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Association of Companies Health Insurance Funds
13 March 2009
Prague, Czech Republic
David Jaimovich, MD
Chief Medical Officer
Joint Commission International
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Joint Commission International
Standards and Survey Process
 Identify and describe the JCI Accreditation
process
 Describe and review tracer methodology
 Discuss a hospital’s preparation for the JCI
Accreditation process
 Describe global standardization of healthcare
services through the process of accreditation
 Accreditation as part of a systems focus
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Objectives
JCI Standards
 System framework
 Checklist of all the important managerial and
clinical functions or activities
 A balance of structure, process and
outcomes standards
 Optimal but achievable expectations
 Measurable
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 Focus on patient perspective in context of
their family
Accreditation Represents a Risk
Reduction Strategy
 That an organization is doing the right
things and doing them well;
 Optimizing the likelihood of good
outcomes.
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 Thereby significantly reducing the risk of
harm in the delivery of care; and
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External, objective evaluation
Uses consensus standards
Involves the health professions
Proactive not reactive
Organization wide
Focus on systems not individuals
Stimulates quality culture in the organization
Periodic re-evaluation against standards
Strengthens public’s confidence
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Strengths of Accreditation
Accreditation Can Help:
 Enhance staff recruitment, retention and
satisfaction
 Increase chances to enter networks and new
provider arrangements
 Provide greater independence from
government oversight
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 Improve or expand sources of payment for
patient care
Accreditation Can Help:
 Build a quality measurement database
 Provide a framework to improve patient
safety
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 Provide comparison with self, others,
and best practices
Quality Improvement and Patient
Safety Programs
 Are leadership driven
 Seek to change the ethos of the organization
 Use data to focus on priority issues
 Seek to demonstrate sustainable improvement
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 Proactively identify and reduce risk and variation
Accreditation as Part of
Continuous Quality Improvement
 Accreditation is a milestone on the continuous journey of
improvement
 Establishing a permanent organizational culture of safe,
quality care is essential for sustaining improvement
 The effort is for your patients, not the certificate
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 Accreditation Standards provide a common quality language
and common set of expectations to point the way forward
Available Resources:
 JCI Accreditation Standards for Hospitals, 3rd
Edition
 Survey Process Guide (electronic version)
 Web-based training on introduction to the
international accreditation process (ISAS)
 Newsletters and publications
 print and electronic (e.g. Getting Started)
 JCI Practicum four times a year
 (Annual JCI Executive Briefings – networking
opportunity with accredited organizations)
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Starting to Prepare
Organizational leaders and managers
Introduction to accreditation philosophy and
approach
Accreditation as a quality improvement and risk
reduction strategy
Review of the standards and measurable elements
Discussion of the survey process and what to
expect
Project planning and next steps
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Begin with Education
Baseline Assessment
Conduct a detailed baseline assessment of
current adherence to the Standards and each
Measurable Element:
 Consider using ISAS as guide
 Include all areas of the organization in the assessment
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 Use knowledgeable and credible evaluators (either
internal or external consultants) who will critically and
objectively assess each area
Baseline Assessment
cont.
 Collect and analyze baseline quality data as
required by the quality monitoring standards
 Establish an ongoing monitoring system for data
collection to identify problem areas and track
progress in improvement
 Set frequency of data collection
 Analyze data
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 Examples: medication errors, hospital-associated
infection rates, antibiotic usage, surgical complications.
Action Planning
 Using the findings of the baseline assessment,
develop a detailed project plan with assigned
responsibilities, deliverables, and time frames.
 Start with priority areas established by leadership
 If available, use a software program such as MS
Project or Excel to confirm project plan in writing
 Hold leaders and staff accountable to the plan
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 Example: Revise informed consent policy, develop a new
informed consent statement, educate staff - to be completed
in two months (specify exact date)
Team Approach
 Assign oversight of each chapter of standards to
a respected champion/leader who will identify
team members from throughout the hospital
 Look for good people skills, time management
skills, and consensus building skills
 Be prepared to change as new champions
emerge, and some leaders drop out
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 Also include those who may be skeptical of the
process
Policies and Procedures
 Compile a list of all required policies and
procedures that will need development and
revision
 Be certain that your policy reflects your actual
practice, as this is one of the yardsticks the
surveyors will use to evaluate your performance
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 Hint: look for list in Survey Guide 2008
 These may take some time to get revise or develop,
undergo organizational review, and obtain final
approval
Mid-Point Strategies
 Continue to monitor your progress in meeting the
standards
 Don’t be afraid to adjust your project plan to be
more realistic – change often takes longer than
one expects
 Continue to involve as many staff as possible in
the process – make it an organizational quality
goal that you are striving to achieve together
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 Ex. Use a mini-evaluation of each chapter at regular
intervals (e.g quarterly)
Strategies That Have Worked
 Importance of physician commitment to the
accreditation process cannot be overstated
 They should see accreditation standards as framework
by which hospital processes will be improve
 Reassure physicians that accreditation is not intended
to tell them how to practice medicine!
