor agree on timetable and set discreet milestones –team reports 

back to sponsor bi-weekly 

9.3. Teams trained on how to work as “rapid results resource team” 

9.4. Where mgmt/exec decisions needed for team implement change –team presents 

issue to sponsor who responds in one week with Y/N response and if yes with 

timetable for action 

9.5. CLEs & Sponsors reward and coach teams on a weekly basis 

9.6. CLE’s quarterly meet (have lunch) with successful teams and provide praise 

10. Establish Communication and Coordination Functions 

11. Identify communication contacts and project deliverables 

12. Establish electronic communication tool 

13. Determine milestones to monitor process and reporting to stakeholders 

14. Establish documentation logging and filing system, templates for meeting agendas and 

minutes, and documentation distribution criteria 

15. Develop and implement project reporting system to effectively communicate progress to 

the various constituencies 

16. Provide MOH management with updated dashboard each week 

DATA COLLECTION 

17. Establish Data Collection Committee with representatives from hospitals, RHA, RGD, 

MOH, Law Enforcement, and Coroner’s office. Committee members to include “frontline” 

personnel. 

20



Task 

18. Data Forms Development and Review 

18.1. Hospitals 

18.1.1. Evaluate and redesign as necessary all data collection forms and ensure they 

meet the needs of the stakeholders. (forced fields, pre-numbered, etc.)" 

18.1.1.1. Establish an interagency Forms Resource Team (subteam of Data 

Collection Committee). Include “front-line” staff from each agency 

and facility 

18.1.1.2. Forms Resource Team to establish goals, objectives, action steps, 

responsibilities, committee meeting consistency and timeline for 

new/revised forms dissemination 

18.1.1.3. Evaluate and redesign all pertinent collection forms for RGD, 

hospitals, Law Enforcement, and Coroners Office 

18.1.1.4. Collect samples of all forms 

18.1.1.5. Review items identified from gap analysis 

18.1.1.6. Prepare draft (new or revised) standardized forms to ensure collection 

of new standardized, annual RGD data set(s). 

18.1.1.7. Ensure forms improve ease of data entry, logging, and routing with the 

appropriate field types to collect data. “Free text” fields should be 

kept to a minimum 

18.1.1.8. Submit draft forms to the Data Collection Committee for approval 

18.1.1.9. Prepare final standardized forms after Data Collection Committee 

(Vital Statistics Commission?) review 

18.1.1.10.Roll out new or revised forms to all appropriate agencies and facilities 

in a phased approach. 

18.1.1.11.Identify data collection issues and repeat steps where necessary 

18.1.1.12.Continue to roll out new forms in a phased approach until all agencies 

and facilities use new/revised forms 

18.2. Autopsy Cases 

18.2.1. Develop a manual system for tracking outstanding autopsy cases for 

improving occurrence reporting (until an electronic system can be 

implemented) 

18.2.1.1. Coroner representative on the Form Resource Team to meet with area 

Coroners to discuss issues with tracking outstanding autopsy cases 

18.2.1.2. Review items identified from gap analysis (data/information is 

required by the new standardized, annual RGD data set(s) and what is 

currently being collected and reported) 

18.2.1.3. Review autopsy reporting policies 

18.2.1.4. Develop form to track outstanding autopsy cases 

18.2.1.5. Submit draft form to Forms Resource Team to perform “Data Forms 

Review” process 

18.2.1.6. Develop policy and procedures for completion of autopsy cases 

18.2.1.7. Submit policy and procedures to Forms Resource Team and 

appropriate Coroners leadership for approval 

18.2.1.8. Roll out new or revised forms to Coroner’s and all appropriate 

21



Task 

agencies in a phased approach. Ex. Week 1 – ABC Parish Coroner’s 

Office 

18.2.1.9. Educate Coroners personnel about new autopsy case tracking forms 

and policies 

18.2.1.10.Identify any data form issues and revise forms when necessary 

18.2.1.11.Develop standards for establishing new or modifying policies 

18.3. Death Reports to Police 

18.3.1. Develop a routine reporting of deaths reported to the police 

18.3.1.1. Law Enforcement representative on the Form Resource Team to meet 

with area police departments to discuss issues with routine reporting 

of deaths reported to the police 




18.3.1.3. Review existing death reporting policies 

18.3.1.4. Develop form to track deaths reported to police 



18.3.1.6. Develop policy and procedures for completion of form 


appropriate Law Enforcement leadership for approval 

18.3.1.8. Roll out new or revised forms to Coroner’s and all appropriate 

agencies in a phased approach. Ex. Week 1 – ABC Police 

Department Office 

18.3.1.9. Educate Law Enforcement personnel about new autopsy case forms 

and policies 

18.3.1.10. Identify any data form issues and revise forms when necessary 

18.3.1.11. Develop standards for establishing new or modifying policies 

18.4. Reporting of Form D to the RGD 

18.4.1. Because the Coroner’s Act, as amended, gives “absolute discretion” to the 

Coroner as to the time to complete Form D and submit it to the RGD, this 

should be clarified to minimize the submission timeframe 

18.4.1.1. Obtain a legal ruling as to the authority of the MOJ to regulate timely 

submission of Form D without legislative changes to the Coroner’s 

Act 

18.4.1.2. If the MOJ may regulate the submission time, then recommend and 

obtain a 72 hour requirement for submission of Form D by the 

Coroner to the RGD 

18.4.1.3. If the MOJ may not regulate the submission time, then recommend 

and pursue an amendment to the Coroner’s Act to accommodate such 

latitude 

18.5. Coders / Physician Communication 

18.5.1. Develop protocols for when a physician should be called by Coders and what 

types of questions should be asked 

22



Task 

18.5.1.1. Clinical representative on the Form Resource Team to meet with area 

hospital physicians to discuss issues with Coders contacting physicians 

for additional info 




18.5.1.3. Review critical data needed by Coders 

18.5.1.4. Develop a checklist to attach to Medical Records to ensure collection 

of data needed by Coders 

18.5.1.5. Develop a Coder Missing Information form that could be faxed to 

physician when necessary 

18.5.1.6. Develop protocols on when to contact physicians (by phone) for 

pertinent info 



18.5.1.8. Develop policy and procedures for completion of form 


appropriate leadership for approval 

18.5.1.10.Roll out new or revised forms to Coders 

18.5.1.11.Educate Coders personnel about new forms, checklists and policies 

18.5.1.12.Identify any data form issues and revise forms when necessary 

18.5.1.13.Develop standards for establishing new or modifying policies 

19. Education and Orientation 

19.1. Clinical Staff 

19.1.1. Orient members of the hospital staff and medical staff about key points in the 

MOH policies concerning births, fetal deaths, and deaths 

19.1.1.1. Prepare pamphlets/brochures with key points of MOH policies 

concerning births, fetal deaths, and deaths 

19.1.1.2. Conduct Data Collection Information Sessions with key leaders at 

RGD, RHA, Law Enforcement, and Coroner’s Office. Discuss new 

processes and educational sessions to be scheduled with personnel. 

