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C o p y r i g h t , J o i n t C o m m i s s i o n I n t e r n a t i o n a l

Association of Companies Health Insurance Funds

13 March 2009Prague, Cech !epu"lic

Joint Commission International

Standards and Survey Process

#a$id %aimo$ich, M#

Chief Medical &fficer

%oint Commission International

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C o p y r i g h t , J o i n t C o m m i s s i o n I n t

e r n a t i o n a l

Objectives

Identify and describe the JCI Accreditationprocess

escribe and revie! tracer methodology

iscuss a hospital"s preparation for the JCI Accreditation process

escribe global standardi#ation of healthcare

services through the process of accreditation Accreditation as part of a systems focus

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e r n a t i o n a l

JCI Standards System frame!or$

Chec$list of all the important managerial andclinical functions or activities

%ocus on patient perspective in conte&t oftheir family

A balance of structure, process andoutcomes standards

Optimal but achievable e&pectations

'easurable

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e r n a t i o n a l

Accreditation (epresents a (is$

(eduction Strategy

)hat an organi#ation is doing the right

things and doing them !ell*

)hereby significantly reducing the ris$of harm in the delivery of care* and

Optimi#ing the li$elihood of good

outcomes+

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&ternal, objective evaluation

-ses consensus standards

Involves the health professions

Proactive not reactive Organi#ation !ide

%ocus on systems not individuals

Stimulates .uality culture in the organi#ation

Periodic re/evaluation against standards

Strengthens public"s confidence

Strengths of Accreditation

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Accreditation Can 0elp1

nhance staff recruitment, retention and

satisfaction

Improve or e&pand sources of payment forpatient care

Increase chances to enter net!or$s and ne!

provider arrangements

Provide greater independence from

government oversight

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Accreditation Can 0elp1

2uild a .uality measurement database

Provide comparison !ith self, others,

and best practices

Provide a frame!or$ to improve patient

safety

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3uality Improvement and Patient

Safety Programs Are leadership driven

See$ to change the ethos of the organi#ation

Proactively identify and reduce ris$ and variation

-se data to focus on priority issues

See$ to demonstrate sustainable improvement

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p y r i g h t , J o i n t C o m m i s s i o n I n t e r n a t i o n a l

Accreditation as Part of

Continuous 3uality Improvement Accreditation is a milestone on the continuous journey of

improvement

Accreditation Standards provide a common .uality languageand common set of e&pectations to point the !ay for!ard

stablishing a permanent organi#ational culture of safe,

.uality care is essential for sustaining improvement

)he effort is for your patients, not the certificate

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Starting to Prepare

A$aila"le !esources'

JCI Accreditation Standards for 0ospitals, 4rd dition

Survey Process 5uide 6electronic version7

8eb/based training on introduction to theinternational accreditation process 6ISAS7

9e!sletters and publications

print and electronic 6e+g+ Getting Started 7

JCI Practicum four times a year 6Annual JCI &ecutive 2riefings : net!or$ing

opportunity !ith accredited organi#ations7

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2egin !ith ducation

&rganiational leaders and managersIntroduction to accreditation philosophy and

approach

Accreditation as a .uality improvement and ris$

reduction strategy

(evie! of the standards and measurable elements

iscussion of the survey process and !hat to

e&pect

Project planning and ne&t steps

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(aseline Assessment

Conduct a detailed "aseline assessment of

current adherence to the )tandards and each

Measura"le *lement'

-se $no!ledgeable and credible evaluators 6eitherinternal or e&ternal consultants7 !ho !ill critically and

objectively assess each area

Consider using ISAS as guide

Include all areas of the organi#ation in the assessment

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2aseline Assessmentcont+

Collect and analy#e baseline .uality data asre.uired by the .uality monitoring standards

&amples1 medication errors, hospital/associated

infection rates, antibiotic usage, surgical complications+

stablish an ongoing monitoring system for data

collection to identify problem areas and trac$

progress in improvement

Set fre.uency of data collection Analy#e data

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Action Planning

-sing the findings of the baseline assessment,develop a detailed proect plan !ith assigned

responsibilities, deliverables, and time frames+

Start !ith priority areas established by leadership &ample1 (evise informed consent policy, develop a ne!

informed consent statement, educate staff / to be completed

in t!o months 6specify e&act date7

If available, use a soft!are program such as 'SProject or &cel to confirm project plan in !riting

