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JCI Frequently asked Questions By Dr.Mahboob ali khan Phd

The Joint Commission is a Chicago-based organization which accredits 15,000

hospitals in the United States. The Joint Commission International (JCI) is its

subsidiary which accredits hospitals outside the U.S. As the medical travel trend

grows, JCI accreditation is becoming an important benchmark for quality

standards.

Patients are concerned about ensuring quality and safety when traveling

abroad for medical care. JCI accreditation sounds like a logical way of

screening unknown hospitals. Can you explain how JCI accreditation

ensures the consumer of quality and safety?

The need to focus on safety is at the center of all of JCI accreditation activities.

All accreditation standards support quality and safety efforts, whether a person

is seeking services from a JCI–accredited hospital, ambulatory care

organization, clinical laboratory, across the care continuum, at a medical

transport organization, or via a JCI–certified disease-specific care provider.

More specifically, standards related to safety and to reducing adverse events

provide a framework for helping to reduce the risk to and ensure the safety of

individuals who receive care, treatment, and services in a health care

organization.

Your question referred to a consumer’s ―screening‖ process, and to that point,

consumers ―screen‖ in the effort to avoid risking their good health in a

substandard health care facility. JCI accreditation is essentially a risk-reduction

activity. Compliance with JCI accreditation standards is intended to reduce the

risk of adverse outcomes and improve safety. JCI standards emphasize the need

to consider risks and to take action to reduce risks before an unwanted event

affects patients or staff. This focus on reducing risks to patients and staff can be

seen in both JCI’s patient-related standards and organization-related standards.

JCI is a subsidiary of the Joint Commission, which has accredited 15,000

U.S. hospitals. How do the international accreditation standards differ

from the U.S. standards?

Development of our international accreditation standards is actively overseen by

a global task force, whose members were drawn from each of the world’s

populated continents. Although many of the JCI standards are similar to those

of the United States–based Joint Commission, U.S. standards reflect many local,

state and national laws which do not apply internationally. JCI standards are

broader-based in order to respect country and cultural differences.

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With each revision, though—especially in the upcoming third edition of our

hospital standards, which will be published in July 2007 and enforced January

2008—international standards are becoming more challenging, rapidly closing

the gap between JCI and U.S. standards.

There are currently about 110 hospitals with JCI accreditation. Why are

there relatively few hospitals accredited by JCI? Is it because very few

hospitals in the world meet your standards? Or is it because the

accreditation process is expensive?

JCI’s hospital accreditation numbers are lesser than those of The Joint

Commission and there are two major reasons for the disparity:

First, JCI is in its infancy when compared The Joint Commission’s 56-year

tenure as an accrediting body. JCI launched its accreditation program in 1999

and has steadily built on its cadre of participating organizations each year.

We’re not where we want to be yet, but we’re comfortable that we’re moving

rapidly in the right direction.

Second, JCI accreditation is voluntary, not mandatory. Organizations choose

JCI accreditation not because they have to—it’s because they want to. Our

accredited organizations want an external quality evaluation model. They want

to bring the common understanding of key quality and patient safety concepts

such as good medication management, infection control, facility management,

community disaster planning, and other risk reduction strategies to their

organization. And, finally, they know that providing the highest quality and

safety of health services for their patients makes not only good management

sense, but good business sense.

What must a hospital typically do in order to get ready for an initial JCI

inspection? How long does it generally take to prepare for this?

We tell organizations that preparing for their initial JCI accreditation survey is

likely to take 12 to 24 months. Leaders who insist on setting an achievable time

frame communicate the importance of taking a steady, comprehensive approach

to accreditation. This approach seeks systems improvements that require

thoughtful analysis to establish, implement, and sustain. Organizations perform

a baseline assessment, measure the gap between their performance and JCI

standards, and then spend the ensuing months refining their policies and

procedures to make certain they are in compliance. Rushing through the

accreditation preparation misses the point that quality and safety standards must

become part of routine operations in order to have a meaningful, lasting impact

that improves quality and safety.