 But it does compel them to look collectively at their
own practices and evaluate their own results
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 Care will ultimately be of higher quality and safer for
their patients
Strategies That Have Worked
Cont.
 Ask JCI for clarification with standards
interpretation – don’t waste time going down
the wrong path
 Take advantage of resources (e.g.
download electronic example policies and
plans and adapt to your organization)
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 Learn from what others have done well and
adapt the experience to the needs of your
organization
Pitfalls to Avoid
 Top leaders “support” the process, but are totally
unrealistic in what it will take to achieve it in
terms of time and resources
 Over-eager managers using the standards as a
threat rather than as a goal – can make entire
accreditation process feel punitive and
inspecting rather than motivating
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 Staff end up feeling that accreditation is extra
work for which they are not rewarded or
recognized
Final Mock Survey
 Use evaluators (internal or external consultants)
who were not involved in the baseline
assessment and preparation, who will look at
the organization with a fresh and objective eye
 Plan final actions and corrections based on the
findings of the final mock survey
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 Plan for a final “mock” or practice survey about
6-8 months in advance of the target date of the
actual accreditation survey
JCI Hospital Standards 3rd Ed.
 Standards in two sections:
 Patient-Centered Standards
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 Healthcare Organization Management Standards
JCI Hospital Standards 3rd Ed.
Cont.
 Access to Care and Continuity of Care
 Patient and Family Rights
 Assessment of Patients
 Care of Patients
 Anesthesia and Surgical Care
 Medication Management and Use
 Patient and Family Education
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Patient-Centered Standards
Anesthesia and Surgical Care
1. Organization and Management
2. Sedation Care
4. Surgical Care
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3. Anesthesia Care
1.
2.
3.
4.
5.
6.
7.
Organization and Management
Selection and Procurement
Storage
Ordering and Transcribing
Preparing and Dispensing
Administration
Monitoring
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Medication Management and Use
JCI Hospital Standards 3rd Ed.
Cont.
 Quality Improvement and Patient Safety
 Prevention and Control of Infections
 Governance, Leadership, and Direction
 Facility Management and Safety
 Staff qualifications and Education
 Management of Communications and
Information
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Healthcare Organization Management Standards
Staff Qualifications and Education
1. Planning
2. Orientation and Education
4. Nursing Staff
5. Other Health Professional Staff
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3. Medical Staff
1. Communication with the Community
2. Communication with Patients and
Families
3. Communication Between Providers
Within and Outside the Organization
4. Leadership and Planning
5. Patient Clinical Record
6. Aggregate Data and Information
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Management of Communication
and Information
Standards Content
 The standard represents the principle
 The intent describes the rationale of the
standard
 The measurable elements are the detailed
requirements from the standard and intent
that are scored
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Each JCI standard contains three
components:
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Standards Content (sample)
 Identify patients correctly at risk points
 Improve effective communication of critical
information
 Improve safety of high-alert medications
 Ensure correct-site, correct-patient, correctprocedure surgery
 Reduce the risk of healthcare-associated
infection
 Reduce the risk of patient harm from falls
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International Patient Safety Goals
Approach and Philosophy
to the On Site Survey
 A Survey is not intended to be punitive, a “got you”
exercise, or an inspection
 Surveyors will “drill down” or focus on areas where
a potential risk area is identified
 Based on common problem areas in many hospitals
 High risk or high volume services
 They have identified a vulnerable area
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 Tracer Methodology is a process of identifying
imperfections, flaws, or broken systems
On-Site Evaluation Process
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Tracer activities – patient
Tracer activities – systems
Facility tour
Special interview / issue resolution
 Feedback sessions
 Daily briefings
 Leadership exit conference
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 Opening conference
 Orientation
 Document review
