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Association of Companies Health Insurance Funds 13 March 2009
Prague, Czech Republic
Joint Commission International Standards and Survey Process
David Jaimovich, MD
Chief Medical Officer
Joint Commission International
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Objectives
Identify and describe the JCI Accreditation process
Describe and review tracer methodology Discuss a hospital’s preparation for the JCI
Accreditation process Describe global standardization of healthcare
services through the process of accreditation Accreditation as part of a systems focus
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JCI Standards System framework
Checklist of all the important managerial and clinical functions or activities
Focus on patient perspective in context of their family
A balance of structure, process and outcomes standards
Optimal but achievable expectations
Measurable
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Accreditation Represents a Risk Reduction Strategy
That an organization is doing the right things and doing them well;
Thereby significantly reducing the risk of harm in the delivery of care; and
Optimizing the likelihood of good outcomes.
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External, objective evaluation Uses consensus standards Involves the health professions Proactive not reactive Organization wide Focus on systems not individuals Stimulates quality culture in the organization Periodic re-evaluation against standards Strengthens public’s confidence
Strengths of Accreditation
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Accreditation Can Help:
Enhance staff recruitment, retention and satisfaction
Improve or expand sources of payment for patient care
Increase chances to enter networks and new provider arrangements
Provide greater independence from government oversight
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Accreditation Can Help:
Build a quality measurement database
Provide comparison with self, others, and best practices
Provide a framework to improve patient safety
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Quality Improvement and Patient Safety Programs
Are leadership driven
Seek to change the ethos of the organization
Proactively identify and reduce risk and variation
Use data to focus on priority issues
Seek to demonstrate sustainable improvement
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Accreditation as Part of Continuous Quality Improvement
Accreditation is a milestone on the continuous journey of improvement
Accreditation Standards provide a common quality language and common set of expectations to point the way forward
Establishing a permanent organizational culture of safe, quality care is essential for sustaining improvement
The effort is for your patients, not the certificate
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Starting to Prepare
Available Resources: JCI Accreditation Standards for Hospitals, 3rd
Edition Survey Process Guide (electronic version) Web-based training on introduction to the
international accreditation process (ISAS) Newsletters and publications
print and electronic (e.g. Getting Started) JCI Practicum four times a year (Annual JCI Executive Briefings – networking
opportunity with accredited organizations)
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Begin with Education
Organizational leaders and managersIntroduction to accreditation philosophy and approach
Accreditation as a quality improvement and risk reduction strategy
Review of the standards and measurable elementsDiscussion of the survey process and what to expect
Project planning and next steps
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Baseline Assessment
Conduct a detailed baseline assessment of current adherence to the Standards and each Measurable Element:
Use knowledgeable and credible evaluators (either internal or external consultants) who will critically and objectively assess each area
Consider using ISAS as guide
Include all areas of the organization in the assessment
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Baseline Assessmentcont.
Collect and analyze baseline quality data as required by the quality monitoring standards
Examples: medication errors, hospital-associated infection rates, antibiotic usage, surgical complications.
Establish an ongoing monitoring system for data collection to identify problem areas and track progress in improvement
Set frequency of data collection Analyze data
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Action Planning
Using the findings of the baseline assessment, develop a detailed project plan with assigned responsibilities, deliverables, and time frames.