Distribute sample pamphlets/brochures. 

19.1.1.3. Schedule educational sessions with appropriate personnel at all 

agencies and hospitals 

19.1.1.4. Identify educational needs at all agencies and hospitals 

19.1.1.5. Conduct educational sessions at RGD, RHA, Law Enforcement, and 

hospitals on how to complete new and/or revised data collection forms 

19.2. Community 

19.2.1. Educate parents about the need to and benefits of registering their children 

19.2.1.1. Prepare pamphlets/brochures with key points of MOH policies and 

benefits of registering births, fetal deaths, and deaths 

19.2.1.2. Conduct Data Collection Information Sessions with key leaders in the 

Parish communities. Distribute sample pamphlets/brochures 

19.2.1.3. Seek out non-profit organizations to assist with distributing 

23



Task 

information regarding the need to and benefits of registering their 

children 

19.2.1.4. Coordinate public service announcements with local radio stations and 

news stations 

19.2.1.5. Coordinate mass mailings to Jamaica residents 

19.2.1.6. Coordinate information distribution at community events 

19.2.1.7. Conduct educational sessions at community centers and churches 

20. Information Systems Deployment for MOH, RHA, and All Facilities 

20.1. Gap analysis for MOH, RHA’s & their facilities 

20.1.1. Assessment of information systems 

20.1.1.1. Perform inventory of hardware, software (MS Office, Outlook), & 

application systems 

20.1.1.2. Identify requirements 

20.1.1.3. Identify Gaps 

20.1.2. Assessment of construction 

20.1.2.1. Gather infrastructure requirements for RHAs & each of the facilities 


20.1.2.3. Identify gaps 

20.2. Budget development 

20.2.1. Based on gaps, prepare IS budget (hardware, software, data center 

construction) by facility 

20.2.2. Prepare IS budget for MOH & RHA main offices (hardware, software, 

construction, staff) 

20.2.3. Finalize overall IS budgets for RHA, MOH & get approvals 

20.3. Project management 

20.3.1. Identify tasks, duration,dependencies & resources involved - prepare project 

plan 

20.3.2. Develop procedures for reporting progress & escalating issues 

20.3.3. Conduct weekly status meetings - monitor & report progress 

20.3.4. Develop a plan to communicate the progress/status to the VSC on a regular 

basis 

20.3.5. Establish a schedule for application rollout by facility 

20.4. Infrastructure development 

20.4.1. Tender for Infrastructure development projects (coordinate with capital 

planning) 

20.4.1.1. Prepare RFPs & advertise tender notices for RHA and all facilities 

20.4.1.2. Receive tenders 

20.4.1.3. Evaluate tenders 

20.4.1.4. Prepare contracts for the vendors 

20.4.1.5. Award tenders 

20.4.1.6. Execute contracts 

20.4.2. Connectivity 

20.4.2.1. Site planning 

24



Task 

20.4.2.1.1. Contact facilities & perform walkthrough for every facility - 

identify Wireless Access Points / LAN drop spots, check for 

electricity availability, identify secure area for communications 

cabinet 

20.4.2.1.2. Design & approve wireless / cabling plan for each facility 

20.4.2.2. Connectivity development execution 

20.4.2.2.1. Prepare facilities 

20.4.2.2.2. Install routers / hubs / access points 

20.4.2.2.3. Configure communication links with load balancing on remote / 

central site 

20.4.2.2.4. Install site domain controller / file server/ print server 

20.4.2.3. Connectivity integration test 

20.4.2.3.1. Generate traffic from remote site to central site / disconnect 

communication links 

20.4.2.3.2. Generate traffic from central site to remote site / disconnect 


20.4.2.4. Design redundant connectivity solution 

20.4.3. Systems hardware 

20.4.3.1. Wireless LAN / optical networking / microwave solution - 

connectivity to internet or MOH wide area network 

20.4.3.1.1. Order T1/ frame relay/ wireless communication links 

20.4.3.1.2. Receive, verify components, assemble, install, configure 

20.4.3.1.3. Unit test 

20.4.3.2. RHA file servers 


20.4.3.2.2. Unit Test 

20.4.3.3. RHA application servers 


20.4.3.3.2. Unit test 

20.4.3.4. Data storage and backup at RHA data center 


20.4.3.4.2. Unit Test 

20.4.3.5. RHA hardware systems complete integration test 

20.4.4. Systems software 

20.4.4.1. Operating systems 

20.4.4.1.1. Receive software, validate license 

20.4.4.1.2. Install, configure & test 

20.4.4.2. Applications like MS Office, email, etc. 



20.4.4.3. RHA software applications complete integration test 

20.5. Patient registration & scheduling system 

20.5.1. Gather application requirements 

25



Task 

20.5.1.1. Gather requirements for the specific system 

20.5.1.2. Finalize functional requirements 

20.5.2. Tender process 

20.5.2.1. Prepare RFP’s & advertise tender notices for hardware & software 





20.5.2.6. Get contracts signed 

20.5.2.7. Prepare implementation project plan 

20.5.3. Install Hardware specific to the system 

20.5.3.1. Assemble parts 

20.5.3.2. Install, configure operating system 

20.5.3.3. Test connectivity with other systems 

20.5.4. Data Conversion from current system (PAS: Patient Admissions System) for 

export into new system 

20.5.4.1. Export data from PAS system to flat files 

20.5.4.2. Integrate Unique ID (if possible) 

20.5.4.3. Develop scripts to migrate data 

20.5.4.4. Scrub and re-format data 

20.5.5. Install test system 

20.5.5.1. Set up static information 

20.5.5.2. System configuration & customization 

20.5.5.3. Load patient data from PAS converted files 

20.5.5.4. Test application with new data 

20.5.6. Design Interfaces 

20.5.6.1. Gather requirements 

20.5.6.2. Finalize Functional requirements 

20.5.6.3. Customize, Test, Implement Interface to other systems 

20.5.7. Install production system 

20.5.7.1. Set up user security and privileges 


20.5.7.3. Load patient data 

20.5.8. Testing / Quality Assurance 

20.5.8.1. Perform unit test 

20.5.8.2. Perform Integration test 

20.5.8.3. Perform system / load test 

20.5.9. Training 

20.5.9.1. Identify users / venue 

20.5.9.2. Schedule resources (users, venue, equipment) 

20.5.9.3. Train Administrator 

20.5.9.4. Train Users 

20.5.10. Implementation 

26



Task 

20.5.10.1.Develop communication plan for rollout - MOH, RHAs, Hospitals & 

clinics 

20.5.10.2.Change management tasks 

20.5.10.3.Roll out application on a planned basis 

20.5.11. Administrator tasks 

20.5.11.1.Set up security, user privileges, protocols 

20.5.11.2.Perform Performance tuning 

20.5.11.3.Create schedule for incremental and full backup 

20.5.11.4.Evaluate options for Disaster recovery / Redundancy 

20.6. Hospital Information System (Lab, Radiology, Emergency Room, Pharmacy, 

Inventory, Materials Management, Electronic Medical Record)" 

