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Karen H. Timmons President and Chief Executive Officer Joint Commission International Association of Companies Health Insurance Funds 13 March 2009 Prague, Czech Republic © Copyright, Joint Commission International Joint Commission International: An Overview – To improve the safety and quality of care in the international community through the provision of education, publications, consultation, evaluation, and accreditation services 2 © Copyright, Joint Commission International Mission of Joint Commission International – “So I am called eccentric for saying in public that hospitals, if they want to be sure of improvement, – Must find out what their results are. – Must analyze their results, to find their strong and weak points. – Must compare their results with those of other hospitals. – Must welcome publicity not only for their successes, but for their errors.”[1] 3 © Copyright, Joint Commission International Ernest A. Codman: End Result Theory – “Encourage those which are doing the best work, and to stimulate those of inferior standard to do better.” 4 © Copyright, Joint Commission International The American College of Surgeons described the need for standardization of hospitals through accreditation as the need to: The Joint Commission 5 © Copyright, Joint Commission International – An independent, non-profit, nongovernmental agency – Accredits over 15,000 health care organizations in the United States The Joint Commission standards: – Are filled with U.S. and state laws and regulations – Include many “political” considerations such as requirements for an organized medical staff – Use American jargon such as “advanced directives” – Rely on National Fire Protection Association requirements for facility review–no international version of these requirements – Have a U.S. cultural overlay for patient rights 6 © Copyright, Joint Commission International Why International Standards? – – – – – – – – – – Brazil Czech Republic Germany Italy Poland Portugal P.R. of China Republic of South Africa Saudi Arabia U.S.A. 7 © Copyright, Joint Commission International Standards Subcommittee: How We Get Stakeholder Input –Arabic –Brazilian Portuguese –Chinese –Czech –Danish –European Portuguese –German –Greek/Cyprus –Italian –Korean –Japanese –Spanish –Turkish 8 © Copyright, Joint Commission International JCI Hospital Standards Translations – – – – – – International Board of Directors International Accreditation Committee International Standards Committee Regional Advisory Councils Four International Offices International translations of many products 9 © Copyright, Joint Commission International International Structure Offices – Headquarters – Oak Brook, IL, USA – Europe – Ferney-Voltaire, France (edge of Geneva) – Milan, Italy (Project Office) – Middle East – Dubai Health Care City – Asia Pacific – Singapore 10 © Copyright, Joint Commission International – International – Asia-Pacific – Europe – Middle East – Provide advice and counsel to JCI management about standards and patient safety initiatives – Guidance on regional or cultural adaptations 11 © Copyright, Joint Commission International Regional Advisory Councils – BQS – Danish Institute for Patient Safety – Danish Institute for Quality and Accreditation in Healthcare (IKAS) – European Parliament – European Society for Quality in Healthcare (ESQH) – Fundación Acreditación Desarrollo Asistencial – Georgian Alliance for Patient Safety – Haute Autorité de Santé (HAS) – Health Care Quality Indicator Project – HOPE (European Hospital Federation) – International Hospital Federation – International Pharmaceutical Federation (FIP) – The Karolinska Institute – Ministry of Health, State of Israel – Ministry of Health, Turkey – National Patient Safety Agency – Socialstyrelsen – Swedish Medical Injury Insurance – WHO 12 © Copyright, Joint Commission International European Regional Advisory Council – Global knowledge disseminator of quality improvement and patient safety – Non-profit affiliate of the Joint Commission – 236 accredited organizations in 35 countries – Commitment to partnering with NGOs, HCOs, etc. – ISQua-accredited – WHO Collaborating Centre for Patient Safety Solutions 13 © Copyright, Joint Commission International JCI Today 14 © Copyright, Joint Commission International International Accreditation Programs Accredited Hospitals in Czech Republic 15 © Copyright, Joint Commission International • Central Military Hospital • Institute of Hematology and Blood Transfusion • Na Homolce Hospital • 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 • Usually a voluntary process 16 © Copyright, Joint Commission International Accreditation – A Definition – The U.S., Canada, and Australia have the oldest accreditation systems – In Europe, Germany, France, Ireland, and Spain have new accreditation systems – In Asia, China, Thailand, and Malaysia are developing national accreditation programs – The WHO, World Bank, and development banks recognize and endorse the accreditation model – The International Society for Quality in Health Care (ISQua) accredits accrediting bodies 17 © Copyright, Joint