Start with priority areas established by leadership Example: Revise informed consent policy, develop a new
informed consent statement, educate staff - to be completed in two months (specify exact date)
If available, use a software program such as MS Project or Excel to confirm project plan in writing
Hold leaders and staff accountable to the plan
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Team Approach
Assign oversight of each chapter of standards to a respected champion/leader who will identify team members from throughout the hospital
Also include those who may be skeptical of the process
Look for good people skills, time management skills, and consensus building skills
Be prepared to change as new champions emerge, and some leaders drop out
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Policies and Procedures
Compile a list of all required policies and procedures that will need development and revision Hint: look for list in Survey Guide 2008 These may take some time to get revise or develop,
undergo organizational review, and obtain final approval
Be certain that your policy reflects your actual practice, as this is one of the yardsticks the surveyors will use to evaluate your performance
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Mid-Point Strategies
Continue to monitor your progress in meeting the standards
Ex. Use a mini-evaluation of each chapter at regular intervals (e.g quarterly)
Don’t be afraid to adjust your project plan to be more realistic – change often takes longer than one expects
Continue to involve as many staff as possible in the process – make it an organizational quality goal that you are striving to achieve together
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Strategies That Have Worked Importance of physician commitment to the
accreditation process cannot be overstated
They should see accreditation standards as framework by which hospital processes will be improve
Care will ultimately be of higher quality and safer for their patients
Reassure physicians that accreditation is not intended to tell them how to practice medicine!
But it does compel them to look collectively at their own practices and evaluate their own results
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Strategies That Have Worked Cont.
Learn from what others have done well and adapt the experience to the needs of your organization
Ask JCI for clarification with standards interpretation – don’t waste time going down the wrong path
Take advantage of resources (e.g. download electronic example policies and plans and adapt to your organization)
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Pitfalls to Avoid
Top leaders “support” the process, but are totally unrealistic in what it will take to achieve it in terms of time and resources
Staff end up feeling that accreditation is extra work for which they are not rewarded or recognized
Over-eager managers using the standards as a threat rather than as a goal – can make entire accreditation process feel punitive and inspecting rather than motivating
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Final Mock Survey
Plan for a final “mock” or practice survey about 6-8 months in advance of the target date of the actual accreditation survey
Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organization with a fresh and objective eye
Plan final actions and corrections based on the findings of the final mock survey
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Standards in two sections:
Patient-Centered Standards
Healthcare Organization Management Standards
JCI Hospital Standards 3rd Ed.
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JCI Hospital Standards 3rd Ed. Cont.
Patient-Centered StandardsAccess to Care and Continuity of CarePatient and Family RightsAssessment of PatientsCare of PatientsAnesthesia and Surgical CareMedication Management and UsePatient and Family Education
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Anesthesia and Surgical Care
1. Organization and Management
2. Sedation Care
3. Anesthesia Care
4. Surgical Care
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Medication Management and Use
1. Organization and Management
2. Selection and Procurement
3. Storage
4. Ordering and Transcribing
5. Preparing and Dispensing
6. Administration
7. Monitoring
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JCI Hospital Standards 3rd Ed. Cont.
Healthcare Organization Management Standards
Quality Improvement and Patient SafetyPrevention and Control of InfectionsGovernance, Leadership, and DirectionFacility Management and SafetyStaff qualifications and EducationManagement of Communications and
Information
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Staff Qualifications and Education
1. Planning
2. Orientation and Education
3. Medical Staff
4. Nursing Staff
5. Other Health Professional Staff
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Management of Communication and Information
1. Communication with the Community2. Communication with Patients and
Families3. Communication Between Providers
Within and Outside the Organization4. Leadership and Planning5. Patient Clinical Record6. Aggregate Data and Information
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Standards Content
Each JCI standard contains three components: The standard represents the principle The intent describes the rationale of the
standard The measurable elements are the detailed
requirements from the standard and intent that are scored
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Standards Content (sample)
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International Patient Safety Goals
Identify patients correctly at risk points Improve effective communication of critical