 Leadership session
 Assessment activities
Is an effective evaluation method that
is used to assess a healthcare
organization’s performance of care
and the services provided as
viewed or experienced by the
patient
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Tracer Methodology
Objectives of Tracer Activity
 Assess relationships among disciplines
and important functions
 Evaluate performance of processes
provided to the patient
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 Follow entire course of care and
services provided to the patient
Types of Tracers
 Patient Tracer – Follows the patient
 Data use
 Medication management
 Infection Control
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 System Tracer – Follows the system
Conducting Tracers
 Selection of patients
 Diagnoses
 High volume
 High volume
 High risk
 Low volume
 Selection of units
 Diagnoses/procedures
 Special care
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 Procedures
Sample Patient Tracer
Hospital Setting
 Patient – Mr. Ramponi
 Surveyor
 Reviews patient record
 Notes what services and transfers occurred
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 Cardiac-surgery related diagnosis (cardiac bypass
surgery)
 Pulmonary complications (pneumonia)
Surveyor Reviews Medical Record
 Treated for diabetes and hypertension
 Recently quit smoking after 33 years
 Sent to cardiac catheterization lab for an angiogram, which revealed
5 blockages
 Put on IV heparin, nitroglycerin and beta-blocker
 Transferred to ICU
 Hypertension was an issue. So medications were adjusted to lower
his blood pressure
 Surgery for a coronary artery bypass graft was scheduled for the
next morning
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72-year old man presented to ER with chest pain
 An electrocardiogram showed signs of sinus tachycardia
 Staff administered aspirin and drew blood
 Mr. Ramponi
At Emergency Department
Communication, assessment, performance improvement, and
medication management issues.
Step 1
Surveyor speaks with ED Staff
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“A little over 2 weeks ago, Mr. Ramponi came
into the ED with chest pains and
a history
“I see
that aofcardiac catheterization was
hypertension and diabetes.necessary;
What processes
how was informed consent obtained
“You’ve said that like many
were followed for triaging and treating him?”
from Mr. Ramponi?”
heart attack victims, Mr.
Ramponi delayed seeking
help after experiencing the
first symptoms. Has your ED
conducted any performance
improvement projects to
decrease the time to begin
treatment?”
Surveyor reviews Medical Record
 Antibiotics were begun at the time of surgery
 Sent to ICU with ventilator which was removed 5 hours later
 Developed pneumonia within 2 days
 IV antibiotic was changed, but history of smoking has weakened his
lungs
 Wean from ventilator within 6 days
 Received pulmonary treatment regimen of nebulizer treatments,
incentive spirometry, and assisted cough
 Transferred to a general medical unit with telemetry after 3 days
 Scheduled to be discharged for continued outpatient rehabilitation
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 Placed on ventilator
 Triage process
 Patient assessment
 Communication prior to patient transfer
 Medication process, including for high risk
concentrated medications and IV solutions
 Communication needs for elderly patients
 Competency of medical and nursing staff in
emergency care
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Emergency Department
points of discussion
At Cardiac Catheterization Lab
Verbal orders, assessment and emergency care issues
Surveyor talks with Staff Nurse and Cardiologist
“What communication took place between
the catheterization lab and the ED before
“What
processarrived
was used
for procedure?”
ensuring
Mr. Ramponi
for his
“How didmedical
you make
certain Mr.
Ramponi
equipment
safety?”
had no allergies to the contrast medium
being used for the procedure?”
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Step 2
 Pre-procedural patient assessment
 Patient identification process
 Informed consent
 Patient privacy and confidentiality
 Infection control
 Patient monitoring during and after procedure
 Use and maintenance of equipment
 Sedation and anesthesia use and safety
 Frequency of cancellation of procedures and
reasons (Quality Improvement project)
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Catheterization Lab
points of discussion
Medication use, anesthesia care, informed consent, site verification,
emergency care issues and infection control.
“Patients undergoing bypass
Surveyor talks to the
“What
assessments
“What processes
do you
surgery
are
at increasedhad
riskbeen
Staff,
Circulating
Nurse,
Stepto3 verify that you had
performed
and
what
follow
of developing
a
surgical
site
“During open-heart
surgery,
concentrated
Anesthesiologist
information
did
you
receive
the correct patient and
infection.