20.6.1. Requirements 



20.6.2. Tender Process 

20.6.2.1. Prepare RFPs & advertise tender notices for Hardware & Software 

20.6.2.2. Receive Tenders 

20.6.2.3. Evaluate Tenders 





20.6.3. Install Hardware 




20.6.4. Data Conversion from current systems into new system 

20.6.4.1. Export data from current systems to flat files 

20.6.4.2. Manually key in data from paper records 

20.6.4.3. Integrate Unique ID (if possible) 


20.6.4.5. Scrub and re-format data 




20.6.5.3. Load patient data from converted files 








27



Task 













20.6.10.1.Develop communication plan 

20.6.10.2.Change management tasks 

20.6.10.3.Roll out application on a planned basis 


20.6.11.1.Setup security, user privileges, protocols 

20.6.11.2.Perform Performance tuning 

20.6.11.3.Create schedule for incremental and full backup 

20.6.11.4.Evaluate options for Disaster recovery / Redundancy 

20.7. Analytical Systems (Data warehouse, Reporting, Dashboard) for RHA and 

MOH 

20.7.1. Requirements 


20.7.1.2. Finalize functional requirements 

20.7.2. Tender Process 

20.7.2.1. Prepare RFPs & advertise tender notices for Hardware & Software 

20.7.2.2. Receive Tenders 

20.7.2.3. Evaluate Tenders 





20.7.3. Install Hardware 




20.7.4. Data Conversion from existing systems 

20.7.4.1. Export data to flat files 

20.7.4.2. Integrate Unique ID (if possible!) 


20.7.4.4. Scrub data 


28



Task 























20.7.10.1. Develop communication plan 

20.7.10.2. Change management tasks 

20.7.10.3. Rollout application on a planned basis 


20.7.11.1. Set up security, user privileges, protocols 

20.7.11.2. Perform Performance tuning 

20.7.11.3. Create schedule for incremental and full backup 

20.7.11.4. Evaluate options for Disaster recovery / Redundancy 

20.8. Training of application users 

20.8.1. Identify users and their training needs 

20.8.2. Develop / customize user guides for the specific users 

20.8.3. Conduct training (basic computer, e-mail & MS Office) in batches 

20.8.4. Conduct application specific training for users 

20.8.5. Receive feedback and refine training materials 

20.9. Development of policies and procedures for MOH, RHAs & Facilities 

20.9.1. Develop Information Systems standards & guidelines 

20.9.2. Formulate Security policies (User privileges, security, access, VPN) 

20.9.3. Identify applications for personnel based on roles / levels 

21. Information systems deployment for Coroners Courts, MOJ, Police 

21.1. Gap analysis for MOH, RHA’s & their facilities 


29



Task 

21.1.1.1. Perform inventory of hardware, software (MS Office, Outlook) & 





21.1.2.1. Gather infrastructure requirements for RHAs & each of the facilities 



21.2. Budget development 

21.2.1. Based on gaps, prepare IS budget (hardware, software, data center 

construction) by facility 

21.2.2. Prepare IS budget for MOH & RHA main offices (hardware, software, 

construction, staff) 

21.2.3. Finalize overall IS budgets for RHA, MOH & get approvals 


21.3.1. Identify tasks, duration, dependencies & resources involved - prepare project 

plan 




basis 




planning) 












cabinet 






central site 

30



Task 













21.4.3.1.3. Unit test 



21.4.3.2.2. Unit Test 



21.4.3.3.2. Unit test 



21.4.3.4.2. Unit Test 









21.4.4.3. RHA software applications complete integration test 

22. Enhancements to Information systems at RGD 

22.1. Gap analysis for RGD & LDRs 


22.1.1.1. Perform inventory of hardware, software (MS Office, Outlook) & 





22.1.2.1. Gather infrastructure requirements for LDRs 




31



Task 

22.2.1. Identify tasks, duration ,dependencies & resources involved - prepare project 

plan 




basis 




planning) 












cabinet 






central site 













22.3.3.1.3. Unit test 



32



Task 

22.3.3.2.2. Unit Test 



22.3.3.3.2. Unit test 



22.3.3.4.2. Unit Test 









22.3.4.3. RGD software applications complete integration test 

23. National Registration Number for all citizens 

23.1. Evaluate the requirements for the generation of an unique identifier 

23.2. Create functional specifications 

23.3. Check compatibility with Hospital Information systems 

23.4. Check compatibility with systems at other Ministries and Government 

Agencies 

23.5. Create technical specifications 

24. Interfaces between RGD & other agencies for data collection and quality control 

24.1. Transfer of data electronically between agencies (MOH-RGD, Coroners- 

RGD, Clinics/Hospitals-LDR-RGD) 

24.1.1. Identify required data elements, format, transfer mechanism (like 

FTP,CD,email) & frequency of transfer (e.g. weekly, monthly) 

24.1.2. Identify roles and responsibilities of people involved in handling data, 

establish communication channels between technicians 

24.1.3. Test transfer of sample data 

24.1.4. Implement electronic data transfer - verify periodic summary data (e.g. 

monthly, quarterly) 

HUMAN RESOURCES ISSUES 

1. Provide training to midwifes on MOH birth reporting policies – make training a 

requirement for licensing/certification 

1.1. Develop self-administered training module which should include laminated fact 

cards that can be easily carried. The module should include a brief post training 

test. 

1.2. Develop and implement communication plan for midwifes to inform them of the 

training 

1.3. Develop plan to distribute self-training modules and to collect self- administered 

33



Task 

post training test. 

2. Standardize medical record technician training 

2.1. Develop skills profile for medical technicians 

2.2. Create training objectives for OJT 

2.3. Design training modules for medical technicians 

2.4. Design and administer pre-test to determine individual training needs 

2.5. Schedule and deliver training based upon pre-test results; administer post training 

test and develop remediation plans for those who do not demonstrate mastery 

2.6. Implement a policy that requires all new hires to meet skills profile/or if that cannot 

be accomplished mandate that they receive all the standardized training. 

