JCI Standards 2006 JCI Standards Effec-

tive 2008 1. Access to Care and Conti-

nuity of Care (ACC)

2. Patient and Family Rights (PFR)

3. Assessment of Patients (AOP)

4. Care of Patients COP)

5. Patient and Family Educa-tion (PFE)

6. Quality Improvement & Patient Safety (QPS)

7. Prevention and Control of Infections (PCI)

8. Governance, Leadership & Direction (GLD)

9. Facility Management and Safety (FMS)

10. Staff Qualifications & Education (SQE)

11. Management of Informa-

2006 Standards #1-10: re-tained with updates

2006 Standard #11: re-named Management of Communication and Infor-mation (MCI)

Plus the following:

1. Anesthesia and Surgical Care (ASC)

2. Medication Management and Use (MMU)

3. International Patient Safety Goals

The JCIA Standards: Then and Now

QuIP Update is published by

the Medical Quality Improve-

ment Office. For comments

and feedback, call local

6289/6290 or email

medqi@medicalcity.com.ph

Page 8

Please turn to page 6

Please turn to page 2

mend policies gov-erning medication management and use, 3) to ensure that medication admini-stration adheres to principles of quality, safety and rational drug use, and 4) to oversee quality im-provement initiatives related to medication management and use.

The Medica-tion Safety Task Force (MSTF) is one task force that is eas-ily formed and organ-ized because we all realize the impor-tance of medication safety in providing quality care. At the core of its member-ship are people al-ready in the estab-lished Hospital Therapeutics Com-mittee. To be more effective in carrying

out its objectives, its membership also comprises represen-tatives from Informa-tion Technology, Systems & Quality, and selected nursing units (see box on page 2).

The MSTF is tasked to carry out the following general objectives: 1) to en-sure compliance to pertinent JCI stan-dards, 2) to recom-

Medication Safety Task Force leads TMC to JCIA 2009

Go JCI 2009: Tested. Acclaimed. Ready. Now.

By this time, these words are al-ready familiar to all of us having been up-loaded as the hospi-tal’s official wallpaper in our computers. These words mean only one thing: our re-accreditation survey with the Joint Com-mission International

(JCI) will be around the corner before we know it and we should be ready. Now.

Obtaining a re-accreditation from JCI is stricter be-cause we have to

The Medical City

March 2008 Vol 5 No 1

QuIP Update Newsletter of TMC’s Quality Improvement Program

Inside this issue:

The new JCI standard on Medication Man-agement and Use

3

JCIA Task Forces undergo Training of Trainers

4

The JCI Stan-dards: Then and Now

8

The MSTF is composed of:

Dr. May N. Agno, Task Force Chair

Ms. Cristela Villa-real, NSO

Dr. Lanie Canonizado, OB-Gynecology

Ms. Aurora Aralar, ICU/OR

Ms. Emilia Abelido, Pharmacy

Ms. Aida Rubia, Nursing 5A/B

Ms. Tess Goersua, Nursing 9A/10A

Mr. Ramil Malonzo, Nursing 14A/15A

Ms. Cristel Hitalla, Nursing 9A/10A

Mr. Rommel Galapon, ITD

Ms. Liaa Katrina Dameg, SQD

Mr. Edward Tolentino, Pharmacy

In addition, the MSTF shall regu-larly review, design and evaluate our medication manage-ment systems and design training pro-grams, materials and interventions for drug safety.

The task force shall serve as the link between policy making and imple-mentation. Monitor-ing will also be an important function of the MSTF especially in endorsing staff-specific performance in medication man-agement. Such per-formance monitoring shall be fed back to Human Resources Department for non-medical staff and the Professional Devel-

opment Staff Office for the medical staff for purposes of re-wards, incentives and sanctions.

One of the initial activities of the MSTF is the presen-tation of the Medica-tion Safety Modules to all our clinical de-partments. The task

force expects that all departments shall be covered by June 2008. The modules provide orientation on important medica-tion issues like safety, rational drug use, formulary use, medication recon-ciliation, and adverse drug reaction moni-toring.

Medication Safety Task Force leads… (from page 1)

Page 2 QuIP Update

Dr. May Agno, MSTF Chair

Some members of the MSTF fully engrossed in a

team-building activity during the Task Forces TOT held in Olongapo

City last February

weary but excited doctors, nurses, ad-ministrative and other allied staff mo-tored to Olongapo City to participate in the TMC JCI Task Forces Training of Trainers. Ms. Marga-ret A. Bengzon, Vice-President for Strate-gic Services, graced the event. The 2-day affair was filled with

meaningful games and team building activities.