Commission International Accreditation: A World Trend Common Core of Health Care Accreditation Around the World Administered by a recognized body • Establishes and publishes standards • Conducts objective on-site evaluations • Publishes accreditation decision • Consensus on standards of quality and safety • Professionals serve as the external evaluators Focus is on continuous improvement 18 © Copyright, Joint Commission International Professional involvement • Maximize quality/minimize safety risk • Improve patient care processes and outcomes • Enhance patient safety • Strengthen the confidence of patients, professionals, and payors about the organization • Improve the management of health services • Enhance staff recruitment, retention, and satisfaction • Provide education on better/best practices 19 © Copyright, Joint Commission International What is Accreditation Intended to Accomplish? Increasing Requests for Ensuring Quality and Safety for Medical Travel • International Medical Travel Association issued position paper advocating that international health care organizations be held to high standards set by recognized accreditation authorities1 • American Medical Association adopted guiding principles on medical tourism2 • Increasing exposure in international trade journals highlighting the need to research quality when considering medical travel3 • Deloitte study mentions JCI in particular in reference to patients’ increasing concerns about quality in international hospitals4 20 © Copyright, Joint Commission International – Outline steps for care abroad for consideration by patients, employers, insurers, and third parties – Require patients to be made aware of their legal rights and have access to physician licensing and facility accreditation Accreditation 21 © Copyright, Joint Commission International – Assesses the capability of an organization to provide good results International Accreditation Philosophy – Maximum achievable standards – Patient-centered – Culturally adaptable – Process stimulates continuous improvement 22 © Copyright, Joint Commission International Joint Commission International Accreditation The Accreditor’s Tools Standards Evaluation Methodology Patient Safety Goals and Tools Data on Performance and Benchmarks Education 23 © Copyright, Joint Commission International – A system framework – Address all the important managerial and clinical functions of a health care organization – Focus on patients in context of their family – A balance of structure, process, and outcomes standards – Set optimal, achievable expectations – Set measurable expectations 24 © Copyright, Joint Commission International Standards – The heart of any accreditation program is the standards upon which all else is based – the evaluation methodology, decision process, evaluator training, and other operational elements – Thus, a standard must be “good”, not just on the day the standard is written, but on a continuing basis 25 © Copyright, Joint Commission International Standards are Continually a “Work in Progress” – Standards have multiple dimensions and thus have multiple sources of evidence – Policy – document review – Knowledge – staff training logs, interviews with staff – Practice – clinical observation, patient interviews – Documentation of practice – open and closed record review – A good standard permits a convergent validity scoring process – all surveyors evaluating all types of evidence and reaching one score 26 © Copyright, Joint Commission International Evidence of Performance is Available Joint Commission International Standards – Patient-Centered Standards – 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 27 © Copyright, Joint Commission International – Organized Around Important Functions JCI Standards, continued – Organization Management Standards – Quality Improvement and Patient Safety – Prevention and Control of Infections – Governance, Leadership, and Direction – Facility Management and Safety – Staff Qualifications and Education – Management of Communication and Information 28 © Copyright, Joint Commission International – Organized Around Important Functions – Set of components that work together toward common goal – Evaluation of how - and how well - the organization’s systems function – Addresses interrelationships of elements – Translates standards compliance issues into potential vulnerabilities as far as patient quality and safety 29 © Copyright, Joint Commission International Patient Tracer: Systems Analysis – Represent proactive strategies to reduce risk of medical error and reflect good practices proposed by leading patient safety experts – Incorporating these new tools into our accreditation requirements is a significant step – Organizations taking responsibility for using the IPSG to foster an atmosphere of continuous improvement is even more important 30 © Copyright, Joint Commission International International Patient Safety Goals and Tools 1. Identify patients correctly 2. Improve effective communication 3. Improve the safety of high-alert medications 4. Ensure right-site, right-patient, right-procedure surgery 5. Reduce the risk