3. Work toward allowing direct supervisor to use standardized format to evaluate 

employee performance 

3.1. Research all applicable civil service and departmental guidelines and develop plan 

within existing rules; 

3.2. Collaborate with executive leadership and or civil service unions to implement 

changes 

4. Develop a system that will allow agencies to develop competency models for all key 

positions related to vital statistics data collection and reporting 

4.1. Develop a roster of the key positions 

4.2. Obtain permission from all necessary bodies to develop competency models 

4.3. Have independent research confirm skills and competencies for key positions 

4.4. Develop new competency models based upon research 

4.5. Publicize the new models 

4.6. Implement the new models in the selection process and for the development of 

existing employees 

5. Develop and implement departmental performance management metrics, measurement 

tools, and monitoring criteria related to the functions of collecting vital statistics source 

data, data set development, and development of vital statistics. 

5.1. Create a detailed, life sized process flow map of the entire system work flow. 

Include volume measurements at points of input and output 

5.2. Work with each “input” and “output” function and determine how success should 

be measured (based upon effective and efficient contribution to the overall system). 

Measurement should be able to be performed daily. Decide on as few performance 

indicators as possible ,; repeat exercise if necessary to narrow indicators to 3 or less 

5.3. Work with each function and or department to implement performance monitoring 

system 

5.4. Adjust system and or metrics after one month where and if necessary 

6. Perform a feasibility study of the conversion to a medical examiner system 

6.1. Collect intelligence on medical examiner systems and or models 

6.2. Draft a model for implementing a system in Jamaica 

6.3. Contrast the cost and benefits of the model against the existing lay coroners model 

6.4. Report findings to CLEs 

7. Implement a system to ensure the strict enforcement of MOH policies concerning the 

reporting of births, fetal deaths, and peri-natal deaths, including audits of such, and 

34



Task 

sanctions for non-compliance 

7.1. MOH schedule a monthly roundtable discussion with RHA CEOs. CEOs report out 

on progress being made including information about compliance audits and their 

timetable for implementing audit remedies 

7.2. MOH develop a pay for performance model that increases funding for superior 

performance in recording occurances and likewise decreases funding for poor 

performance 

7.3. RHA CEOs schedule monthly roundtable discussions with their hospital CEOs. 

Hospital CEOs report out on progress being made including information about 

compliance audits and their timetable for implementing audit remedies 

7.4. RHA develop a pay for performance model that mirrors the MOH model and 

appropriately rewards/penalizes hospitals based upon performance 

7.5. Hospital CEOs receive one on one coaching on developing performance 

improvement plans that take into consideration their individual hospital challenges 

and resources. 

7.6. MOH inform private hospitals that non-compliance with MOH polices will result in 

fines 

7.7. Develop punitive damage policy for private hospitals and begin assessing fines six 

months after hospitals have received notification of the policy change; if hospitals 

have any outstanding audit deficiencies. 

8. Implement an overall quality improvement program for the collecting and reporting of 

vital statistics 

8.1. Cabinent level executive select appropriate executive sponsorship for the quality 

initiative 

8.2. Develop a Quality Improvement Program Model - ensure employees of all levels 

are both empowered and enabled to provide input as well as manage the 

8.3. Market the quality improvement program to all employees within the stakeholder 

organizations and departments 

8.4. Implement the quality improvement program in each affected organization ; rapidly 

implement “low hanging fruit” provide credit to the employee(s) and widely 

publicize the result 

8.5. Develop a case management system to track and monitor progress of coroner’s 

cases being investigated, including the issuance of a preliminary registration to the 

RGD 

9. Improve the storage conditions for medical records should ensure that records are 

safeguarded against damage (humidity, water, vermin, etc.) 

9.1. Create and implement plan to address data storage in 3 phases 

9.1.1. Phase I short term low cost measures such as photocopying 

9.1.2. Phase II mid term measures such as moving records to climate controlled 

settings 

9.1.3. Phase III long term measures such as converting files to an electronic format 

and storing them in electronic data wharehouses 

9.1.4. Commence phase I and begin implementing the foundation for phases II and 

III 

35



Task 

10. Create formal, written policies and procedures which describe communication 

methodologies and processes between the Ministries and agencies as related to vital 

statistics 

10.1. Procedure governing communication should be drafted and tested in a short time 

period 

10.2. After an initial test the procedures should be reviewed and revised based upon 

input from the trial period 

11. At the conclusion of the vendor section for the scanning of birth, fetal deaths, deaths, 

and marriages, developa detailed project plan 

11.1. Project plan needs to detail the following 

11.2. Whom within the RGD will provide what to the vendor 

11.2.1. A detailed timetable for the completion of task 

11.2.2. A simple methodology for monitoring progress and taking correction 

action 

11.2.3. Detail on whom within the respective organizations will have authority to 

make what types of decisions 

DATA DISSEMINATION 

1. Recommend that RGD produce annual vital statistics data sets (births and deaths) based 

upon occurrences for a particular calendar year 

1.1. Births 

1.1.1. Identify data elements required for reporting birth statistics 

1.1.2. Identify data format, transfer mechanism (like FTP, CD) & dates of transfer 

for preliminary and final data 



1.1.4. Develop Data Sharing Agreement to be used between RGD & MOH, PIOJ, 

STATIN 

1.1.5. Submit the agreement to VSC for review and approval 

1.2. Deaths 

1.2.1. Identify data elements required for reporting death statistics 

1.2.2. Identify data format, transfer mechanism (like FTP, CD) & dates of transfer 

for preliminary and final data 



1.2.4. Develop Data Sharing Agreement to be used between RGD & MOH, PIOJ, 

STATIN 

1.2.5. Submit the agreement to VSC for review and approval 

1.3. Implement data sharing agreements 

1.3.1. Create sample statistical data sets 

1.3.2. Test data exchanges 

2. All vital statistics and related studies produced by Jamaican government agencies should 

utilize the same standard data sets, methodologies, and definitions and should be subject 

to a clearance process 

36



Task 

2.1. Identify appropriate methodologies and definitions to be used 

2.2. Develop a government-wide clearance process in which each of the key 

stakeholders has an opportunity to comment on vital statistics and related research 

protocols prior to implementation and reports prior to publication 

3. The RGD should publish annually a set of technical notes with a description of the data 

collection process and the methodologies utilized to construct the vital statistics data 

sets, including control totals 

3.1. Develop draft technical notes 

3.2. Submit to VSC for review and approval 

3.3. Publish technical notes 

4. The STATIN should publish annually a set of technical notes detailing the 

methodologies, definitions, and procedures used to produce its statistics 

4.1. Develop draft technical notes 

4.2. Submit to VSC for review and approval 

4.3. Publish technical notes 

37


EXHIBIT A 

Cross-Reference of Recommendations to Findings 

I.D. Recommendation 

1. Deaths reported to the coroner by the police should be reported to the 

RGD and registered within a reasonable time frame (72 hours) 

2. Develop and implement a PC-based electronic data collection, 

logging, tracking, and reporting system 

3. Develop and implement an island-wide network information system 

for data collection, logging, tracking, and reporting system 

4. The new JEMS system should be evaluated to determine if it can be 

used to support data tracking, case management, and backlogs as 

related to deaths 

5. Perform a feasibility study of the conversion to a medical examiner 

system 

6. There must be a strict enforcement of MOH policies concerning the 

reporting of births, fetal deaths, and neonatal deaths, including audits 

of such, and sanctions for non-compliance 

7. MOH policies concerning the reporting of births, fetal deaths, and 

deaths, including audits of births and peri-natal deaths and sanctions 

for non-compliance, should be applicable to both public and private 

providers 

8. Develop and implement an island-wide, electronic hospital 

information system interfaced with other agencies. 