What
preventive
potassium
was
used.
How
is
access
to
“Can you explain the process to
before
Mr.
Ramponi
procedure
before
youthis
measures
did
take
toarrived
help in
Surveyor also
requests
credentialling
files
for
theyou
undiluted
concentrated
electrolyte
obtain informed
consent
for Mr.surgeon.the OR?”
anesthesiologist
and cardiac
started
Mr. Ramponi’s
reduce
that
risk
for the
controlled?”
“What
do
you
do
in
the
event
of fire?”
“How
was
the
placement
Ramponi for this surgery?”
surgery?”
patient?”
of Mr. Ramponi’s
“How do you maintain this
pulmonary artery catheter
equipment? How were you
confirmed?”
trained to use it?”
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At Operating Room
At Recovery Room
Verbal orders, clinical practice guidelines and equipment management
At OR Recovery
Step 4“Following Mr. Ramponi’s
surgery, Area
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he started on an IV infusion pump
for pain management. What
checks did you perform on the
equipment before starting him on
“What guidelines
did you follow for postthe pump?”
anesthesia monitoring of Mr. Ramponi?”
“Who made the decision to discharge Mr.
Ramponi from the Recovery, OT?”
At Cardiac ICU
Communication, assessment, clinical practice guidelines,
credentialling, infection control, equipment management and
medication management
“Mr. Ramponi was receiving IV pain medication
“Was
Mr. Ramponi
restrained
while
onme where you
following
surgery.
Can you
show
ventilator?
How was
the decision
made
to
documented
Mr. Ramponi’s
pain
assessment,
“How
didRamponi
the
communicate
what
remove
Mr.
from the ventilator?”
treatment
andOR
reassessment?”
procedures took place when Mr.
Ramponi was transferred to the ICU?
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Step 5
Surveyor talks with attending Physician, ICU Nurse,
Respiratory Therapist, Infection Control Practitioner
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


Communications received from Recovery Room
Patient assessment and monitoring
Patient privacy and confidentiality
Infection control
Use and maintenance of equipment, especially clinical
alarm systems
Staff competency based on patient populations cared for in
ICU
End-of-life issues
Medication management
Handling of verbal orders
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Cardiac ICU
points of discussion
At Medical - Surgical Unit
Equipment management, patient education, rights & ethics,
discharge planning, continuum of care.
“Can you
describe
Mr. Ramponi’s
medication
protocols?”
“What
written
information
will Mr. Ramponi
receive
about his medications
process was
followed
for ordering
when“What
he is discharged
this
afternoon?
Does the patient know about his
respiratory
therapy
fortalks
Mr.
medications?
When
did you
educate
him?Cardiac
How?”
Surveyor
toRamponi?”
Staff Nurse,
Rehab Nurse,
Respiratory Therapist, Nutritionist, Patient Educator
“What
is your
plan for Mr.
“How was nutrition and
weight
management
discharge?”
education
provided
toRamponi’s
the
patient?”
“I see that
Mr. Ramponi
was
on telemetry.
How would
you explain
how the
you know if theCan
equipment
is working?
is monitored
on this
Surveyor reviews patient
patient education
materials.
system?”
Speaks with Mr. Ramponi and his wife about ongoing
education, informed consent process and the care
provided.
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Step 6
Patient Tracer
Summary
 Surveyor visits areas within the organization where the
tracer patient was physically treated.
 Surveyor might also tour other areas, e.g., laboratory and
pharmacy to explore issues such as diagnostics and
medication management.
 Surveyor could theoretically visit any location in the
organization if it related to the care provided to the patient,
including registration, dietary dept, physical therapy,
outpatient pharmacy, etc.
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 Wherever the surveyor is, he/she is assessing numerous
standards.
Infection Control Assessment
 Assess processes to identify, prevent & manage
healthcare acquired infections throughout organization
 Uses information obtained from other assessment
activities
 Facility tour
 Tracer activities to diagnostic services
 Document review
 Open & closed record review activities
 System tracers activities, e.g. Pharmacy
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 Tracer activities to inpatient / outpatient care areas
Infection Control System Tracer
Goals
Surveillance data
Analysis
Prevention & control strategies
Areas of concern & action
Outbreaks
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Group discussion
Infection Control System Tracer
Cont.
