Mahidol U.Thailand

22/01/2552

Joint Commission International (JCI)

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•The U.S., Canada, and Australia have the oldest accreditation systems

•In Europe, Germany, France, Ireland and Spain have new accreditation systems

•In Japan, Korea, Malaysia, and Thailand there are new systems with government role

•The WHO, World Bank and development banks recognize and endorse the accreditation model

Accreditation : A Accreditation : A World TrendWorld Trend

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The Joint Commission International (JCI) Is a Major Subsidiary of Joint Commission Accreditation of Healthcare Organizations (JCAHO)

To Improve the Safety and Quality of Care in the International Community Through the Provision of Education, Publications, Consultation and Evaluation Services

Mission Mission of JCIof JCI

About JCIAbout JCI

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JCAHO - JCAHO - HistoryHistory• 1910 – 1913 : Concerned for

the Quality of Hospital Care in the U.S.A.

• 1910 : Ernest A Codman Focused on Results

• 1918 : American College of Surgeons Began a Hospital Standardization Program

• 1951 : Joint Commission on Accreditation of Hospitals Formed to Continue the Challenge

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Joint Commission Joint Commission on Accreditationon Accreditation• Non-profit Affiliate of JCAHO

• Separate Board with International Members

• Accreditation Committee with International Members

• Advisory Structure with International Members

• International Division Is Known As Joint Commission International (JCI)

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Origin Origin andand Content of Content of JCI JCI

StandardsStandards

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International International Hospital Hospital

StandardsStandards• International Principles and Standards Development Task Force Formed February 1998

• First Meeting of the Task Force in June 1998

• Meeting Held in Chicago, Budapest, Barcelona in 1998 and 1999

• Publication of Standards in October 1999

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Standards Standards Subcommittee Subcommittee

Members Members • Brazil• China• Czech Republic• Germany• Ireland (pending)

• Italy• Poland• Portugal (pending)• Republic of South Africa• Saudi Arabia

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ACCREDITAACCREDITATIONTION

Benefits and Benefits and CharacteristicsCharacteristics

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Benefits for Benefits for the Hospitalthe Hospital• Improves Care and

Enhances Public Confidence• Stimulates Continuous Improvement• Demonstrates Commitment to Quality Care• Raises Community Confidence• Comparison with Self and Other Similar Organization

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Benefits for the Benefits for the Medical & Nursing Medical & Nursing

StaffStaff• Improves Professional Staff Development

• Provides Education on Consensus Standards• Provides Leadership for Quality Improvement within Medicine and Nursing• Increases Satisfaction with Working Conditions, Leadership and Accountability

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Benefits for Benefits for Hospital Hospital

EmployeesEmployees• Values Employee Opinions• Measures Employee Satisfaction• Involvement in Quality Activities• Improved Employee Safety and Security• Clearer Lines of Authority and Accountability• Promotes Teamwork

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Benefits for Benefits for PatientsPatients• Access to a Quality Focused

Organization• Rights Are Respected and Protected• Understandable Education and Communication• Satisfaction Is Evaluated• Involvement in Care Decisions and Care Process• Focus on Patient Safety

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CharacteCharacteristicsristics• Usually a VOLUNTARY

Process by Which a Government or Non-Government Agency Grants RECOGNITION to Health Care Institutions Which Meet Certain STANDARDS That Require Continuous IMPROVEMENT in Structures, Processes, and Outcomes

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JCIAJCIA

Definition of Definition of StandardsStandards• Requirements That Define

Performance Expectations with Respect to STRUCTURE, PROCESS, and OUTCOMES That Must Be Substantially in Place in an Organization to Enhance the Safety and Quality for Patient Care

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Performance Performance ComponentsComponents• STRUCTURE : Resources• E.g. Adequate Staff, Supplies, Building

• PROCESS : Activities• E.g. Patient Education, Nursing Assessment

• OUTCOMES : Results• E.g. Infection Rates, Maternal Mortality

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StandaStandardsrds• A System Framework (i.e.