9. All data collection forms should be evaluated as to meeting the needs 

of the stakeholders and redesigned as necessary (forced fields, prenumbered, 

etc.) 

10. MOJ policies concerning the reporting of births and peri-natal deaths, 

including audits of births and peri-natal deaths and sanctions for noncompliance, 

should be investigated to ensure they adequately support 

the collection of vital statistics 

11. RGD should continue its efforts to educate parents about the need to 

and benefits of registering their children 

12. Members of the hospital staff and medical staff should be oriented 

about key points in the MOH policies concerning births, fetal deaths, 

and deaths 

13. Medical record technicians should be properly trained through a 

standardized, structured system. They should either already have the 

qualifications or should be provided the structured training 

14. The MOH should develop and conduct training for midwifes 

concerning MOH birth reporting policies – make such a requirement 

Finding(s) 

1, 2, 3, 4, 5 

11, 12 

12, 14 

12, 14, 103, 

104 

80 

22, 23, 24, 

25, 26, 27, 

28, 29, 30, 

31, 32, 55, 

56, 84, 85, 

107, 108, 

109, 110 

33 

34, 35, 36, 

37, 57 

38, 39, 40 

22, 23, 24, 

25, 26, 27, 

28, 29, 30, 

31, 32, 56, 

109, 110 

32 

6, 72, 73, 88 

74, 75 

76 

38


EXHIBIT A 



Finding(s) 

of licensing or certification 

15. There should be a threat of bodily harm or summary execution if 

deficiencies in medical records are not corrected 

16. Clarify the duties and responsibilities of each agency involved in the 7, 77, 81, 82, 

collection and reporting of vital statistics 

83, 89 

17. Develop formal, written policies and procedures which describe 8, 9, 46, 89, 

communication methodologies and processes between the Ministries 90, 91, 92, 

and agencies as related to vital statistics 

111 

18. The storage conditions for medical records should ensure that records 93, 94 

are safeguarded against damage (humidity, water, vermin, etc.) 

19. The Ministry of Health should establish a team to review definitions 7, 10, 47, 

related to vital statistics and make recommendations for standardizing 115, 116, 117 

20. Management control systems should be developed that enable 48, 49 

hospital staff to systematically check and correlate reported numbers 

of births, fetal deaths, and deaths 

21. Until an electronic system can be implemented, develop a manual 50 

system for tracking outstanding autopsy cases for improving 

occurrence reporting 

22. An overall quality improvement program for the collecting and 51 

reporting of vital statistics should be developed and implemented 

23. The CC should establish a team to evaluate means of reducing the 13 

time taken to clear cases (sometimes taking up to five years) 

24. We recommend that the Coroner be responsible for submitting Forms 1, 2, 3, 4, 5, 

D (may need to check applicable laws) 

25. Ideally, employee performance evaluations should include the use of 78 

a standardized, objective format at the direct supervisor level 

26. Develop a case management system to track and monitor progress of 9, 52, 95, 96, 

coroner’s cases being investigated, including the issuance of a 97, 103, 104 

preliminary registration to the RGD 

27. Until an electronic record system is implemented, the CC should 96, 98 

retain copies of all Forms D and E generated (use pre-numbered, twopage 

NCR forms 

28. Electronic and manual information systems of the MOH and MOJ 9, 52, 81, 82, 

related to vital statistics should be interfaced to allow exchange of 83, 99, 111 

common information 

29. Departmental performance management metrics, measurement tools, 97, 102 

and monitoring criteria related to the functions of collecting vital 

statistics source data, data set development, and development of vital 

statistics should be developed and implemented 

30. Recommend that a universal personal identification number system 53 

be implemented 

31. A written policy and procedures should be developed to establish 15 

39


EXHIBIT A 



protocols for when a physician should be called and what types of 

questions should be asked. 

32. An electronic, automated coding system should be utilized to improve 

consistency and accuracy of coding 

33. Recommend that RGD produce an annual vital statistics data set 

based upon occurrences for a particular calendar year 

34. LDR should be networked with the RGD information system to allow 

data entry at the LDR point of service 

35. Employ a system that will allow agencies to develop competency 

models for all key positions related to vital statistics data collection 

and reporting 

36. Designate technical points of contact for all data requests and 

technical assistance, allowing direct technician to technician 

interaction 

37. Data sharing agreements should be developed and executed between 

the RGD and all vital statistics user agencies 

38. We recommend that at the conclusion of the vendor section for the 

scanning of birth, fetal deaths, deaths, and marriages, a detailed 

project plan be developed 

39. We recommend that the RGD develop and implement a plan to link 

births and deaths 

40. All vital statistics produced by Jamaican government agencies should 

utilize the same standard data sets, methodologies, and definitions 

41. The RGD should publish annually a description of the data collection 

process and the methodologies utilized to construct the vital statistics 

data sets, including control totals 

42. The STATIN should publish annually a set of technical notes 

detailing the methodologies, definitions, and procedures used to 

produce their statistics 

43. The police should produce a routine reporting of deaths reported to 

the police 

Finding(s) 

16 

17 

18, 19, 20, 21 

79 

100 

91, 92, 112, 

113, 118 

101 

54 

105, 119, 

120, 121 

122 

123 

106 

40


Exhibit A 

I.D. Finding 

1. For Coroner’s cases, it is often difficult to obtain post mortem cooperation from 

families for registration information because there is no penalty for non-compliance. 

If there is an estate in question or a will to be probated, then the family is inclined to 

ensure registration procedures are completed 

2. Form D, Certificate of Coroner, is obtained by the family to register a death. The 

form is manually logged but there is no reconciliation to registrations reported at the 

RGD 

3. Parish Officers present to the CC to obtain all Form Ds not picked up by family 

members but there is no written policy or expectation. 