of health care-associated infections 6. Reduce the risk of patient harm from falls 31 © Copyright, Joint Commission International JCI International Patient Safety Goals JCI’s Measurement Strategy Accreditation is continuous Accreditation status publicly disclosed Complements existing standards requirements International comparisons Meets needs of multiple stakeholders Develop and identify measures that address clinical and managerial dimensions – Need for and rigor of data validation – Measurement system supported by IT platform – JCI currently has 20 performance measurement requirements 32 © Copyright, Joint Commission International – – – – – – © Copyright, Joint Commission International 33 • Pilot program addressing international clinical cardiac indicators • Enables hospitals to evaluate the current status of their coronary artery bypass graft (CABG) and valverelated surgery risk-adjusted mortality rates • Encourages hospitals to implement and measure rates of improvement using the New York State Department of Health (NYSDOH) Cardiac Surgery Reporting System (CSRS) as a model 34 © Copyright, Joint Commission International International Cardiac Surgery Benchmarking (ICSB) Project • Participating hospitals will get information to help them improve quality of care and assess a patient’s risk factors before cardiac surgery • Multi-site and multi-country use of the ICSB assessment and reporting tool to guide organized quality improvement and benchmarking efforts • Long-term goal–to improve the outcomes of cardiac surgical procedures in participating organizations 35 © Copyright, Joint Commission International ICSB Project Objectives – – – – – – – – – – – Help Prevent Errors in Your Care Help Avoid Mistakes in Your Surgery Information for Living Organ Donors Five Things You Can Do to Prevent Infection Help Avoid Mistakes With Your Medicines What You Should Know About Research Studies Planning Your Follow-up Care Help Prevent Medical Test Mistakes Know Your Rights Understanding Your Doctors and Other Caregivers What You Should Know About Pain Management 36 © Copyright, Joint Commission International Speak Up™ – Sentinel Event database collects data from accredited organizations on errors that have occurred – Information in database led to the publication of Sentinel Event Alert, published by The Joint Commission – Sentinel Event Alerts highlight significant risk areas in care – Offer suggestions and recommendations for mitigating risk – Latest Alert focuses on information technology 37 © Copyright, Joint Commission International Sentinel Event Database Sentinel Event Experience to Date 741 698 631 492 442 341 218 212 189 175 132 113 86 85 85 992 Events of wrong site surgery Inpatient suicides Operative/post op complications Events relating to medication errors Deaths related to delay in treatment Patient falls Assault/rape/homicide Retained foreign objects Deaths of patients in restraints Perinatal death/injury Transfusion-related events Infection-related events Deaths following elopement Anesthesia-related events Fires “Other” = 5632 RCAs 38 Client name/ Presentation Name/ 12pt - 38 © Copyright, Joint Commission International Of 5632 sentinel events reviewed by the Joint Commission, January 1995 through December 2008: – That an organization is doing the right things and doing them well; – Thereby significantly reducing the risk of harm in the delivery of care; and – Optimizing the likelihood of good outcomes. 39 © Copyright, Joint Commission International Accreditation Represents a Risk Reduction Strategy 40 © Copyright, Joint Commission International The Value and Impact of Accreditation – What is the evidence that – Accreditation improves quality and safety of care? – High quality lowers cost of health care? – The cost of implementing accreditation standards is worth the achievable benefit? 41 © Copyright, Joint Commission International Impact of Accreditation – The process of Joint Commission International accreditation has set many of the fundamental principles that guide health care organizations today – Many of these principles are routine in health care today but were revolutionary in their time 42 © Copyright, Joint Commission International Impact of Accreditation (cont’d) Medical Records • First required in 1917, many considered the medical record unnecessary • Today the medical record is inarguably the central point of information gathering for treatment decisions, research, patient monitoring, outcomes measurement, and even billing 43 © Copyright, Joint Commission International Impact of Accreditation: Some Examples Infection Control Programs – In the mid-1950s, patients, especially surgery patients and newborns, acquired infections in epidemic proportions – In the 1950s, hospitals were required to appoint infection control committees to direct activities aimed at curbing epidemics of infections – Infection control programs were created that reduced the spread of devastating infectious agents 44 © Copyright, Joint Commission International Impact of Accreditation: Some Examples Impact of Accreditation: Some Examples Fire Safety – Non-smoking standards for hospitals were