information Improve safety of high-alert medications Ensure correct-site, correct-patient, correct-
procedure surgery Reduce the risk of healthcare-associated
infection Reduce the risk of patient harm from falls
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Approach and Philosophy to the On Site Survey
A Survey is not intended to be punitive, a “got you” exercise, or an inspection
Tracer Methodology is a process of identifying imperfections, flaws, or broken systems
Surveyors will “drill down” or focus on areas where a potential risk area is identified
Based on common problem areas in many hospitals High risk or high volume services They have identified a vulnerable area
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On-Site Evaluation Process
Opening conference Orientation Document review Leadership session Assessment activities
Tracer activities – patient Tracer activities – systems Facility tour Special interview / issue resolution
Feedback sessions Daily briefings Leadership exit conference
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Tracer Methodology
Is an effective evaluation method that is used to assess a healthcare
organization’s performance of care and the services provided as
viewed or experienced by the patient
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Objectives of Tracer Activity
Follow entire course of care and services provided to the patient
Assess relationships among disciplines and important functions
Evaluate performance of processes provided to the patient
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Types of Tracers
Patient Tracer – Follows the patient
System Tracer – Follows the system
Data use Medication management Infection Control
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Conducting Tracers Selection of patients
Diagnoses High volume
Procedures High volume High risk Low volume
Selection of units Diagnoses/procedures Special care
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Sample Patient Tracer Hospital Setting
Patient – Mr. Ramponi Cardiac-surgery related diagnosis (cardiac bypass
surgery) Pulmonary complications (pneumonia)
Surveyor Reviews patient record Notes what services and transfers occurred
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72-year old man presented to ER with chest pain An electrocardiogram showed signs of sinus tachycardia Staff administered aspirin and drew blood Mr. Ramponi
Treated for diabetes and hypertension Recently quit smoking after 33 years Sent to cardiac catheterization lab for an angiogram, which revealed
5 blockages Put on IV heparin, nitroglycerin and beta-blocker Transferred to ICU Hypertension was an issue. So medications were adjusted to lower
his blood pressure Surgery for a coronary artery bypass graft was scheduled for the
next morning
Surveyor Reviews Medical Record
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Communication, assessment, performance improvement, and medication management issues.
Surveyor speaks with ED Staff
At Emergency Department
“You’ve said that like many heart attack victims, Mr. Ramponi delayed seeking help after experiencing the first symptoms. Has your ED conducted any performance improvement projects to decrease the time to begin treatment?”
Step 1
“I see that a cardiac catheterization was necessary; how was informed consent
obtained from Mr. Ramponi?”
“A little over 2 weeks ago, Mr. Ramponi came into the ED with chest pains and a history of hypertension and diabetes. What processes were followed for triaging and treating him?”
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Surveyor reviews Medical Record
Antibiotics were begun at the time of surgery
Sent to ICU with ventilator which was removed 5 hours later
Developed pneumonia within 2 days
IV antibiotic was changed, but history of smoking has weakened his lungs
Placed on ventilator
Wean from ventilator within 6 days
Received pulmonary treatment regimen of nebulizer treatments, incentive spirometry, and assisted cough
Transferred to a general medical unit with telemetry after 3 days
Scheduled to be discharged for continued outpatient rehabilitation
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Emergency Department points of discussion
Triage process Patient assessment Communication prior to patient transfer Medication process, including for high risk
concentrated medications and IV solutions Communication needs for elderly patients Competency of medical and nursing staff in
emergency care
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Verbal orders, assessment and emergency care issues
Surveyor talks with Staff Nurse and CardiologistStep 2
At Cardiac Catheterization Lab
“What communication took place between the catheterization lab and the ED before Mr. Ramponi arrived for his procedure?”“How did you make certain Mr. Ramponi
had no allergies to the contrast medium being used for the procedure?”
“What process was used for ensuring medical equipment safety?”
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Catheterization Labpoints of discussion Pre-procedural patient assessment Patient identification process Informed consent Patient privacy and confidentiality Infection control Patient monitoring during and after procedure Use and maintenance of equipment Sedation and anesthesia use and safety Frequency of cancellation of procedures and
reasons (Quality Improvement project)
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Medication use, anesthesia care, informed consent, site verification, emergency care issues and infection control.
Step 3
Surveyor also requests credentialling files for the anesthesiologist and cardiac surgeon.
Surveyor talks to the Staff, Circulating Nurse,
Anesthesiologist
At Operating Room
“What assessments had been performed and what information did you receive before Mr. Ramponi arrived in the OR?”