4. CC claims that approximately 3-4 Forms D are lost per month by the RGD 

5. RGD does make an effort to collect From D 

6. Cause of death is not always reported correctly 

7. Lack of distinction between registration data and occurrence data 

8. Efforts are being made by the RGD to collect violent death information from the CC 

9. Violent deaths – Form D was usually attached to the certificate but Form E was 

often missing 

10. Law says a delayed registration is 12 months. RGD uses a three month definition 

11. The MOJ’s current tracking and reporting system provides aggregate volume 

numbers, not the details around the causes, locations, etc. of deaths 

12. MOJ systems are all manual. There are limited capabilities for evaluating backlogs 

and systemic problems (Data analysis is not being performed to identify systemic 

problems for solutions) 

13. In some cases investigations of deaths have taken up to five years to be completed 

and the findings sent to the Coroner 

14. The MOJ is in the process of installing and implementing a new information system 

(JEMS) to be used to track all cases in courts 

15. Coders do call physicians for clarification of coding issues, but they do not use a 

standard set of parameters 

16. Coding at the RGD is manually performed 

17. The RGD database is organized according to registrations, not occurrences, but vital 

statistics data can be extracted from this type of database 

18. LDR 

19. Open air facility 

20. No computerization, only paper registrations 

21. Parish officers pick up the paper forms for transport to the RGD 

22. Anecdotal evidence suggests that there apparently are problems in tracking peri-natal 

deaths, particularly neonatal deaths occurring within seven days of delivery in 

hospitals 

23. Areas when/were births were being missed 

24. C-sections 

25. Weekend staffing (no ward secretary to complete a notification form) 

41


Exhibit A 

I.D. Finding 

26. Fetal deaths - 50% of the time the mother does not show up to identify the body 

so the hospital staff do not provide notification 

27. Bed availability – if no bed is available post partum, the mother may be admitted 

to a bed outside of the maternal ward and the information may not be gathered 

because the staff that do that would not round there. 

28. Babies that die in the nursery – if cause of death is unknown, post mortem is 

performed. If the mother does not present to claim the body within 30 days, the 

body is buried but the birth and death are not registered (hospital 

29. If post mortem takes a long time, the mother may not return to claim the body, so 

birth and death may not be registered 

30. Born before arrival – inconsistency in applying responsibility for registering 

births 

31. Allegations were made of impropriety with regard to requiring payments of hospital 

bills before birth notifications are completed 

32. Births attended by certified midwifes, uncertified attendants, and physicians outside 

of the hospital may not be reported completely 

33. There is a lack of information concerning births and deaths occurring in private 

hospitals and clinics 

34. Lack of a robust, computerized hospital information system that allows electronic 

interfacing of data and minimizes manual data entry of the same information from 

agency to agency 

35. The hospitals’ PAS has limited capabilities in terms of type of information collected 

and reporting capability 

36. There is no electronic information system in the clinics 

37. According to the RHA, data obtained from the clinics is considered very inaccurate 

38. Many hospital forms provide for free-form information entry, not forced fields entry 

39. By observation, MOH forms do not provide for the collection of some information 

required for accurate vital statistics reporting 

40. Official information collection forms are the responsibility of RGD to develop and 

maintain 

41. Births and deaths in prisons are not being reported completely 

42. The RGD’s data entry standards and procedures are rigorous 

43. Lack of discharge summaries was indicated by the NDMR to be a problem, but our 

findings did not support that indication 

44. Maternal deaths – information goes to the MOH but that information is not routed to 

the RGD, reported out by the MOH only 

45. Birth and death records are not linked – more of a security risk to prevent fraudulent 

use of a birth certificate 

46. A manual of written policies and procedures for establishing and maintaining a 

patient’s medical record, including how information concerning births and deaths 

should be reported, was developed and issued by the MOH 

42


Exhibit A 

I.D. Finding 

47. The definition of “fetal death” as provided by the MOH is not consistent with the 

hospital’s policies. Right now the MOH’s definition is 28 weeks but the new law, 

consistent with WHO and the hospitals, will make it 22 weeks. 

48. Births, deaths, and fetal deaths in a hospital are not reconciled with admissions 

49. Monthly hospital census summaries are a manual system and prone to errors. There 

is no verification process between the summaries and actual data (medical records) 

50. No system in hospitals, manual or electronic, to track number of outstanding autopsy 

reports 

51. While data quality research was being performed, we did not find any mechanisms 

in place to ensure the results were being used to improve data collection and 

reporting at the hospitals and the RGD 

52. Form E, Coroner’s Certificate of Finding of Jury, is routed by the CC to the RGD 

but there is no tracking of delivery or reconciliation with RGD records 

53. There is no universal, unique personal numbering system to facilitate linking of 

births and deaths 

54. It is our understanding that the RGD intends to develop a birth and death linkage 

55. The RHAs collect information from the hospitals and if information is missing the 

RHA is supposed to call the hospital to obtain the information 

56. Spanish Town – 15% of registrations are delayed registrations 

57. Transfer of mortality and morbidity information from hospitals to MOH is not 

automated (is paper-based) 

58. RGD coders had been trained by PAHO in the ICD-10 methodology. 

59. Little or no training in demography or demographic methods for RGD staff 

60. RGD quarterly and annual performance reviews are conducted of all employees and 

reviews are a performance metric of managers. We reviewed several of the 

performance reviews and found them to be thorough. 

61. The RGD has an assessment center for evaluating employment candidates 

62. The RGD utilizes a psychometric analysis tool and checks references of candidates 

63. The statistical training of the RGD staff is not extensive 

64. The RGD’s vital statistics department manager has no training in statistics or 

demography 

65. RGD unit managers are responsible for reviewing job descriptions every year and as 

necessary, modifying the job descriptions to accommodate needed changes in 

requirements 

66. We evaluated competency of one of the RGD coders by asking her to select a 

certificate and walk through a coding of that chart. We believe the employee is well 

able to perform her duties. 

67. We reviewed the RGD’s standard interview questions, job descriptions, and an 

orientation checklist 

68. PIOJ has trained demographers and statisticians on staff 

69. PIOJ has programming staff capable of manipulating any data provided by RGD 

43


Exhibit A 

I.D. Finding 

70. STATIN has trained demographers and statisticians on staff 

71. STATIN has programming staff capable of manipulating any data provided by RGD 

72. The NDMR suggests that we may want to recommend an orientation for the medical 

staff concerning the written medical record policy 

73. Senior management of some hospitals did not seem to have a strong understanding 

of the processes around births, fetal deaths (stillbirths), and deaths 

74. No formal training of hospital medical record staff, only OJT 

75. No established competency model for hospital medical record, OJT’d staff. Mgt. 

acknowledged that people were hired with skills deficiencies and then provided OJT 

to meet minimal job requirement 

76. The NDMR believes that midwifes need to be better trained in the gathering and 

reporting of birth information 

77. CC employees lacked clarity as to what information could/should be completed by 

the CC and what information by the RGD. In general, there appears to be a lack of 

clarity around roles and responsibilities of other organizations 

78. The annual performance evaluations of CC personnel come under the auspices of the 

human resources function of the MOJ. We did not review any of the evaluations or 

the system utilized. 

