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JCIA Awareness Program

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A History of International Accreditation

Organizational Structure
Joint Commission Resources (JCR) is a whollyowned subsidiary of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Joint Commission International (JCI) is a Division of JCR

JCIA PHILOSOPHY

Maximum achievable standards


Over

Time Perfection is not required to start

Process that stimulates continuous


improvement Patient-centered approach Cultural adaptability
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Mission
The mission of Joint Commission Resources is to
continuously improve the safety and quality of care in the United States and the in the international community through the provision of education and consultation services and international accreditation.

DEFINITIONS

LICENSURE

CERTIFICATION
ACCREDITATION

ACCREDITATION
A voluntary process by which a government or
non-government agency grants recognition to health care institutions which meet higher standards that require continuous improvement in structures, processes, and outcomes. Focus is on Quality Management and Improvement. Accreditation is not an end point it is a Ongoing Process. Time Limited.
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International Accreditation
October 1997 JCAHO Board decision to provide
international accreditation Decision based on work in over 30 countries and frequent requests from health care organizations to be evaluated against JCAHO standards which were viewed as the benchmark for hospitals

U.S. Accreditation Standards were not appropriate internationally


Filled with U.S. and state laws and regulations such as

Clinical Laboratory Improvement Act and Patient Self Determination Act Contained many political considerations such as requirements for an organized medical staff Used U.S. jargon such as advanced directives Relied on US (NFPA) requirements for facility review with no international version of those requirements Had a U.S. cultural overlay for patient rights
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International Standards developed by an International Task Force


International Principles and Standards
Development Task Force formed February 1998 Task Force Represented 7 World Regions First meeting of the Task Force in June 1998 Meetings held in Chicago, Budapest, Barcelona

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Task Force Members



Saeed Almulla - United Arab Emirates Rodolfo ArmasMerino, MD - Chile Lluis Bohigas, PhD - Spain Willis Goldbeck - United States Ping Huang - Taiwan Niek Klazinga, MD - The Netherlands David Marx, MD - Czech Republic Raphal Nizankowski, MD - Poland
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Members Continued

Jose Noronha, MD - Brazil Yazid Ohaly, MD - Saudi Arabia Clive Ross, FDSRCS - New Zealand Charles Shaw, MD - England Christoph Straub, MD - Germany Margretta Styles, EdD, MN,RN - United States Stuart Whittaker, MD - South Africa
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Development of Standards

Consensus of the Task Force Paper review by individuals from 10 countries Six focus groups in different world regions Expert panel on Patient and Family Rights Expert panel on Facility Management and Safety Survey process tested in 5 countries Final approval by Task Force and Board July 1999 First International Accreditation- December 1999

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Standards
Organized around important functions Focus on the patient Designed to be interpreted/surveyed within the
culture and legal framework of a country Set core or threshold standards that all organizations must pass Set reach or better practice standards for all to achieve
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Comparisons
International standards include all topics from
JCAHO standards including newer ones related to pain management, patient safety,and care at the end of life 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. (Baldrige) quality award
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PURPOSES OF ACCREDITION

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WHAT ACCREDITATION ACCOMPLISHES

Continuously improves quality Improves the management of health


services Reduces costs Increases efficiency Strengthens the publics confidence

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WHAT IS ACCREDITATION INTENDED TO ACCOMPLISH


Continued

Rationalizes reimbursement Encourages a public/private partnership Builds a database of health care quality
information Provides recognition for excellence

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ACCREDITATION MEETS STAKEHOLDERS NEEDS

Maintains and improves quality Enhances public safety Establishes higher level requirements than
License Justifies budget needs

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ACCREDITATION PERMITS COMPARISON

Within Hospital over Time Local Hospital to Hospital Regional International

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ACCREDITATION MEANS

That an organization is doing the right things


and doing the right things well; Thereby significantly reducing the risk of harm in the delivery of care; and Optimizing the likelihood of good outcomes.

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JCIA Chapters
Patient-centered standards:


Access to Care & Continuity of Care Patient & Family Rights Assessment of Patients Care of Patients Patient & Family Education
Quality Improvement & Patient Safety Prevention & Control of Infections Governance, Leadership & Direction Facility Management & Safety Staff Qualifications & Education Management of Information
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Management standards:

Access to Care & Continuity of Care


A hospital is an integrated, coordinated system of services
and providers in which we match patient needs with services available and to ensure an appropriate progression through different levels of care:

Emergency, admission, referral, intensive care, transfer and discharge

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Patient & Family Rights

A patient is a unique set of cultural, psychosocial and spiritual


values and the hospital is obliged to understand and protect each patients needs and inform them of their rights:

Informed consent, participation in decisions and receiving


information in relation to the hospital, their condition and care.

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Assessment of Patients

Assessment process identifies a patients health, social


and psychological needs for emergency, immediate and continuing treatment through collecting and analyzing information:

Laboratory & Radiology Regs, safety, training, equipment, controls,


results,handling of specs. & external links

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Care of Patients
A hospital prioritizes, delivers, monitors and follows-up
planned, coordinated, safe, efficient and effective care by qualified staff in accordance with documented procedures and records across all clinical areas and services:

General, high risk, anaesthesia, palliative, nutrition and medication.