“Can you explain the process to obtain informed consent for
Mr. Ramponi for this surgery?”
“What processes do you follow to verify that you had
the correct patient and procedure before you started Mr. Ramponi’s
surgery?”
“During open-heart surgery, concentrated potassium was used. How is access to this undiluted concentrated electrolyte controlled?”
“Patients undergoing bypass surgery are at increased risk of developing a surgical site infection. What preventive measures did you take to
help reduce that risk for the patient?”
“How was the placement of Mr. Ramponi’s pulmonary artery catheter confirmed?”
“How do you maintain this equipment? How were you trained to use it?”
“What do you do in the event of fire?”
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At OR Recovery Area
Verbal orders, clinical practice guidelines and equipment management
Step 4
At Recovery Room
“Following Mr. Ramponi’s surgery, he started on an IV
infusion pump for pain management. What checks did you perform on the equipment
before starting him on the pump?”
“Who made the decision to discharge Mr. Ramponi from the Recovery, OT?”
“What guidelines did you follow for post-anesthesia monitoring of Mr. Ramponi?”
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Communication, assessment, clinical practice guidelines, credentialling, infection control, equipment management and medication management
Surveyor talks with attending Physician, ICU Nurse, Respiratory Therapist, Infection Control PractitionerStep 5
At Cardiac ICU
“Was Mr. Ramponi restrained while on ventilator? How was the decision made to remove Mr. Ramponi from the ventilator?”“How did the OR communicate what
procedures took place when Mr. Ramponi was transferred to the ICU?
“Mr. Ramponi was receiving IV pain medication following surgery. Can you show me where you documented Mr. Ramponi’s pain assessment, treatment and reassessment?”
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Cardiac ICUpoints of discussion
Communications received from Recovery Room Patient assessment and monitoring Patient privacy and confidentiality Infection control Use and maintenance of equipment, especially clinical
alarm systems Staff competency based on patient populations cared for in
ICU End-of-life issues Medication management Handling of verbal orders
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Equipment management, patient education, rights & ethics, discharge planning, continuum of care.
Step 6 Surveyor talks to Staff Nurse, Cardiac Rehab Nurse, Respiratory Therapist, Nutritionist, Patient Educator
At Medical - Surgical Unit
“I see that Mr. Ramponi was on telemetry. How would you know if the equipment is working? Can you explain how the
patient is monitored on this system?”
“What process was followed for ordering respiratory therapy for Mr. Ramponi?”
“Can you describe Mr. Ramponi’s medication protocols?”
“How was nutrition and weight management education provided to the patient?”
“What is your plan for Mr. Ramponi’s discharge?”
Surveyor reviews patient education materials.
Speaks with Mr. Ramponi and his wife about ongoing education, informed consent process and the care provided.
“What written information will Mr. Ramponi receive about his medications when he is discharged this afternoon? Does the patient know about his medications? When did you educate him? How?”
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Patient TracerSummary
Surveyor visits areas within the organization where the tracer patient was physically treated.
Wherever the surveyor is, he/she is assessing numerous standards.
Surveyor might also tour other areas, e.g., laboratory and pharmacy to explore issues such as diagnostics and medication management.
Surveyor could theoretically visit any location in the organization if it related to the care provided to the patient, including registration, dietary dept, physical therapy, outpatient pharmacy, etc.
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Infection Control Assessment
Assess processes to identify, prevent & manage healthcare acquired infections throughout organization
Uses information obtained from other assessment activities
Facility tour
Tracer activities to inpatient / outpatient care areas
Tracer activities to diagnostic services
Document review
Open & closed record review activities
System tracers activities, e.g. Pharmacy
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Infection Control System Tracer
Group discussionGoalsSurveillance dataAnalysisPrevention & control strategiesAreas of concern & actionOutbreaks
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Infection Control System Tracer Cont.