Policy, Procedures, Indicators, Monitor, Feed-Back)• Address All the Important Managerial and Clinical Functions of a Healthcare Organization• Focus on Patient in Context of Their Family• A Balance of Structure, Process and Outcomes Standards• Set Optimal, Achievable Expectations• Set Measurable Expectations

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Components of Components of Standards Standards

DevelopmentDevelopment• Multiple Information Sources

• Scientific Literature

• Survey Compliance Data

• Research Findings

• Individual Input from Field Experts and Key Stakeholders

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JCI JCI StandardsStandards

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Patient-Patient-Centered Centered StandardsStandards

• Access to Care and Continuity of Care (ACC)• Patient and Family Rights (PFR)• Assessment of Patient (AOP)• Care of Patients (COP)• Anesthetic and Surgical Care (ASC)•Medical Management and Use (MMU)• Patient and Family Education (PFE)

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Health Care Health Care Organization Organization Management Management

StandardsStandards• Quality Improvement and Patient Safety (QPS)• Prevention and Control of Infection (PCI)• Government, Leadership & Direction (GLD)• Facility Management & Safety (FMS)• Staff Qualification & Education (SQE)• Management of Information (MOI)

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Priority Focus

Process

Priority Focus

Process

Patient and Family Rights

(PFR)

Patient and Family Rights

(PFR)

Staff Qualifications & Education

(SQE)

Staff Qualifications & Education

(SQE)

Governance, Leadership, and Direction

(GLD)

Governance, Leadership, and Direction

(GLD)

Performance Performance ReviewReview

Performance Performance ReviewReview

Management of Information

(MOI)

Management of Information

(MOI)

DriverDriver SystemSystemResultsResults

Cause - Cause - Effect Effect Cause - Cause - Effect Effect

Quality Improvement & Patient Safety (QPS)

Facility Management & Safety (FMS) Prevention & Control of Infections (PCI)

Access to Care and Continuity of Care (ACC)

Patient and Family Rights (PFR) Assessment of Patients (AOP)

Care of Patients (COP) Patient and Family Education (PFE)

Quality Improvement & Patient Safety (QPS)

Facility Management & Safety (FMS) Prevention & Control of Infections (PCI)

Access to Care and Continuity of Care (ACC)

Patient and Family Rights (PFR) Assessment of Patients (AOP)

Care of Patients (COP) Patient and Family Education (PFE)

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6. Process Management

6. Process Management

3. Focus on Patients/Customers

3. Focus on Patients/Customers

5. Staff Focus (HR)5. Staff Focus (HR)1. Leadership1. Leadership

1. Health Care Results2. Patient and Other Customer-focused Results

3. Financial Results4. Staff and Work System Results

5. Organizational Effectiveness Results6. Governance and Social Responsibility Results

7. Health Promotion Results

1. Health Care Results2. Patient and Other Customer-focused Results

3. Financial Results4. Staff and Work System Results

5. Organizational Effectiveness Results6. Governance and Social Responsibility Results

7. Health Promotion Results

2. Strategic Management2. Strategic Management

4. Information and Knowledge

Management

4. Information and Knowledge

Management

DriverDriver SystemSystemResultsResults

Cause - Cause - Effect Effect Cause - Cause - Effect Effect

1. Risk, Safety, and Quality Management

2. Professional Governance3. Physical Structure and Environment

of Care4. Prevention and Control of Infection

5. Medical Record System6. Medication Management System

7. Diagnostic Investigation and Related Services

8. Disease and Health Hazard Surveillance

9. Working with Community

1. Entry1. Entry

2. Patient Assessment2. Patient Assessment

3. Planning of Care3. Planning of Care

4. Patient Care Delivery4. Patient Care Delivery

5. Information and 5. Information and EmpowermentEmpowerment

6. Discharge Planning & 6. Discharge Planning & Continuity of CareContinuity of Care

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HA 2006 JCIA 2008

Clinical Tracer of Quality

HA-Thailand PSGs

Tracer Methodology/DSC 2007 IPSGs

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