0old leaders and staff accountable to the plan

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)eam Approach

Assign oversight of each chapter of standards toa respected champion;leader !ho !ill identify

team members from throughout the hospital

Also include those !ho may be s$eptical of the

process

-oo. for good people s$ills, time management

s$ills, and consensus building s$ills

2e prepared to change as ne! champions

emerge, and some leaders drop out

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Policies and Procedures

Compile a list of all re.uired policies andprocedures that !ill need development and

revision

0int1 loo$ for list in Survey 5uide

)hese may ta$e some time to get revise or develop,undergo organi#ational revie!, and obtain final

approval

2e certain that your policy reflects your actualpractice, as this is one of the yardstic$s the

surveyors !ill use to evaluate your performance

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'id/Point Strategies

Continue to monitor your progress in meeting thestandards

&+ -se a mini/evaluation of each chapter at regular

intervals 6e+g .uarterly7

on"t be afraid to adjust your project plan to be

more realistic : change often ta$es longer than

one e&pects

Continue to involve as many staff as possible inthe process : ma$e it an organi#ational .uality

goal that you are striving to achieve together

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p y r i g h t , J o i n t C o m m i s s i o n I n

t e r n a t i o n a l

Strategies )hat 0ave 8or$ed

Importance of ph/sician commitment to theaccreditation process cannot be overstated

)hey should see accreditation standards as frame!or$by !hich hospital processes !ill be improve

Care !ill ultimately be of higher .uality and safer fortheir patients

(eassure physicians that accreditation is not intendedto tell them ho! to practice medicine?

2ut it does compel them to loo$ collectively at theiro!n practices and evaluate their o!n results

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Strategies )hat 0ave 8or$ed Cont+

-earn from !hat others have done !ell andadapt the e&perience to the needs of your

organi#ation

As. %CI for clarification !ith standardsinterpretation : don"t !aste time going do!n

the !rong path

a.e ad$antage of resources 6e+g+do!nload electronic e&ample policies and

plans and adapt to your organi#ation7

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Pitfalls to Avoid

)op leaders @support the process, but are totallyunrealistic in !hat it !ill ta$e to achieve it interms of time and resources

Staff end up feeling that accreditation is etraor. for !hich they are not re!arded orrecogni#ed

&$ereager managers using the standards as a

threat rather than as a goal : can ma$e entireaccreditation process feel punitive andinspecting rather than motivating

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%inal 'oc$ Survey

Plan for a final @moc$ or practice survey aboutB/> months in advance of the target date of theactual accreditation survey

-se evaluators 6internal or e&ternal consultants7!ho !ere not involved in the baselineassessment and preparation, !ho !ill loo$ atthe organi#ation !ith a fresh and objective eye

Plan final actions and corrections based on the

findings of the final moc$ survey

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Standards in t!o sections1

Patient/Centered Standards

0ealthcare Organi#ation 'anagement Standards

JCI 0ospital Standards 4rd d+

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JCI 0ospital Standards 4rd d+

Cont+

PatientCentered )tandards Access to Care and Continuity of Care

Patient and %amily (ights

Assessment of Patients

Care of Patients

Anesthesia and )urgical Care

Medication Management and 4se

Patient and %amily ducation

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Anesthesia and Surgical Care

+ Organi#ation and 'anagement

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'edication 'anagement and -se

+ Organi#ation and 'anagement

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JCI 0ospital Standards 4rd d+ Cont+

Healthcare &rganiation Management )tandards

3uality Improvement and Patient Safety

Prevention and Control of Infections5overnance, Geadership, and irection

%acility 'anagement and Safety

)taff 5ualifications and *ducationManagement of Communications and

Information

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Staff 3ualifications and ducation

+ Planning

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'anagement of Communication

and Information + Communication !ith the Community

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Standards Content

ach JCI standard contains three

components1

)he standard represents the principle

)he intent describes the rationale of the

standard

)he measurable elements are the detailed

re.uirements from the standard and intent

that are scored

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Standards Content 6sample7

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International Patient Safety 5oals

Identify patients correctly at ris$ points

Improve effective communication of criticalinformation

Improve safety of high/alert medications

nsure correct/site, correct/patient, correct/procedure surgery

(educe the ris$ of healthcare/associated

infection(educe the ris$ 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 youe&ercise, or an inspection

)racer 'ethodology is a process of identifyingimperfections, fla!s, or bro$en systems

