Understanding JCIA

By: Team Healthcare Consulting

Accreditation
A voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standards that require continuous improvement in structures, processes, and outcomes.

Accreditation Accomplishes:
1. Stimulate continuous improvement in patient care processes and outcomes 2. Increase efficiency/reduce costs 3. Strengthen the public confidence 4. Improve the management of health services 5. Provide education on better or best practices 6. Provide recognition for excellence

JCIA
A subsidiary of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now called THE JOINT COMMISSION). Mission: To improve the quality of health care in the international community through provision of accreditation, consultation, and education services.

JCIA Today
3rd edition will be issued June 2007 effective for survey Jan. 2008 120+ hospitals and other healthcare organizations are accredited around the world as of Dec. 2007.

JCIA Standards
1. 2. 3. 4. 5. 6. 7. International Patient Safety Goals Access to Care and Continuity of Care (ACC) Patient and Family Rights (PFR) Assessment of Patients (AOP) Care of Patients (COP) Anesthesia and Surgical Care (ASC) Medication Management and Use (MMU) Patient and Family Education (PFE)

Section I: Patient Centered Standards:

Section II: Healthcare Organization Management Standards

8. Quality Improvement & Patient Safety (QPS) 9. Governance, Leadership, and Direction (GLD) 10. Facility Management & Safety (FMS) 11. Staff Qualifications & Education (SQE) 12. Prevention & Control of Infections (PCI) 13. Management of Communication and Information (MCI)

Structure of Standards

PATIENT SAFETY GOALS

The purpose of the International Patient Safety Goals is to promote specific improvements in patient safety. The goals highlight problematic areas in health care and describe evidence- and expert-based consensus solutions to these problems.

GOALS
Goal 1 Identify Patients Correctly

Requirement of Goal 1 The organization develops an approach to improve accuracy of patient identifications.

Measurable Elements of Goal 1

Require the use of two patient identifiers, not including the use of the patients room number or location. Patients are identified before:
administering medications, blood, or blood products. taking blood and other specimens for clinical testing. providing treatments and procedures.

Goal 2 Improve Effective Communication

Requirement of Goal 2 The organization develops an approach to improve the effectiveness of communication among caregivers.

Measurable Elements of Goal 2

The complete verbal and telephone order or test
result is:
written down by the receiver read back by the receiver

The order or test result is confirmed by the individual who gave the order or test result. (signed)

Goal 3
Improve the Safety of High-Alert Medications

Requirement of Goal 3 The organization develops an approach to improve the safety of high-alert medications.

Measurable Elements of Goal 3 Concentrated electrolytes are not present in

patient care units unless clinically necessary and actions are taken to prevent inadvertent administration in those areas where permitted by policy.

Goal 4
Ensure Correct-Site, Correct-Procedure, CorrectPatient Surgery

Requirement of Goal 4
The organization develops an approach to ensuring correct-site, correct-procedure, and correct-patient surgery.

Measurable Elements of Goal 4

mark for surgical site identification involves the patient in the marking process. verify that all documents and equipment needed are on hand, correct, and functional.

use checklist and time-out procedure just before starting a surgical procedure.

Goal 5
Reduce the Risk of Health CareAssociated Infections

Requirement of Goal 5
The organization develops an approach to reduce the risk of health careassociated infections.

Measurable Elements of Goal 5

adapted currently published and generally accepted hand hygiene guidelines. implements an effective hand hygiene program.

Goal 6
Reduce the Risk of Patient Harm Resulting from Falls

Requirement of Goal 6
The organization develops an approach to reduce the risk of patient harm resulting from falls.

Measurable Elements of Goal 6

implements a process for the initial assessment of patients for fall risk reassessment of patients when indicated by a change in condition, medications, etc. Measures are implemented to reduce fall risk for those assessed to be at risk.

Patient Centered Standards: (ACC)

Overview: Information is essential to match the patients health care needs with the services available. Coordinate the services provided by the organization. Plan for discharge and follow-up

Patient Centered Standards: (PFR)

Overview: Identify, protect, and promote patient rights Inform patients of their rights Include the patients family in patient care decisions Obtain informed consent Educate staff about patient rights Establish an ethical framework.

Patient Centered Standards: (AOP)

Overview: A effective assessment process results in decisions about the immediate and continuing treatment needs. Patient assessment is ongoing, dynamic, and multidisciplinary process: 1.Collecting information and data on patients physical, psychological, social status, and health history. 2.Analyzing data and information to identify the patients health care needs. 3.Developing a plan of care to meet the patients identified needs. 4.Performed by qualified individuals.

Patient Centered Standards: (COP)

Overview: 1. Plan and deliver uniform care to all patients especially frail and elderly 2. Make care seamless through effective communication 3. Provide safe care of high risk patients 4. Use medications safely 5. Support patient nutrition needs 6. Pain management and care of the dying

Patient Centered Standards: (ASC)

Overview: The use of anaesthesia, sedation and surgical intervention are common and complex processes They require complete and comprehensive patient assessment Integrated care planning Continuous monitoring of patients And criteria to determine transfer to another level of care or discharge Managing patient at risk of complications The standards are applicable for all areas where surgical and invasive procedures, anaesthesia and sedation are used within the organization

Patient Centered Standards (MMU)

Overview: MMU Important component of patient care Encompasses systems and processes to provide pharmaceutical care to patients Multidisciplinary and coordinated efforts to manage medication use by:
Process design Implementation and improvement Selection of medication Procurement, storing, ordering/prescribing, transcribing, distribution, preparing, administering, documenting and monitoring of medication therapies.

Patient Centered Standards: (PFE)

Overview: 1. Assessment of educational needs 2. Education includes: Medication, medical equipment, interaction between food & medication, nutritional guidance, and rehabilitation techniques. 3. Staff have appropriate knowledge and skills

Healthcare Organization Management Standards: (QPS)

Overview: 1. Governance and leadership participation 2. Comprehensive approach 3. A framework for: Designing processes, implementing and sustaining changes that result in improvement. 4. PI plan and indicators.

Healthcare Organization Management Standards: (PCI)

Overview: 1. Understand infection risks in the entire organization 2. Plan and implement surveillance and prevention strategies 3. Integrate the program with quality management and improvement

Healthcare Organization Management Standards: (GLD)

Overview: 1. Identify governance structure and responsibility 2. Provide collaborative leadership 3. Provide responsible leadership at department and service level

Healthcare Organization Management Standards: (FMS)

Overview: 1. Reduce and control hazards and risks 2. Prevent accidents and injuries 3. Maintain safe conditions 4. Plan space, equipment, and resources 5. Educate staff to reduce risks and report incidents 6. Use data to monitor performance

Healthcare Organization Management Standards: (SQE)

Overview: 1. Mix of skills to fulfill hospital mission 2. Managerial and clinical leaders identify the number and types of staff needed 3. Recruiting, evaluating, and appointing staff are best accomplished through a coordinated uniform process 4. Documented skills, knowledge, education, and experience 5. Review of credentials of medical and nursing personnel 6. Provide staff with the required education to update their competencies

Management of Communication and Information (MCI)

Overview: Assure that Organizations are effective in: Identifying information needs Designing and information management system Defining and capturing data and information Analyzing data and transforming it into information And integrating and using information

Thank You Questions?