developed due to the adverse effects of passive non-smokers and significant fire hazards – Protects patients from a life or death they would not have wished – Requires organizations to establish Do-Not-Resuscitate (DNR) standards and request an advance directive from each patient so the individual’s wishes can be documented in the patient chart – In the 1980s only 20% of hospitals addressed this issue; since the implementation of the standard, nearly 100% of accredited organizations are in compliance with the standard 45 © Copyright, Joint Commission International Advance Directives – JCI has conducted descriptive research with a sample of accredited hospitals to determine the value of accreditation – Accredited hospitals report significant improvements in: – Leadership – Medical records management – Infection control – Reduction in medication errors – Staff training and professional credentialing – Improved quality monitoring 46 © Copyright, Joint Commission International Accreditation: The Value Equation – Longo study showed that accreditation is a significant factor in whether facilities engaged in actions widely recognized to improve patient safety; advocates accreditation as a means for improving health care5 – Health Affairs report indicated that Joint Commission accreditation requirements influenced hospitals’ efforts toward implementing patient safety initiatives6 – Study in Hospital Topics found accreditation to be effective in driving efforts to reduce errors7 47 © Copyright, Joint Commission International Recent Studies Support the Value of Joint Commission Accreditation to address the problem of patient safety worldwide 48 © Copyright, Joint Commission International WHO World Alliance for Patient Safety World Alliance for Patient Safety: Ten Action Areas Solutions to improve patient safety Global Patient Safety Challenges : 1. Clean Care is Safer Care 2. Safe Surgery Saves Lives High 5s Patients for Patient Safety International Classification for Patient Safety (ICPS) Reporting & Learning Technology for Patient Safety Knowledge Management Special projects: - Education - Radiotherapy - Rewarding excellence - When things go wrong - Vincristine sulphate © Copyright, Joint Commission International Research for Patient Safety Catalyse countries’ action to achieve safety of care 50 © Copyright, Joint Commission International Solutions for Patient Safety 51 © Copyright, Joint Commission Resources Clean Care is Safer Care • A patient engagement initiative • Focus on individuals (“champions”), not organizations • Links to other World Alliance strands • Creation of regional groups 52 © Copyright, Joint Commission Resources Patients for Patient Safety 53 © Copyright, Joint Commission Resources Taxonomy for Patient Safety International Patient Safety Events Taxonomy 54 © Copyright, Joint Commission Resources • Cornerstone of patient safety communications 55 © Copyright, Joint Commission Resources Reporting and Learning Research for Patient Safety Canadian Adverse Event Study 2004 Harvard Practice Medical Study 1984 Danish Adverse Event Study 2001 The Commonwealth Fund Survey 2005 French Adverse Event Study 2004 Australian Quality in Healthcare Study 1992 Adverse Events in New Zealand Study 2002 56 © Copyright, Joint Commission Resources Utah Colorado Study 1992 Adverse events in British Hospitals 1999-2001 – “To identify and clarify the role and objectives of technology in improving patient safety both in the developed and developing world, and future directions (research, education, implementation) for the alliance regarding technology for patient safety.” 57 © Copyright, Joint Commission Resources Technology for Patient Safety – To achieve significant, sustained, and measurable reduction in the occurrence of patient safety problems over 5 years in at least 7 countries and build an international, collaborative learning community that fosters the sharing of knowledge and experience in implementing innovative standardized operating protocols and evaluating their impact. 58 © Copyright, Joint Commission Resources High 5s Project Objective – Managing Concentrated Injectable Medicines (U.K.) – Assuring Medication Accuracy at Transitions in Care (Canada) – Performance of Correct Procedure at Correct Body Sites (U.S.) – Improved Hand Hygiene to Prevent Health CareAssociated Infections (New Zealand) (deferred) – Communication During Patient Care Handovers (Australia) (deferred) 59 © Copyright, Joint Commission Resources High 5s Standardized Operating Protocols – Identify Current Regional Safety Problems and Solutions Available – Understand Regional Barriers to Solutions – Assess Risk of Solutions – Adapt Solutions to Local/Regional Needs – Develop/Disseminate Solutions 60 © Copyright, Joint Commission International WHO Collaborating Centre for Patient Safety Solutions Definition 61 © Copyright, Joint Commission International A Patient Safety Solution is any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care. – – – – – – – Sentinel Event Topic Areas Expert Panels National Agencies and Governments Professional societies and organizations Patient and family advocacy organizations