 Tracing infection control processes across the
organization
 Example 1: a TB patient admitted through
Emergency to Medical Unit to Radiology to
Medical Unit to Rehab
 Example 2: an immuno-compromised patient
admitted through Emergency to Oncology to
Intensive Care Unit to Medical Unit to End-of Life care unit.
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 Focused tracer
Data System Tracer
 20 Minute presentation – optional
 Required measures and sustained
improvements reviewed
 Steps – selection, collection, analysis,
dissemination/transmission, action, monitoring,
sustained improvement
 How data is used throughout the organization
 Short surveys
 Include medication management and infection
control data issues
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Group Discussion
Benefits of Tracers
For Patients
 Improves Safety and Quality of care
 Improves patient flow
 Encourages team building
 Creates systems thinkers
 Creates a better understanding of roles
For Organizations
 Reduces risk to patients
 Increases patient satisfaction
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For Staff
Tracer Methodology
You can learn more
than in 20 hours of
chart review
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in 8 hours of tracing
Follow-up Process
 Focused survey is required within 6 months for
standards that require surveyor observation, staff
or patient interviews, or the inspection of the
physical facility
 If both are required, written report is reviewed at
time of focused survey
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 Written report is required within 6 months for
standards that require a plan, policy or procedure,
or documentation
 A required follow-up focused survey has not
resulted in acceptable compliance with the
applicable standards and/or International Patient
Safety Goal requirements
 JCI withdraws its accreditation for other reasons
 Organization voluntarily withdraws from the
accreditation process
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Accreditation Denied
After the Survey
 Celebrate the success!
 Let your patients know what
you have achieved
 May need to work on areas for improvement
and submit a follow-up progress report to JCI
 Maintain the momentum from the survey –
establish an ongoing system of standards
compliance and survey readiness
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 Take a week off and then start again
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The Globalization of Healthcare
JCI
Why International Standards?
 JCAHO standards filled with U.S. and state laws and
regulations
 JCAHO standards contain many “political” considerations
such as requirements for an organized medical staff
 JCAHO standards rely on NFPA requirements for facility
review with no international version of those
requirements
 JCAHO standards have a U.S. cultural overlay for patient
rights
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 JCAHO standards use U.S. jargon such as “advanced
directives”
JCI’s Commitment to Globalization
 International Board Members Mandated
 International Standards Committee
 Regional Offices
 Regional Advisory Councils
 WHO Collaborating Centre for Patient Safety
Solutions
 International Standards
 International Patient Safety Goals
 ISQua Accredited
 International Surveyors
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 Asia Pacific
 Europe
 Middle East
Comparisons
 International standards contain many of the
quality control and quality leadership ISO
9000 criteria
 International standards include the criteria of
the European (EFQM) and U.S. (Baldridge)
quality award
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 International standards include all topics from
Joint Commission standards including newer
ones related to pain management, and care
at the end of life
JCI Standards Address Key Issues
Relevant to Globalization
Truth in admission policies
 Patients are admitted for care only if the
organization can provide the necessary services
and settings for care.
 There is an established framework for ethical
management including marketing, admissions,
transfer, and discharge, and disclosure of
ownership and any professional conflicts that may
not be in the patients’ best interests.
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 At admission patients and families are provided
information on the proposed care, expected
results of care, and expected costs.
JCI Standards Address Key Issues
Relevant to Globalization
Professional Competence
 The credentials of medical staff members
are reevaluated at least every three years to
determine their qualifications to continue to
provide patient care services in the
organization.
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 The organization has an effective process to
authorize all medical staff members to admit
and treat patients and provide other clinical
services consistent with their qualifications.
Accreditation as Part of a
Systems Focus
 A focus on systems examines
conditions where staff work and targets
strategy development to ensure that
there are fewer errors and risk is
reduced
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 Focusing on staff would mean reviewing
the mistakes of individuals
 Errors need to be seen as
consequences, not as causes
 The best professionals can make the
worst mistakes
 Errors tend to have recurrent patterns
 Organizations should review high
reliability systems and anticipate the
worst possibilities
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Accreditation as Part of a
Systems Focus
Accreditation as Part of a
Systems Focus
Furthermore, increasing the
consistency of care provision will
decrease the frequency of errors.
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If systems are designed with the full
understanding that we do mistakes,
and nobody is perfect, errors should
occur less frequently.