Surveyors will @drill do!n or focus on areas !here

a potential ris$ area is identified 2ased on common problem areas in many hospitals 0igh ris$ or high volume services )hey have identified a vulnerable area

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&n)ite *$aluation Process

Opening conferenceOrientationocument revie! Geadership session

Assessment activities )racer activities : patient )racer activities : systems %acility tour Special intervie! ; issue resolution

%eedbac$ sessions aily briefings Geadership e&it conference

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)racer 'ethodology

Is an effective evaluation method that

is used to assess a healthcare

organi#ation"s performance of careand the services provided as

$ieed or eperienced "/ the

patient

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Objectives of )racer Activity

%ollo! entire course of care and

services provided to the patient

Assess relationships among disciplines

and important functions

valuate performance of processesprovided to the patient

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)ypes of )racers

Patient )racer : %ollo!s the patient

System )racer : %ollo!s the system

ata use

'edication management

Infection Control

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Conducting )racers

Selection of patients iagnoses

0igh volume

Procedures

0igh volume

0igh ris$

Go! volume

Selection of units iagnoses;procedures

Special care

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Sample Patient )racer

0ospital Setting

Patient : 'r+ (amponi

Cardiac/surgery related diagnosis 6cardiac bypass

surgery7 Pulmonary complications 6pneumonia7

Surveyor

(evie!s patient record

9otes !hat services and transfers occurred

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F

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Communication, assessment, performance impro$ement, and

medication management issues+

Surveyor speaks with ED Staff

At mergency epartment

@ou"ve said that li$e many heart

attac$ victims, 'r+ (amponidelayed see$ing help after

e&periencing the first symptoms+

0as your conducted any

performance impro$ement

proects to decrease the time tobegin treatment

Step 1

@I see that a cardiac catheteri#ation !as

necessary* ho! !as informed consent

obtained from 'r+ (amponi

@A little over < !ee$s ago, 'r+ (amponi came

into the !ith chest pains and a history of

hypertension and diabetes+ 8hat processes

!ere follo!ed for triaging and treating him

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Surveyor revie!s 'edical (ecord

Antibiotics !ere begun at the time of surgery

Sent to IC- !ith ventilator !hich !as removed E hours later

eveloped pneumonia !ithin < days

IH antibiotic !as changed, but history of smo$ing has !ea$ened hislungs

Placed on ventilator

8ean from ventilator !ithin B days

(eceived pulmonary treatment regimen of nebuli#er treatments,incentive spirometry, and assisted cough

)ransferred to a general medical unit !ith telemetry after 4 days

Scheduled to be discharged for continued outpatient rehabilitation

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mergency epartment

points of discussion

)riage process

Patient assessment

Communication prior to patient transfer 'edication process, including for high ris$

concentrated medications and IH solutions

Communication needs for elderly patients

Competency of medical and nursing staff inemergency care

At C di C th t i ti G b

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8er"al orders, assessment and emergenc/ care issues

Surveyor talks with Staff Nurse and Cardiologist Step 2

At Cardiac Catheteri#ation Gab

@8hat communication too$ place bet!een

the catheteri#ation lab and the before 'r+(amponi arrived for his procedure

@0o! did you ma$e certain 'r+ (amponi

had no allergies to the contrast medium

being used for the procedure

@8hat process !as used for ensuring

medical e.uipment safety

C th t i ti G b

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o p y r i g h t , J o i n t C o m m i s s i o n I n t e r n a t i o n a l

Catheteri#ation Gab

points of discussion

Pre/procedural patient assessmentPatient identification process

Informed consent

Patient privacy and confidentiality

Infection control

Patient monitoring during and after procedure

-se and maintenance of e.uipment

Sedation and anesthesia use and safety

%re.uency of cancellation of procedures and

reasons 63uality Improvement project7

At O ti (

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Medication use, anesthesia care, informed consent, site $erification,

emergenc/ care issues and infection control+

Step 3

Surveyor also requests credentialling files for theanesthesiologist and cardiac surgeon.