Field reviews Open solicitations 62 © Copyright, Joint Commission International Topic Selection Process 63 © Copyright, Joint Commission International Confusing drug names is one of the most common causes of medication errors and is a worldwide concern. With tens of thousands of drugs currently on the market, the potential for error created by confusing brand or generic drug names and packaging is significant. The recommendations focus on using protocols to reduce risks and ensuring prescription legibility or the use of preprinted orders or electronic prescribing. © Copyright, Joint Commission International The widespread and continuing failures to correctly identify patients often leads to medication, transfusion and testing errors; wrong person procedures; and the discharge of infants to the wrong families. The recommendations place emphasis on methods for verifying patient identity, including patient involvement in this process; standardization of identification methods across hospitals in a health care system; and patient participation in this confirmation; and use of protocols for distinguishing the identity of patients with the same name. 64 © Copyright, Joint Commission International Gaps in hand-over (or hand-off) communication between patient care units, and between and among care teams, can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient. The recommendations for improving patient hand-overs include using protocols for communicating critical information; providing opportunities for practitioners to ask and resolve questions during the hand-over; and involving patients and families in the hand-over process. 65 © Copyright, Joint Commission International Considered totally preventable, cases of wrong procedure or wrong site surgery are largely the result of miscommunication and unavailable, or incorrect, information. A major contributing factor to these types of errors is the lack of a standardized preoperative process. The recommendations to prevent these types of errors rely on the conduct of a preoperative verification process; marking of the operative site by the practitioner who will do the procedure; and having the team involved in the procedure take a “time out” immediately before starting the procedure to confirm patient identity, procedure, and operative site. 66 67 © Copyright, Joint Commission International While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions that are used for injection are especially dangerous. The recommendations address standardization of the dosing, units of measure and terminology; and prevention of mix-ups of specific concentrated electrolyte solutions. © Copyright, Joint Commission International Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient transition points. The recommendations address creation of the most complete and accurate list of all medications the patient is currently taking— also called the “home” medication list; comparison of the list against the admission, transfer and/or discharge orders when writing medication orders; and communication of the list to the next provider of care whenever the patient is transferred or discharged. 68 69 © Copyright, Joint Commission International The design of tubing, catheters, and syringes currently in use is such that it is possible to inadvertently cause patient harm through connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route. The recommendations address the need for meticulous attention to detail when administering medications and feedings (i.e., the right route of administration), and when connecting devices to patients (i.e., using the right connection/tubing). © Copyright, Joint Commission International One of the biggest global concerns is the spread of Human Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles. The recommendations address the need for prohibitions on the reuse of needles at health care facilities; periodic training of practitioners and other health care workers regarding infection control principles; education of patients and families regarding transmission of blood borne pathogens; and safe needle disposal practices. 70 © Copyright, Joint Commission International One of the biggest global concerns is the spread of Human Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles. The recommendations address the need for prohibitions on the reuse of needles at health care facilities; periodic training of practitioners and other health care workers regarding infection control principles; education of patients and families regarding transmission of blood borne pathogens; and safe needle disposal practices. 71 Preventing Central Line Infections Communicating Critical Test Results Recognizing and Responding to Deteriorating Patients Preventing Pressure Ulcers Preventing Harm from Patient Falls 72 © Copyright, Joint Commission International Next Set of Solutions Next Set of Solutions (cont’d) Prototype will target four audiences: 1. Government policy at ministry of health level 2. Health care organization at the CEO level 3. Clinician/provider levels 73 © Copyright, Joint Commission International 4. Patient and family level