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Patient & Family Education

To provide education in a way which best promotes


understanding and enables patients to make informed decisions, participate in their own health care and the safe, effective use of medications and treatments.

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Quality Imp. & Pt. Safety

Quality and safety are integral to staff performance. A


program is a coordinated, comprehensive, hospital-wide and multidisciplinary approach to quality improvement and risk reduction that ensures clinical and managerial processes are designed, planned, monitored, evaluated and improved through leadership, education, communication and participation.

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Prevention & Control of Infections

Infection Control is coordinated, planned, monitored and


documented in order to identify and reduce the risks of acquiring and transmitting infections among patients, staff and public.

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Governance, Leadership & Direction


Effective leadership requires defining positions, authority and
responsibilities; providing direction and resources; and ensuring compliance with requirements, efficient and effective management, integration and improvement of all hospital processes and services.

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Facility Management & Safety


Provide a safe and functional facility for patients, staff
and public by reducing risk, hazards, incidents and injury through planning, education, documentation and monitoring/testing including:

Security, Hazardous materials, Emergency plans, Fire,


Medical Equipment, Utility systems.

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Staff Qualifications & Education

Provide qualified staff to meet patient and facility needs


through planning and standardized job descriptions, records, recruitment, appointment and appraisal processes, including:

orientation, education, review of credentials and


assignment of responsibilities.

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Management of Information
Information is a resource that integrates and supports
patient care, management and quality. Information is to be planned and managed to identify needs and design systems which capture, analyze, transmit and use information, taking into consideration: documentation control, confidentiality, safety, security, access, collection and collation of data.

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2007 edition to include Patient Safety Goals

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2006 INTERNATIONAL PATIENT SAFETY GOALS Goal 1. Identify Patients Correctly

1a. Use at least two (2) ways to identify a patient when giving medicines, blood, or blood products; taking blood samples and other specimens for clinical testing; or providing any other treatments or procedures. The patients room number cannot be used to identify the patient.

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Goal 2. Improve Effective Communication

a. Implement a process/ procedure for taking verbal or telephone orders, or for the reporting of critical test results that requires a verification read-back of the complete order or test result by the person receiving the information.
Note: Not all countries permit verbal telephone orders. or

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Goal 3. Improve the Safety of High-Alert Medications

3a. Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units.

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Goal 4. Eliminate wrong-site, wrong-patient, wrong-procedure surgery:


4a. Use a checklist, including a time-out just before starting a surgical procedure, to ensure the correct patient, procedure, and body part. 4b. Develop a process or checklist to verify that all documents and equipment needed for surgery are on hand and correct and functioning properly before surgery begins.

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4c. Mark the precise site where the surgery will be performed. Use a clearly understood mark and involve the patient in doing this. Note: Hospitals in many countries have downloaded the Universal Protocol and are using it. Because the Universal Protocol is a set of three complementary, evidence-based practices that together will prevent wrong-site surgery, please note that protocols 4a through 4c of these International Patient Safety Goals are the same as the requirements for the Universal Protocol.
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Goal 5. Reduce the risk of health careassociated infections. 5a. Comply with current published and generally accepted hand hygiene guidelines. Note: This should recognize that not all countries have an agency that is equivalent to the Centers for Disease Control and Prevention (CDC) or may not recognize guidelines of the U.S. CDC.

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Goal 6. Reduce the risk of patient harm resulting from falls.

6a. Assess and periodically reassess each patients risk for falling, including the potential risk associated with the patients medication regimen, and take action to decrease or eliminate any identified risks.

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Steps to Accreditation

Decision Structure & mobilization Preparation & development Internal assessment JC Consultation & assessment Improvements to meet standards External survey Attainment of Certificate of Accreditation

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Overview of the Survey Process


Pre-Survey Activities During Survey Activities Post-Survey Activities

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Survey Process
Pre-Survey Activities

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Applying for Accreditation


Completion of Survey
Application

Submit application in electronic or written format to JCI Office

Must inform JCI if changes to information in application after submission

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Applying for Accreditation


Completion of Survey Application

Used to

Determine length of survey Determine number of surveyors Prepare a preliminary agenda

Prepare a contract for


survey
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Accreditation Renewal Process


Request for Resurvey

Sent by JCI prior to organizations triennial accreditation due date Must be completed and submitted by specified date

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Scheduling the Survey and Planning the Survey Agenda


JCI and the organization selects
survey date usually within 90 days from receipt of application Survey team assigned Agenda prepared in collaboration with organization staff

Responsibility of survey team leader

Provided electronically usually within 30 days prior to survey

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Postponement of Scheduled Survey


Advance notice must be provided at least 30 days
prior to date of scheduled survey State reason(s) for request

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Survey Process
During Survey

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During Survey Process



Opening Conference Orientation of Surveyors to the Organizations Services Document Review Assessment Activities

Functional Interviews Visits to Patient Care Areas Visits to Selected Departments Facility Tour Special Interview/Issue Resolution
Daily Briefings Leadership Exit Conference