The participants not only learned the technical part of what they are supposed to teach; they also learned how to be effective trainers. More importantly, they learned how to be team players –

something that they expect to cascade to the rest of the TMC community.

Rest as-sured that in the months to come, we will be experiencing the stimulating and refreshing insights from our JCI Task Forces trainers.

“ Despite the

limited time, the

TOT was fun

and definitely

informative. We

learned more

about

ourselves as

leaders and as

members of a

team” - Mr.

Ramil Malonzo,

MSTF member

Page 7 Vol 5 No 1

JCIA Task Forces undergo Training of Trainers (from page 5)

potential allergies, real or potential inter-actions, variation for use, patient’s weight and other informa-tion, and other con-traindications.

Administration (MMU.6): sets new expectations for the process of verifying the medication prior to administration wherein the following

are verified with the prescription or order: medication, time and frequency of admini-stration, dosage amount, route of ad-ministration, and identity of the patient.

Monitoring (MMU.7): requires a policy to identify re-portable adverse effects and a system of reporting and documenting them.

Ensuring safe medication proc-esses in the hospital is a collaborative effort between the members of the health care team.

This involves the doctors who order the medications, the nurses who adminis-ter them, the phar-macists who dis-pense them, and the rest of us who are responsible for their management, stor-age, procurement, evaluation, and monitoring.

At a glance: the new JCI standard on Medication Management and Use (From page 3)

Go JCI 2009... (from page 1)

Ensuring safe

medication

processes in a

hospital is a

collaborative

effort between

the members of

the health care

team

Page 6 QuIP Update

adopted, imple-mented and docu-mented all the rele-vant and necessary policies and proc-esses.

This year’s is-sues of the QuIP Update are therefore dedicated to these JCIA preparations. We will feature arti-cles on training, new

policies, improved procedures and other activities regarding the standards that we need to concen-trate on for 2008. For this issue, we feature the new JCI standard on medication man-agement and our newly-formed Medi-cation Safety Task Force.

show that we are compliant to all the standards for 12 months prior to the survey. That’s why, the focus of our preparations now is not on November 2009 when the on-site survey will be conducted but on October 2008 when we can show that we have already fully

Continued on Page 6

The Medication Management and Use (MMU) standard is one of the three new ones added to the existing 11 chap-ters. The MMU stan-dards came from several measurable elements formerly under the Care of Patients chapter. The old standards were reviewed and new ones were added to respond to required primary processes of safe medication. These processes are organized into:

Organization and management (MMU.1): includes new requirements for plan or policy on how medication use is organized; Policy-driven medication use throughout the hospital; documented review of the medica-tion management

system at least every 12 months, and mak-ing sure sources of drug information are available.

Selection and pro-curement (MMU.2): contains new expec-tations related to the management of the hospital formulary list, including moni-toring of patient re-sponse to medica-tions added to the list and an annual review of the list based on safety and efficacy information.

Storage (MMU.3): contains new, more specific expectations regarding storage of medications, includ-ing the storage of concentrated electro-lytes. Also has revi-sions on required policies and proce-dures related to stor-age of several types

of medications in-cluding that of par-enteral nutritional products.

Ordering and tran-scribing (MMU.4): describes the re-quired elements of a complete order or prescription; includes policy actions that address reduction of illegibility of prescrip-tions.

Preparing and dis-pensing (MMU.5): sets new and explicit requirements for the review of the appro-priateness of a medi-cation prescription or order wherein the review includes evaluation of appro-priateness of drug, dose, frequency and route, therapeutic duplication, real or

At a glance: the new JCI standard on

Medication Management and Use

The MMU

standard

demonstrates

the importance

of maintaining

medication

safety in the

hospital

Page 3 Vol 5 No 1

In 2007, after we have just barely basked under our international accredi-tation with the JCI, the hospital created the JCI Compliance Committee to ensure our continued adher-ence to the Commis-sion’s standards. In

the midst of our on-going mock tracer surveys, the commit-tee also recom-mended the forma-tion of task forces that would lead and guide us in making the hospital and the staff JCI-ready.

Early this year, four task forces were identified to address those stan-dards wherein our compliance should be reinforced. They are the Documenta-tion, Patient Educa-tion, Team Commu-

JCIA 2009 Task Forces

The TOT

strengthened

trust and

communication

among the

participants.

Page 4 QuIP Update

undergo Training of Trainers undergo Training of Trainers

Page 5 Vol 5 No 1

nication, and Medi-cation Safety Task Forces.

The Compli-ance Committee applied the same strategy that worked for us in 2006 – identify trainers, both among the

medical and non-medical staff, and rely on them to dis-seminate the infor-mation to the rest of the staff.

Thus, on February 7-8, 2008, a group of 50 TMC-

Continued on page 7