Surveyor talks to the

Staff, Circulating Nurse,

Anesthesiologist

At Operating (oom

@8hat assessments had been

performed and !hat

information did you receive

before 'r+ (amponi arrived inthe O(

@Can you e&plain the process to

obtain informed consent for 'r+(amponi for this surgery

@8hat processes do you follo!

to verify that you had the

correct patient and

procedure before you started'r+ (amponi"s surgery

@uring open/heart surgery,

concentrated potassium !as used+ 0o!

is access to this undiluted concentratedelectrolyte controlled

@Patients undergoing bypass

surgery are at increased ris$

of developing a surgical site

infection+ 8hat preventive

measures did you ta$e tohelp reduce that ris. for the

patient@0o! !as the placement of

'r+ (amponi"s pulmonary

artery catheter confirmed@0o! do you maintain this

e5uipment 0o! !ere you

trained to use it

@8hat do you do in the event of fire

At (eco er (oom

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At O ecovery Area

8er"al orders, clinical practice guidelines and e5uipment management

Step 4

At (ecovery (oom

@%ollo!ing 'r+ (amponi"s surgery,he started on an IH infusion pump

for pain management+ 8hat chec.s

did you perform on the e5uipment

before starting him on the pump

@8ho made the decision to discharge 'r+

(amponi from the (ecovery, O)

@8hat guidelines did you follo! for post/

anesthesia monitoring of 'r+ (amponi

At Cardiac IC-

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Communication, assessment, clinical practice guidelines,

credentialling, infection control, e5uipment management and

medication management

Surveyor talks with attending !hysician, "C# Nurse,

espiratory $herapist, "nfection Control !ractitioner Step 5

At Cardiac IC-

@8as 'r+ (amponi restrained !hile on

ventilator 0o! !as the decision made to

remove 'r+ (amponi from the ventilator@0o! did the O( communicate !hat

procedures too$ place !hen 'r+ (amponi!as transferred to the IC-

@'r+ (amponi !as receiving IH pain medication

follo!ing surgery+ Can you sho! me !here you

documented 'r+ (amponi"s pain assessment,

treatment and reassessment

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Cardiac IC-

points of discussion Communications received from (ecovery (oom

Patient assessment and monitoring

Patient privacy and confidentiality

Infection control

-se and maintenance of e.uipment, especially clinicalalarm systems

Staff competency based on patient populations cared for inIC-

nd/of/life issues 'edication management

0andling of verbal orders

At 'edical Surgical -nit

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*5uipment management, patient education, rights ethics,

discharge planning, continuum of care+

Step 6 Surveyor talks to Staff Nurse, Cardiac eha% Nurse, espiratory $herapist, Nutritionist, !atient Educator

At 'edical / Surgical -nit

@I see that 'r+ (amponi !as on telemetry+ 0o! !ould

you $no! if the e.uipment is !or$ingCan you e&plain ho! the

patient is monitored on this

system

@8hat process !as follo!ed for ordering

respiratory therapy for 'r+ (amponi

@Can you describe 'r+ (amponi"s medication protocols

@0o! !as nutrition and !eight management

education provided to the patient

@8hat is your plan for 'r+

(amponi"s discharge

Surveyor reviews patient education &aterials.

Speaks with 'r. a&poni and his wife a%out ongoing

education, infor&ed consent process and the care

provided.

@8hat !ritten information !ill 'r+ (amponi receive about his medications

!hen he is discharged this afternoon oes the patient $no! about his

medications 8hen did you educate him 0o!

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Patient )racer

Summary Surveyor visits areas !ithin the organi#ation !here the tracer

patient !as physically treated+

8herever the surveyor is, he;she is assessing numerous

standards+ Surveyor might also tour other areas, e+g+, laboratory and

pharmacy to e&plore issues such as diagnostics andmedication management+

Surveyor could theoretically visit an/ location in theorgani#ation if it related to the care provided to the patient,including registration, dietary dept, physical therapy,outpatient pharmacy, etc+

Infection Control Assessment

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Infection Control Assessment

Assess processes to identify, prevent K managehealthcare ac.uired infections throughout organi#ation

-ses information obtained from other assessmentactivities

%acility tour

)racer activities to inpatient ; outpatient care areas

)racer activities to diagnostic services

ocument revie! Open K closed record revie! activities

System tracers activities, e+g+ Pharmacy

I f ti C t l S t )

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Infection Control System )racer

5roup discussion5oals

Surveillance data

Analysis

Prevention K control strategies

Areas of concern K actionOutbrea$s

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o p y r i g h t , J o i n t C o m m i s s i o n I

n t e r n a t i o n a l

Infection Control System )racer Cont+

%ocused tracer )racing infection control processes across the

organiation

&ample 1 a ( patient admitted throughmergency to 'edical -nit to (adiology to

'edical -nit to (ehab

&ample

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ata System )racer

:roup #iscussion 20 Minute presentation ; optional

!e5uired measures and sustainedimpro$ements revie!ed

)teps : selection, collection, analysis,dissemination;transmission, action, monitoring,sustained improvement

0o! data is used throughout the organi#ation

Short surveys Include medication management and infection

control data issues

2 fit f )

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2enefits of )racers

For Patients

Improves Safety and 3uality of care Improves patient flo!