79. When we reviewed the RGD’s competency profile for 2005, we discovered a listing 

of job descriptions and summaries of the skills and experiences of the incumbents in 

the position, not a catalog of the competencies for success in a given position 

80. The MOJ suggested that if Medical Examiners (physicians) were appointed as 

Coroners, then cases could be processed faster because of the dual role 

81. Staff at the CC stated that the RGD will require an individual to return to the CC to 

obtain missing information on Form D. However, 

82. One manager in the RGD stated that such would be true because the RGD is not 

authorized to modify an official form (by entering missing information or 

correcting any obvious errors) 

83. Another manager in the RGD stated that her staff would indeed enter missing 

information if provided by the CC via telephone or if it was obvious, such as a 

street address. Corrections would also be made by RGD staff under similar 

circumstances 

84. No system in place to measure individual or departmental performance within 

hospitals with respect to collection of birth, fetal death, and death information 

85. Hospital procedures for filling out forms are often not followed – told that no one 

reads the procedure manuals 

86. The District Medical Officer is employed by the MOH. However, findings and 

reports are filed with the MOJ (Coroner) 

87. No direct RHA link or collaboration with the RGD 

88. According to the NDMR, the role of an accurate hospital medical record is not 

understood and appreciated by hospital management and staff outside of the medical 

records department 

44


Exhibit A 

I.D. Finding 

89. No real (information) collaboration between the MOH and other Ministries related to 

vital statistics 

90. No formal communication methodologies and processes within the MOH agencies 

related to vital statistics. For example, there are no formal mechanisms for the 

sharing of information among the MOH agencies. 

91. It is our understanding that all requests for information or data from the RGD must 

be made through the CEO/Registrar General 

92. There no official data sharing agreements between the RGD and other agencies 

93. Because research around births, fetal deaths, and deaths may be required from time 

to time and such research may require access to medical records, the storage 

conditions for (hospital) medical records should ensure that records are safeguarded 

against damage 

94. CC records are at risk of being destroyed because of environmental factors, e.g., 

humidity, hurricanes, and vermin. 

95. Monthly and quarterly returns (reports) are generated by the CC to indicate the status 

of the case load. The Coroner reconciles individual completed cases with the log, 

then signs the Form E 

96. Form D for a given individual is not linked to Form E for the same individual. 

There may be a Form E but not a Form D. 

97. No system in place to measure or monitor performance of the CC so that 

improvements can be made in the CC’s role of collecting vital statistics (improve 

throughput, decrease time to completion of cases, etc.) 

98. The CC does not retain a copy of Form D or Form E 

99. There is no electronic (system) link between the CC with the RGD 

100. No means for direct clarification of data requests (technician to technician) 

101. The RGD intends to scan all birth, fetal death, death, and marriage registrations 

since 1920 but a project plan has not been developed 

102. The RGD performance targets for 2004-2005 are a combination of job descriptions 

and process overviews. Missing or absent were actual processes that one would 

expect. For example, the coders call the physicians if they need clarification for 

cause of death. What should be in place would be a protocol for when a physician 

should be called and what types of questions should be asked. 

103. The CC logs do not include the date the police investigation started, so tracking of 

progress is not documented. Law states that police are to report cases to the CC 

within 48 hours and investigation completed within 21 days. 

104. The backlog of Coroner’s cases is monitored by manually counting outstanding 

cases from the diary (log), which may include several different ledgers 

105. The PIOJ does not perform any analyses with the data they receive from the RGD 

106. No data sharing agreement between the police and the RGD 

107. According to the National Director of Medical Records, hospital administration is 

responsible for ensuring compliance with the provisions of the medical record 

policies 

45


Exhibit A 

I.D. Finding 

108. According to the NDMR, there is usually little correction of or follow-up on 

deficiencies noted in the inspection reports. Consequently, the same deficiencies 

remain from year to year. In the last two years, there are only two instances where 

hospitals asked questions about the audit reports. 

109. Medical record compliance inspections are conducted by the NDMR on a routine 

basis, with a goal of surveying every hospital (23) at least annually 

110. After an inspection is performed a report of findings is generated and sent to the 

hospital CEO 

111. There is no formal mechanism for data sharing between the CC and the RGD 

112. No formal data sharing agreement between the PIOJ and the RGD 

113. No formal data sharing agreement between STATIN and RGD 

114. The PIOJ’s publication schedule is the same as that used by STATIN 

115. Definitions are not always consistent between the agencies, e.g., what is “raw” data? 

116. STATIN’s parish and district codes are different from RGD’s 

117. STATIN’s defined districts and RGD’s registration districts are not the same 

118. Because of STATIN’s publication schedule they need a preliminary cut of the 

database by the end of February 

119. STATIN has concern about multiple estimates of the same indicator (different 

numbers for the same indicator) about the RGD data 

120. No official data set for STATIN to use 

121. STATIN - confusion about the format of the RGD data and how it should be used 

122. STATIN needs control totals to ensure they are coming up with the right numbers 

123. For STATIN, there is a lack of a published set of technical notes detailing the 

methodologies, definitions, and procedures used to produce their data 

46


Exhibit B 

Flows of Data 

47


Exhibit B 


48


Exhibit B 


49


Exhibit B 


Coroner’s Court & Police Facilities 

Proposed Flow of Data 

Death Reported by 

Police 

Notification Sent to 

RGD 

NO 

Death 

Suspicious or 

Sudden? 

YES 

Police 

Investigation & 

Notification to 

Coroner 

Color Indicates 

Recommended 

Additional Step 

Coroner 

Preliminary 

Registration of 

Death 

Inquisition to 

be Held? 

YES 

Jury? 

YES 

Jury 

NO 

NO 

Coroner 

Criminal 

Responsibility? 

NO 

Cause of Death 

Determined 

YES 

NO 

Criminal 

Responsibility? 

YES 


Determined 

File Sent to the 

Supreme Court 


Supreme Court 


Determined 

Certificate of 

Finding 

Registrar 

General’s 

Department 

Certificate of 

Finding 


Director of Public 

Prosecution 

50


Exhibit B 


Hospital Births, Fetal Deaths, and Deaths 

Current Flow of Data 

Hospital Patient 

Admission 

Admission for 

delivery? 

NO 

Death while in 

Hospital? 

NO 

Patient Discharged 

YES 

YES 

Mother Delivers 

Baby 

Mother 

Survives 

Delivery? 

NO 


Documented in 

Medical Record? 

YES 

Notification of 

Death to RGD 

YES 

Live Birth? 

NO 

NO 

Death/Cause of 

Death Not Reported 

YES 

Post Partum Patient 

on Maternity Ward? 

NO 

YES 

YES 

Infant Dies Post 

Delivery & Pre- 

Discharge? 

Current Breakdown in 

Data Collection 

Ward Secretary 

on Duty? 