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Having said that, it is also important to note that once an organization has gone

through a survey and has been accredited by JCI, we encourage—and expect—

the organization to strive for continuous standards compliance; that is, to always

be ready for a survey. Organizations that are continually performing in the

patient’s best interests don’t have to prepare for a survey; they’re ready all day,

every day.

Renewal of accreditation is every three years. Are there any spot checks in

the interim?

There are no ―spot checks‖ in the truest sense of those words, but there are

reasons for JCI to return to an organization sooner than the triennial survey.

First, we have begun performing ―validation surveys‖ in all organizations

within 60 to 180 days of all initial or triennial re-surveys. These validation

surveys are free to an organization and do not impact the organization’s

accreditation decision, but they do provide JCI with immediate feedback on the

validity of the survey’s results.

Also, if during an organization’s survey we find standards not met, we will

respond by scheduling what we call a ―focused survey‖ for that organization. A

focused survey is exactly as it sounds—a concentrated examination of only the

areas in which an organization does not meet standards. If, in the view of the

JCI Accreditation Committee, the organization’s performance during the

focused survey meets standards, the organization is then deemed accredited.

Does JCI collect safety data (mortality rates, hospital acquired infections,

etc.) for international hospitals, benchmarked to U.S. averages? If not, does

any other organization collect such information so that consumers can

check the track record of an international hospital?

We do collect data and we intend to do even more collection in the future. JCI

introduced the Hospital Quality Indicator project in January 2006 in response to

accredited hospitals expressing an interest in performance measurement to

support quality improvement efforts and to provide a valid base for local,

national, and international comparisons. This initiative focuses on data

collection for seven standardized performance indicators currently in use in the

United States:

For Acute Myocardial Infarction:

Measure 1. Aspirin at Arrival

Measure 2. Aspirin Prescribed at Discharge

Measure 3. Angiotensin Converting Enzyme Inhibitor or Angiotensin Receptor

Blocker for Left Ventricular Systolic Dysfunction

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Measure 4. Beta Blocker Prescribed at Discharge

Measure 5. Beta Blocker at Arrival

For Heart Failure:

Measure 1. Left Ventricular Function Assessment

Measure 2. Angiotensin Converting Enzyme Inhibitor or Angiotensin Receptor

Blocker for Left Ventricular Systolic Dysfunction

Measures are assessed for interpretability, applicability, and usefulness to the

international community, feasibility of data collection, data collection effort,

and overall resource use. In addition to indicator evaluation, assessment of the

potential limitations related to electronic data transmission, preferences for data

feedback mechanisms, expectations regarding support services, and data use by

JCI in accreditation activities are also being addressed. Evaluation findings are

being used to assist in planning for a voluntary, automated, standardized

indicator set.

Accredited hospital organizations, which volunteer to participate, collect

indicator data using tools provided by JCI. These tools include a data dictionary,

data elements, and Indicator Information Forms for the seven indicators.

Although these data are not currently available to the public, we envision a

future public-reporting scenario similar to The Joint Commission’s Quality

Check Web portal, which provides public access to United States hospitals’

performance on The Joint Commission’s National Patient Safety Goals and

National Quality Improvement Goals. The latter goals allow hospitals to report

quarterly on key quality of care indicators in up to five treatment areas: heart

attack, heart failure, community acquired pneumonia, pregnancy and related

conditions, and surgical infection prevention.

In your presentation, you mentioned that JCI has a policy about “truth and

admission.” Could you elaborate?

Patient safety has made significant strides in some parts of the world during the

past 10 years, thanks to a willingness to acknowledge that adverse events occur

in health care and that a systematic approach must be employed to reduce the

very real risk of patient harm. We feel that honesty from all parties—caregivers,

patients, and patients’ families—is an essential aspect of safe heath care. Just as

caregivers expect patients to provide honest answers in order to discern the

proper course of the patient’s care, patients and their families have the right to

honest communication with caregivers to help the patients or loved ones make

informed decisions.