For )taff ncourages team building

Creates systems thin$ers Creates a better understanding of roles

For &rganiations

(educes ris$ to patients Increases patient satisfaction

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)racer 'ethodology

(ou can learn &ore

in ) hours of tracing

than in *+ hours of

chart review

%ollo! up Process

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%ollo!/up Process

8ritten report is re.uired !ithin B months forstandards that re.uire a plan, policy or procedure,or documentation

%ocused survey is re.uired !ithin B months forstandards that re.uire surveyor observation, staffor patient intervie!s, or the inspection of thephysical facility

If both are re.uired, !ritten report is revie!ed attime of focused survey

Accreditation enied

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Accreditation enied

A re.uired follo!/up focused survey has notresulted in acceptable compliance !ith the

applicable standards and;or International Patient

Safety 5oal re.uirements

JCI !ithdra!s its accreditation for other reasons Organi#ation voluntarily !ithdra!s from the

accreditation process

After the Survey

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After the Survey

Celebrate the success?

Get your patients $no! !hat

you have achieved

)a$e a !ee$ off and then start again

'ay need to !or$ on areas for improvementand submit a follo!/up progress report to JCI

'aintain the momentum from the survey :establish an ongoing system of standardscompliance and survey readiness

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8hy International Standards

JCA0O standards filled !ith -+S+ and state la!s andregulations

JCA0O standards contain many @political considerationssuch as re.uirements for an organi#ed medical staff

JCA0O standards use -+S+ jargon such as @advanceddirectives

JCA0O standards rely on 9%PA re.uirements for facilityrevie! !ith no international version of those

re.uirements

JCA0O standards have a -+S+ cultural overlay for patientrights

JCI" C it t t 5l b li ti

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JCI"s Commitment to 5lobali#ation

International 2oard 'embers 'andated International Standards Committee (egional Offices

Asia Pacific urope 'iddle ast

(egional Advisory Councils 80O Collaborating Centre for Patient Safety

Solutions International Standards

International Patient Safety 5oals IS3ua Accredited International Surveyors

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Comparisons

International standards include all topics fromJoint Commission standards including ne!erones related to pain management, and careat the end of life

International standards contain many of the.uality control and .uality leadership ISOL=== criteria

International standards include the criteria ofthe uropean 6%3'7 and -+S+ 62aldridge7.uality a!ard

JCI Standards Address Mey Issues

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(elevant to 5lobali#ation

)ruth in admission policies

Patients are admitted for care only if theorgani#ation can provide the necessary servicesand settings for care+

At admission patients and families are providedinformation on the proposed care, e&pectedresults of care, and e&pected costs+

)here is an established frame!or$ for ethical

management including mar$eting, admissions,transfer, and discharge, and disclosure ofo!nership and any professional conflicts that maynot be in the patients" best interests+


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(elevant to 5lobali#ation

Professional Competence

)he organi#ation has an effective process toauthori#e all medical staff members to admit

and treat patients and provide other clinicalservices consistent !ith their .ualifications+

)he credentials of medical staff members

are reevaluated at least every three years todetermine their .ualifications to continue toprovide patient care services in theorgani#ation+

Accreditation as Part of a

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Systems %ocus %ocusing on staff !ould mean revie!ing

the mista$es of individuals

A focus on systems e&amines

conditions !here staff !or$ and targets

strategy development to ensure that

there are fe!er errors and ris$ isreduced


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Systems %ocus rrors need to be seen as

conse.uences, not as causes

)he best professionals can ma$e the

!orst mista$es rrors tend to have recurrent patterns

Organi#ations should revie! highreliability systems and anticipate the!orst possibilities

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Systems %ocusIf systems are designed !ith the full

understanding that !e do mista$es,

and nobody is perfect, errors should

occur less fre.uently+

%urthermore, increasing the

consistency of care provision !ill

decrease the fre.uency of errors+

Documents

090313 Standards