JCIA Introduction1 2008

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    Understanding JCIA

    By:

    Team Healthcare Consulting

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    Accreditation

    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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    Accreditation Accomplishes:

    1. Stimulate continuous improvement inpatient care processes and outcomes

    2. Increase efficiency/reduce costs

    3. Strengthen the public confidence

    4. Improve the management of healthservices

    5. Provide education on better or bestpractices

    6. Provide recognition for excellence

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    JCIA

    A subsidiary of Joint Commission onAccreditation of Healthcare Organizations

    (JCAHO) now called THE JOINT

    COMMISSION).

    Mission:

    To improve the quality of health care in the

    international community through provisionof accreditation, consultation, and

    education services.

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    JCIA Today

    3rd edition will be issued June 2007

    effective for survey Jan. 2008

    120+ hospitals and other healthcare

    organizations are accredited around the

    world as of Dec. 2007.

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    JCIA Standards

    International Patient Safety Goals

    Section I: Patient Centered Standards:

    1. Access to Care and Continuity of Care (ACC)

    2. Patient and Family Rights (PFR)

    3. Assessment of Patients (AOP)

    4. Care of Patients (COP)

    5. Anesthesia and Surgical Care (ASC)

    6. Medication Management and Use (MMU)

    7. Patient and Family Education (PFE)

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    Section II: Healthcare Organization

    Management Standards

    8. Quality Improvement & Patient Safety(QPS)

    9. Governance, Leadership, and Direction

    (GLD)10. Facility Management & Safety (FMS)

    11. Staff Qualifications & Education (SQE)

    12. Prevention & Control of Infections (PCI)13. Management of Communication and

    Information (MCI)

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    Structure of Standards

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    PATIENT SAFETY GOALS

    The purpose of the International Patient Safety Goalsis to promote specific improvements in patient safety.

    The goals highlight problematic areas in health careand describe evidence- and expert-based consensussolutions to these problems.

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    GOALS

    Goal 1

    Identify Patients Correctly

    Requirement of Goal 1

    The organization develops an approach to

    improve accuracy of patient identifications.

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    Measurable Elements of Goal 1

    Require the use of two patient identifiers, notincluding the use of the patients room number orlocation.

    Patients are identified before: administering medications,

    blood, or blood products.

    taking blood and other specimens for clinical testing.

    providing treatments and procedures.

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    Goal 2

    Improve Effective Communication

    Requirement of Goal 2

    The organization develops an approach to

    improve the effectiveness of

    communication among caregivers.

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    Measurable Elements of Goal 2 The complete verbal and telephone order or testresult is:

    written down by the receiver

    read back by the receiver

    The order or test result is confirmed by the

    individual who gave the order or test result. (signed)

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    Goal 3Improve the Safety of High-Alert Medications

    Requirement of Goal 3The organization develops an approach to

    improve the safety of high-alert medications.

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    Measurable Elements of Goal 3 Concentrated electrolytes are not present inpatient care units unless clinically necessary and

    actions are taken to prevent inadvertent

    administration in those areas where permitted by

    policy.

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    Goal 4

    Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery

    Requirement of Goal 4The organization develops an approach to

    ensuring correct-site, correct-procedure, and

    correct-patient surgery.

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    Measurable Elements of Goal 4mark for surgical site identification involves the patient in the marking process.

    verify that all documents and equipment

    needed are on hand, correct, and functional. use checklist and time-out procedure just

    before starting a surgical procedure.

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    Goal 5Reduce the Risk of Health CareAssociatedInfections

    Requirement of Goal 5The organization develops an approach to reduce

    the risk of health careassociated infections.

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    Measurable Elements of Goal 5 adapted currently published and

    generally accepted hand hygiene

    guidelines. implements an effective hand hygiene

    program.

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    Goal 6

    Reduce the Risk of Patient Harm Resulting fromFalls

    Requirement of Goal 6The organization develops an approach to reduce

    the risk of patient harm resulting from falls.

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    Measurable Elements of Goal 6implements a process for the initial assessmentof patients for fall risk

    reassessment of patients when indicated by achange in condition, medications, etc.