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There is a growing body of research indicating that patients and families will

forgive medical errors more readily if the caregiver will admit them. Likewise,

with increased public reporting of medical errors—in the United States, The

Joint Commission has required its accredited organizations to report their

adverse events since 2001, which are then compiled into what is called the

Sentinel Event Database—and infection control data and the like, there is a

positive trend toward more open and honest communication between caregiver

and patients. We agree wholeheartedly, and our standards reflect this. One JCI

hospital standard states that the hospital must inform patients and families about

how they will be told about the outcomes of care and treatment, including

unanticipated outcomes, and who will tell them. With that sort of

communication model in place, patients and families can be assured that they

From a consumer’s (or patient’s) standpoint, what is the difference

between JCI accreditation and other accreditations, such as ISO? As long

as a hospital has some sort of accreditation, is that a reasonable assurance

of quality and safety?

ISO is not truly a health care accreditation body; it is more of a federation of

national standards bodies. While concepts within ISO requirements may apply

to health care, many of the concepts do not easily apply, especially to the

clinical aspects of health care. ISO requirements are more focused on

manufacturing, and ISO standards concentrate on adhering to a specified

process of quality management designed to consistently produce a product (or

service) that meets pre-established specifications and on assessing that

conformity.

Although I think it’s safe to say that some sort of accreditation is better than

none, we are convinced that JCI’s accreditation process provides the best

organizational available path to health care excellence.

What is the function of JCI’s Center for Patient Safety?

The Joint Commission International Center for Patient Safety (ICPS) is virtual

organization that allows The Joint Commission, JCR, and JCI to further its

patient safety mission: to continuously improve patient safety in all health care

settings.

The Center’s Web site is a valuable online resource for health care

professionals, patients, and their families. Nearly 1,000 articles and Web links

covering topics ranging from adverse events and product safety to the National

and International Patient Safety Goals are available for download, free of

charge. A monthly electronic newsletter, Patient Safety Links, is available at no

cost to subscribers.

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The Center is also the operational arm for the World Health Organization

(WHO) Collaborating Centre on Patient Safety, the world’s first such

organization dedicated solely to patient safety. The Collaborating Centre

focuses worldwide attention on patient safety solutions and best practices with

the intent of reducing safety risks to patients, and it helps coordinate

international efforts to share, develop, and disseminate these solutions as

broadly as possible.

Tell me more about JCI's collaboration with the WHO?

Since its launch in August 2005, the WHO Collaborating Centre for Patient

Safety has been building an international network to identify, evaluate, adapt

and disseminate patient safety solutions worldwide. The Collaborating Centre is

identifying existing solutions that would be applicable to a wide variety of

countries and health-care settings.

Patient safety solutions are any system design or intervention that has

demonstrated the ability to prevent or mitigate patient harm stemming from

health care processes. Solutions disseminated by the Collaborating Centre will

be evidence-based, and presented in a standard format.

In order to facilitate the accurate identification of solutions and the adaptation of

solutions to different needs, an international steering committee composed of

recognized leaders and experts in patient safety was convened. At the inaugural

meeting of the International Steering Committee in June 2006, the following

nine solutions were prioritized for further development:

1. Look-alike/Sound-alike Medications

2. Patient Identification

3. Hand-Off Communication

4. Wrong Site, Wrong Procedure, Wrong Person Surgery

5. High-Concentration Medications

6. Medication Reconciliation

7. Catheter and Tubing Misconnections

8. Needle Reuse

9. Hand Hygiene

Three Regional Advisory Groups were also established to review the priority

draft solutions and provide feedback on how the solutions need to be adapted

for different regions of the world. A large international field review via

electronic survey was undertaken to determine the relevance, adaptability,

feasibility, and barriers to acceptance of the solutions in different regions of the

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world. The field review audience includes leading patient safety entities,

accrediting bodies, Ministries of Health international health professional

associations, and WHO and Joint Commission International network of

contacts. The target date for dissemination of the initial set of Solutions is May

2007.

Another one of the exciting programs spawned through the WHO Collaborating

Centre on Patient Safety is the ―Action on Patient Safety (High 5s) Initiative," a

seven-country collaborative project that leverages the implementation of five

standardized patient safety solutions to prevent avoidable catastrophic events in

hospitals. The overall goal of the initiative is to achieve significant, sustained,

and measurable reduction or elimination of five highly prevalent patient safety

problems in selected hospitals worldwide over a five-year period—hence ―High

5s.‖

The initiative builds on the partnership established by the Commonwealth Fund

with Australia, Canada, New Zealand, the United Kingdom, and the United

States of America, and the more recent expansion of this international program

to include Germany and The Netherlands.