NO 

NO 

YES 

Mother Discharged 

Notification of 

Birth Sent to 

RGD 

Notification May 

Not Be Sent to 

RGD 

Infant Discharged 

51


Exhibit B 


52


Exhibit B 


53


Exhibit C 

Meetings and Attendees 

Project Kick-Off Meeting 

July 20, 2005 at 9:00 a.m. (FINSAC) 

Attendees 

E&Y/PARMA/PAHO 

Vital Statistics Commission 

Dr. Jackie Gernay Dr. Deanna Ashley Easton Williams 

Dr. Margaret Hazlewood Dr. Patricia Holness Toni-Shea James 

Cyril Joseph Andrea Frazer Sergeant Wright 

J.R. Murray Howard Lynch Dr. Affette McCaw-Binns 

Donnett Edmondson Juliet McCalla-Smith 

Meeting on July 20, 2005 at 2 p.m. – Ministry of Health (MOH), 5 th floor 

Attendees 

E&Y/PARMA 

MOH 

Cyril Joseph Howard Lynch Mr. Walters (IT) 

J.R. Murray Ms. Bryan (IT) Ms. Hendricks (Health 

Records Administrator) 

Meeting on July 21, 2005 at 9 a.m. – Victoria Jubilee Hospital (VJH) 

Attendees 


MOH/VJH 

Dr. Margaret Hazlewood Dr. Jackie Gernay Ms. Hendricks 

Cyril Joseph J.R. Murray Dr. Douglas McDonald 

Mrs. Jackie Barrett 

Meeting on July 21, 2005 at 11:30 a.m. – Kingston Public Hospital (KPH) 

Attendees 


MOH/VJH 

Dr. Margaret Hazlewood Ms. Ann Marie Dean Clark Ms. Hendricks 

Cyril Joseph 

Ms. Lovett Smith 

J.R. Murray 

Mr. Joseph Dewdney 

54


Exhibit C 


Facility Tour on July 21, 2005 at 1 p.m. – Registrar General’s Department 

(RGD) 

Attendees 

E&Y/PARMA 

RGD 

Cyril Joseph Dr. Patricia Holness Ruth Ferguson 

J.R. Murray Sydian Bisset Maria Hamilton 

Bryan Aikman 

Jackie Freeman 

Meeting on July 22, 2005 at 10 a.m. – Ministry of Justice (MOJ) 

Attendees 


MOJ 

Dr. Margaret Hazlewood Dr. Jackie Gernay Chief Justice Lensley Wolfe 

Cyril Joseph J.R. Murray PS Mrs. Carol Palmer 

Michael Bass 

Andrea Frazer 

Meeting on July 22, 2005 at 2 p.m. – Police Statistics Division 

Attendees 


Police 

Dr. Margaret Hazlewood Dr. Jackie Gernay Sergeant Wright 

Cyril Joseph J.R. Murray Intern 

Michael Bass 

Meeting on July 25, 2005 at 10 a.m. – Statistical Institute (STATIN) 

Attendees 

E&Y/CDC 

STATIN 

Dr. Bob Anderson Ms. Donnett Edmondson Ms. Juliet McCalla-Smith 

Cyril Joseph 

Meeting on July 25, 2005 at 2 p.m. – MOH 

Attendees 

E&Y/PARMA/CDC 

MOH 

Dr. Bob Anderson Michael Bass Ms. Deanna Ashley 

Cyril Joseph 

J.R. Murray 

55


Exhibit C 


Meeting on July 25, 2005 at 3 p.m. – MOH 

Attendees 

E&Y/PARMA/CDC 

MOH 

Dr. Bob Anderson Michael Bass Ms. Deanna Ashley 

Cyril Joseph J.R. Murray Dr. Affette McCaw-Binns 

Georgianna 

Meeting on July 25, 2005 at 3 p.m. – National Registration Unit (NRU) 

Attendees 

E&Y 

NRU 

Cyril Joseph 

Ms. Pat Samuels 

Meeting on July 25, 2005 at 4:45 p.m. – MOH 

Attendees 

E&Y/PARMA/CDC 

MOH 

Dr. Bob Anderson Michael Bass Ms. Chambers, HR director 

Cyril Joseph 

J.R. Murray 

Meeting on July 26, 2005 at 9 a.m. – RGD 

Attendees 

E&Y/PARMA/CDC 

RGD 

Cyril Joseph Dr. Bob Anderson Dr. Patricia Holness 

J.R. Murray 

Michael Bass 

Attendees 

Cyril Joseph 


E&Y 

RGD 

Maria Hamilton, Director IT 


CDC 

Dr. Bob Anderson 

Ms. Sydian Bissett 

RGD 

56


Exhibit C 



J.R. Murray 

Michael Bass 

E&Y 

RGD 

Ms. Jackie Foreman 

Meeting on July 26, 2005 at 1 p.m. – RGD 

E&Y/PARMA/CDC 

RGD 

J.R. Murray Dr. Bob Anderson Ms. Monique Lyn Quee 

Michael Bass 

Ms. Trudy Edwards 

Meeting on July 26, 2005 at 2 p.m. – RGD 

E&Y/CDC 

Cyril Joseph 


RGD 

Gene Thomas, database administrator 

Meeting on July 27, 2005 at 3 p.m. – Southeast Regional Health Authority 

Attendees 

E&Y/CDC 

SERHA 

Cyril Joseph Dr. Bob Anderson Ms. Mary Mckenzie 

Michael Bass 

Ms. Guy Walker 

Dr. Harris 

Meeting on July 27, 2005 at 4:10 p.m. – Planning Institute of Jamaica 

(POIJ) 

Attendees 

E&Y/ CDC 

PIOJ 

Michael Bass Dr. Bob Anderson Ms. Tony-Shea James 

Cyril Joseph 

Mr. Easton Williams 

Mr. Fredrick (IT) 

57


Exhibit C 


Attendees 

Michael Bass 

Cyril Joseph 

Meeting on July 28, 2005 at 9 a.m. – MOH 

E&Y 

MOH 

Ms. Jackie Ricketts 

Mr. Carter 

Mr. Howard Lynch 

Meeting on July 28, 2005 at 9 a.m. – Spanish Town Coroner 

Attendees 

CDC 

Coroner 


Hon. Miss Andrea Thomas 

Meeting on July 29, 2005 at 10:30 a.m. – Spanish Town Police Department 

Attendees 

CDC 

Police 


Detective Constable West-Grant 

Constable Rose 

Meeting on July 29, 2005 at 11:00 a.m. – Spanish Town Hospital 

Attendees 

CDC 

ST Hosp 


Ms. Pauline Reid 

Ms. Claudette Jackson 

Meeting on July 29, 2005 at 12:30 p.m. – Local District Registrar - Spanish 

Town 

Attendees 


CDC 

Ms. Violet Downer 

Mr. Bryan Aikman 

LDR 

58

Vital Statistics Commission of Jamaica - Planning Institute of Jamaica

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