    Measures are implemented to reduce fall riskfor those assessed to be at risk.

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    Patient Centered Standards:

    (ACC)

    Overview:

    Information is essential to match the

    patients health care needs with the

    services available.

    Coordinate the services provided by the

    organization.

    Plan for discharge and follow-up

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    Patient Centered Standards:

    (PFR)

    Overview:

    Identify, protect, and promote patient rights

    Inform patients of their rights

    Include the patients family in patient care

    decisions

    Obtain informed consent

    Educate staff about patient rightsEstablish an ethical framework.

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    Patient Centered Standards:

    (AOP)Overview:

    A effective assessment process results in decisions aboutthe immediate and continuing treatment needs. Patientassessment is ongoing, dynamic, and multidisciplinary

    process:1.Collecting information and data on patients physical,psychological, social status, and health history.

    2.Analyzing data and information to identify the patientshealth care needs.

    3.Developing a plan of care to meet the patients identifiedneeds.

    4.Performed by qualified individuals.

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    Patient Centered Standards:

    (COP)

    Overview:

    1. Plan and deliver uniform care to all patients

    especially frail and elderly

    2. Make care seamless through effectivecommunication

    3. Provide safe care of high risk patients

    4. Use medications safely5. Support patient nutrition needs

    6. Pain management and care of the dying

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    Patient Centered Standards:

    (ASC) Overview:

    The use of anaesthesia, sedation and surgicalintervention are common and complex processes

    They require complete and comprehensive patientassessment

    Integrated care planning

    Continuous monitoring of patients

    And criteria to determine transfer to another level of careor discharge

    Managing patient at risk of complications The standards are applicable for all areas where surgical

    and invasive procedures, anaesthesia and sedation areused within the organization

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    Patient Centered Standards

    (MMU)Overview:

    MMU Important component of patient care

    Encompasses systems and processes toprovide pharmaceutical care to patients

    Multidisciplinary and coordinated efforts tomanage medication use by: Process design

    Implementation and improvement

    Selection of medication Procurement, storing, ordering/prescribing,

    transcribing, distribution, preparing, administering,documenting and monitoring of medication therapies.

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    Patient Centered Standards:

    (PFE)

    Overview:

    1. Assessment of educational needs

    2. Education includes: Medication, medicalequipment, interaction between food &

    medication, nutritional guidance, and

    rehabilitation techniques.

    3. Staff have appropriate knowledge and

    skills

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    Healthcare Organization Management

    Standards: (QPS)

    Overview:

    1. Governance and leadership participation

    2. Comprehensive approach3. A framework for: Designing processes,

    implementing and sustaining changes

    that result in improvement.

    4. PI plan and indicators.

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    Healthcare Organization Management

    Standards: (PCI)

    Overview:

    1. Understand infection risks in the entire

    organization

    2. Plan and implement surveillance and

    prevention strategies

    3. Integrate the program with quality

    management and improvement

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    Healthcare Organization Management

    Standards: (GLD)

    Overview:

    1. Identify governance structure and

    responsibility

    2. Provide collaborative leadership

    3. Provide responsible leadership at

    department and service level

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    Healthcare Organization Management

    Standards: (FMS)

    Overview:

    1. Reduce and control hazards and risks

    2. Prevent accidents and injuries

    3. Maintain safe conditions

    4. Plan space, equipment, and resources

    5. Educate staff to reduce risks and report

    incidents6. Use data to monitor performance

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    Healthcare Organization Management

    Standards: (SQE)Overview:

    1. Mix of skills to fulfill hospital mission

    2. Managerial and clinical leaders identify the numberand types of staff needed

    3. Recruiting, evaluating, and appointing staff are bestaccomplished through a coordinated uniform process

    4. Documented skills, knowledge, education, andexperience

    5. Review of credentials of medical and nursingpersonnel

    6. Provide staff with the required education to updatetheir competencies

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    Management of Communication

    and Information (MCI)

    Overview:

    Assure that Organizations are effective in:

    Identifying information needs

    Designing and information management system

    Defining and capturing data and information

    Analyzing data and transforming it into

    information And integrating and using information

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    Thank YouQuestions?