The solution areas selected for the High 5s initiative were drawn from a broader

set of patient safety solutions that are being developed by the WHO

Collaborating Centre for Patient Safety for distribution to all of the WHO

member nations later in 2007. These include:

1. Prevention of patient care hand-over errors

2. Prevention of wrong site/wrong procedure/wrong person surgical errors

3. Prevention of continuity of medication errors

4. Prevention of high concentration drug errors

5. Promotion of effective hand hygiene practices

The Collaborating Centre will work with the participating countries to refine the

current draft solutions through the development of standardized operating

protocols similar to those used in high reliability industries such as aviation and

nuclear energy.

We are excited about the innovative programs we have developed with WHO to

date and we are open to more such alliances with WHO in the future.

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Can you explain what ISQua is, and how your role there relates to JCI?

ISQua is The International Society for Quality in Health Care, and, simply put,

is the ―accreditor’s accreditor.‖ I’m proud of my role with ISQua and am so

convinced of that organization’s value to the health care quality issue that JCI is

currently undergoing ISQua accreditation. ISQua’s mission and ours are

similar—excellent health care delivery for everyone—and we support that

undertaking completely.

International Accreditations

"Driven by the rise in medical tourism, Asian healthcare organisations are fast

embracing international accreditations and the awareness level is on the rise.

Joint Commission International (JCI), the leading international accreditation

body, has emerged as the gold standard in this area. It has already accredited 30

hospitals in the Asian region. JCI has also set up its first international office in

Singapore recently.

1. What has been the response so far from Asian Hospitals to your

accreditations? How do you view the demand for accreditations from Asia

going forward?

I think the response so far has been very strong in Asia. Driven by the response

JCI is opening its first Asia Pacific regional office in Singapore. Also, the

hospitals are keenly interested in learning about issues like quality

improvement, patient safety, Infection control or looking at how they can

improve their care, for example, in the area of disease management, so the

response really is strong. A recently held five-day practicum at Singapore was

fully booked about six weeks in advance! This shows that there is a very strong

interest in education about quality standards in Asia. Going forward, I think the

demand for accreditations will continue to be very strong. For one thing it’s

such a huge region and there is a lot of activity - both at the public and private

healthcare centres. And as we know, interest in healthcare tourism has really

sparked off an interest in looking at some kind of distinction amongst hospitals.

I think that the interest in accreditation will only continue to rise in the future.

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2. Is your strategy for tapping the Asian market different from that for

other markets in developed countries such as USA?

Asia, as I mentioned earlier, is a very broad and diverse region. In terms of

strategy, JCI has just tried to be responsive to organizations that have expressed

interest in some way working with us. It could be that they are interested in

accreditations – this could be on a national level as well. For example, on July

31, 2006 JCI signed a memorandum of understanding with the government of

China to work together in areas such as accreditations, quality improvement,

patient safety and standards. Again, we have a very strong relationship with the

Ministry of Health in Singapore and with some private associations in India. In

Hong Kong the government’s priorities are, looking at infection control and

readiness for hospitals to handle major disease outbreaks, there may be very

different issues for example in Malaysia and other countries.

I think we try to respond to the needs of the region. It’s often at a country level

dealing with issues that may be going on over there.

3. Do you think that the accreditations accorded to a few hospitals in the

region, should generate peer pressure among the hospitals in the region?

Well, I think that has already happened. In the unfolding of that scenario, JCI

has been more of an observer. I think it is certainly true that almost any where

in the world now, including the United States, healthcare is a very competitive

market and as I mentioned before, particularly in the area of health tourism,

where a hospital may be interested in attracting patients from outside its local

market, definitely an accreditation is a way to distinguish for a hospital. Also a

part of the competition is looking at working with multi-national corporations.

For example, some large multi-national corporations are very interested in

knowing where they should be sending their employees around the world for

treatments.

4. What do you think about the incentives being offered by many American

companies for getting treated in low-cost destinations like those in Asia?