Focused tracer Tracing infection control processes across the
organization Example 1: a TB patient admitted through
Emergency to Medical Unit to Radiology to Medical Unit to Rehab
Example 2: an immuno-compromised patient admitted through Emergency to Oncology to Intensive Care Unit to Medical Unit to End-of -Life care unit.
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Data System Tracer
Group Discussion 20 Minute presentation – optional Required measures and sustained
improvements reviewed Steps – selection, collection, analysis,
dissemination/transmission, action, monitoring, sustained improvement
How data is used throughout the organization Short surveys
Include medication management and infection control data issues
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Benefits of Tracers
For Patients Improves Safety and Quality of care Improves patient flow
For Staff Encourages team building Creates systems thinkers Creates a better understanding of roles
For Organizations Reduces risk to patients Increases patient satisfaction
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Tracer Methodology
You can learn more
in 8 hours of tracing
than in 20 hours of
chart review
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Follow-up Process
Written report is required within 6 months for standards that require a plan, policy or procedure, or documentation
Focused survey is required within 6 months for standards that require surveyor observation, staff or patient interviews, or the inspection of the physical facility
If both are required, written report is reviewed at time of focused survey
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Accreditation Denied
A required follow-up focused survey has not resulted in acceptable compliance with the applicable standards and/or International Patient Safety Goal requirements
JCI withdraws its accreditation for other reasons Organization voluntarily withdraws from the
accreditation process
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After the Survey Celebrate the success!
Let your patients know whatyou have achieved
Take a week off and then start again
May need to work on areas for improvement and submit a follow-up progress report to JCI
Maintain the momentum from the survey – establish an ongoing system of standards compliance and survey readiness
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The Globalization of Healthcare
JCIJCI
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Why International Standards?
JCAHO standards filled with U.S. and state laws and regulations
JCAHO standards contain many “political” considerations such as requirements for an organized medical staff
JCAHO standards use U.S. jargon such as “advanced directives”
JCAHO standards rely on NFPA requirements for facility review with no international version of those requirements
JCAHO standards have a U.S. cultural overlay for patient rights
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JCI’s Commitment to Globalization International Board Members Mandated International Standards Committee Regional Offices
Asia Pacific Europe Middle East
Regional Advisory Councils WHO Collaborating Centre for Patient Safety
Solutions International Standards International Patient Safety Goals ISQua Accredited International Surveyors
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Comparisons
International standards include all topics from Joint Commission standards including newer ones related to pain management, and care at the end of life
International standards contain many of the quality control and quality leadership ISO 9000 criteria
International standards include the criteria of the European (EFQM) and U.S. (Baldridge) quality award
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JCI Standards Address Key Issues Relevant to Globalization
Truth in admission policies Patients are admitted for care only if the
organization can provide the necessary services and settings for care.
At admission patients and families are provided information on the proposed care, expected results of care, and expected costs.
There is an established framework for ethical management including marketing, admissions, transfer, and discharge, and disclosure of ownership and any professional conflicts that may not be in the patients’ best interests.
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JCI Standards Address Key Issues Relevant to Globalization
Professional Competence
The organization has an effective process to authorize all medical staff members to admit and treat patients and provide other clinical services consistent with their qualifications.
The credentials of medical staff members are reevaluated at least every three years to determine their qualifications to continue to provide patient care services in the organization.
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Accreditation as Part of a Systems Focus
Focusing on staff would mean reviewing the mistakes of individuals
A focus on systems examines conditions where staff work and targets strategy development to ensure that there are fewer errors and risk is reduced
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Accreditation as Part of a Systems Focus Errors need to be seen as
consequences, not as causes The best professionals can make the
worst mistakes Errors tend to have recurrent patterns Organizations should review high
reliability systems and anticipate the worst possibilities
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Accreditation as Part of a Systems Focus
If systems are designed with the full understanding that we do mistakes, and nobody is perfect, errors should occur less frequently.
Furthermore, increasing the consistency of care provision will decrease the frequency of errors.