There is sort of a growing movement among US companies. It is still relatively

small.

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5. What are the key pre-requisites for a hospital to get accredited

successfully and retain it then on?

Well, one is that the hospital needs to have high level of commitment at the

leadership level. I think that is perhaps the most important variable for a

hospital to be able to be accredited. And the hospitals should also subject their

processes to a very critical self-evaluation. They may break those processes up

in terms of patient care or the safety of the facility or information management,

but the standards really look at the overall framework of almost every aspect of

the hospitals operations. So, it has to be the whole organization. It can’t just be

one person or one department (the quality department) that’s told to look at this

accreditation. This is something that ensures that the accreditation is sustained.

And that starts with the leadership.

6. Given the industry demographics of the Asian hospitals (most of which

are in the developing nations), do you think it is worthwhile for a mid-size

Asian hospital to go for accreditation in cost-benefit terms?

That’s probably an individual decision for each hospital. But I have seen it in

organizations with limited resources that JCI accreditation is still achievable and

reach the standards. The way JCI has designed the standards we want it to be a

very high level of care, but that could be how the organization meets the

standards could allow some creativity. And I think ultimately by improving care

and, for example, by reducing risks for patients it is a benefit in terms of cost

benefit ratio. For example, there will be lower infection rates, better retention of

staff, a general reduction in errors. That is also something that over a period of

time we would like to study to see the specific improvements going forward

with an organization. It would certainly be worthwhile in the long term for a

smaller organization to be accredited.

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7. What changes did Asian hospitals experience post-accreditation?

The difference is not so much to get the accreditation award, that’s the final step

of the journey, but for the organization overtime. It takes about one to two years

for an organization to become accredited. We have seen that the accreditation

has made a lot of difference in terms of important aspects of care. Some of the

feedback that we have got from hospitals in Asian region – and this is true about

the hospitals around the world –is significant reduction in medication errors,

reduced infection rates in hospital-acquired infections, improved pain

management, and also a much developed system of assuring the competence

level of the staff.

It’s interesting to note that some organizations have reduced medication errors

by almost 75% to 80 %. That obviously translates into a better patient

experience.

8. What challenges do hospitals face while preparing for accreditation and

post accreditation?

I think it is important to be aware of what it takes to do this. It is not just ―we’ll

get ready for getting the accreditation‖ and then getting back to business as

usual. It is really about transforming an organization and its processes. To really

implement the processes and the policies, staff training is needed to ensure that

this is sustained and I think the organizations that do this well really get to see a

huge difference in the way they manage their hospitals. And this is a challenge;

I mean that’s not something that is so easy to do. It takes strong commitment

from the top management and particularly for some of the physician leaders.

The physicians especially need to be very much on board with the entire

process.

But while the top management needs to be fully committed, the role of the other

staff cannot be ignored. We believe that their role is absolutely essential

because so many of the standards touch on aspects of the patient rights,

infection control, patient assessment and that’s actually by design –the way we

have set up the standards. It is not like chapters of what nurses do or the staff

does. It really is about taking a patient outward approach. And that is going to

impact anybody who is involved in the running of the hospital or whose work

interfaces with the patient’s stay at the hospital.

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9. What effect does the implementation of accreditation standards has on

the staff?

What we have heard from the organizations around the world, especially if this

is done in a very positive way, as something like the entire organization is

striving for, is that this can be enormously inspiring for the organization and

they can take a lot of pride in things like team building. Again it’s the role of

leadership to make it that way, and not really doing it because somebody else is

doing it but because we think that it’s the right thing to do.

10. What is your message to the hospital directors of Asia?

We strongly believe that accreditations have been a very valuable organizing

framework for looking at quality and patient safety and it demonstrates

commitment to international standards to improve healthcare quality and patient

safety. And JCI would encourage hospitals to go for the JCI or any other

accreditation program and to really look at it as a management tool to monitor

the operations on an ongoing basis. JCI would like very much to work with the

hospitals in Asia in a supportive way and help them to understand the standards

and help them to implement them by providing more education in the region

which was emphasized by the Singapore Practicum with more to follow in

countries like India, China and elsewhere in the region.