Feedback Sessions

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Opening Conference
Introductions

Staff Hospital leadership Modifications as needed Discussion of key survey activities

Review agenda

Daily briefings Process for requesting patient records for closed record review Process for requesting medical staff and hospital staff files for review

Surveyor Scoring Process

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Orientation of Surveyors
Brief orientation of surveyors to
the organization and their scope of services Limited to 30 minutes, or as scheduled in the agenda Organization should NOT prepare other presentations to present during survey, unless scheduled in the agenda

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Document Review
Documents
organized/available for review according to list

Select few required to be in English Survey team will review documents


May choose to use interpreters to review records May choose to conduct review though an interview with small group of requested staff members and interpreters

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Document Review

Additional document review sessions may be conducted

Often for surveys longer than 3 days

Additional documents, other than those on the document list may be requested for review throughout the survey

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Function Interviews
Leadership Infection Control Management of
Information/Patient Records Staff Qualifications and Education Quality Improvement and Patient Safety Patient Care
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Leadership Interview
To foster an interactive process,
a small group recommended Information validated from document review Evaluates collaborative involvement of senior leaders in

Governing; Managing; and Directing the organization


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Infection Control Interview


Assesses processes to identify,
prevent, and manage nosocomial infections Uses other information obtained from other survey activities

Facility tour Visits to inpatient and outpatient care areas Visit to Pathology and Laboratory Services Document Review Patient Record Review Visit to Pharmacy

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Management of Information/Patient Records Interview


Scheduled as separate
interviews in larger organizations with longer surveys

Information management interview usually conducted by administrator surveyor Patient Records Interview usually conducted by nurse and physician surveyors In 2 day surveys, one or more surveyors may conduct a joint session

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Information Management Interview


Evaluates hospitals ability
to meet information needs of

Clinical staff Management Those outside the organization who require data/information

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Patient Records Interview


Surveyors will request a sample
of discharged (closed) patient records for review during the interview

Surveyors will select records according to diagnoses and/or procedures from a specified time frame Will provide list/instructions for preparing patient records, during document review session Will confirm appropriate review tool for use in review
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Patient Records Interview


Interpreters will assist, as requested Separate computer should be provided for each surveyor for electronic patient records Survey team will aggregate the completed forms to determine compliance

Findings from active or open patient record review are included in aggregation

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Staff Qualifications and Education Interview


Separate interviews for medical
staff and nursing and other health care staff

Physician surveyor will conduct interview for medical staff and others, as indicated Nurse and administrator surveyors will conduct joint interview of nursing and other health care staff

Surveyors may choose to conduct separate nursing and non-nursing interviews

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Staff Qualifications and Education Interview


Reviews processes for

Recruitment; orientation; education; evaluation of staff

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Staff Qualifications and Education Interview


Interview with appropriate
representatives

Medical staff Nursing Other health care staff Surveyors will request specific files during document review session on first day of survey Surveyor will provide instructions for submission of information and confirm appropriate survey tool
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Review of sample of staff files

Quality Improvement and Patient Safety Interview


Evaluates effectiveness of quality
improvement and patient safety activities

Validate implementation of plan Review analysis and use of measurement data Determine improvements in quality of care and patient safety

Organization may be invited to


give one 15 minute presentation of an improvement process

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Quality Improvement and Patient Safety Interview


Surveyors will integrate
information from other survey activities

Document review Visits to patient care areas/departments Staff feedback Functional interviews

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Patient Care Interview


Addresses selected issues in the
provision of patient care Explores unresolved issues identified during other survey activities Obtains information on standards that have not been addressed during survey Usually conducted as the last survey activity before final integration of findings

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Visits to Patient Care Settings: Inpatient and Ambulatory



Anesthetizing Areas Ambulatory/Outpatient Clinics Emergency Services Inpatient Units Imaging/Radiology Services Pathology and Clinical Laboratory Services Pharmacy Rehabilitation Services

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Visits to Patient Care Settings


Evaluates the processes for
caring for patients in different settings across the organization

A sample selected of inpatient and outpatient areas Usually 100% of anesthetizing locations scheduled Surveyors may visit any other unit or location not on the agenda

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Visits to Patient Care Settings: Inpatient and Ambulatory Care


Include the following activities:

Brief description of services provided by the manager

NO formal or unscheduled presentations are to be given

Tour A meeting with multidisciplinary group of care givers Review of sample of active patient records

Selected by surveyor

Discussion of involvement in quality improvement and patient safety Brief conversation with a patient or family, when appropriate

Selected by surveyor Do Not approach patients or families in advance of surveyors request


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Visit to Anesthetizing Locations


Assesses areas where
anesthesia provided, including

operating suites same-day surgery suites recovery rooms endoscopy suites dental clinics invasive radiology areas

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Visits to Selected Departments


Pharmacy Imaging/Radiology
Services Pathology and Clinical Laboratory Services Rehabilitation Services

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Facility Tour
Addresses issues related to

Physical facility Security Medical and other equipment Hazardous waste Fire safety Utility systems Patient and visitor safety Infection control
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Special Interview/Issue Resolution


Performed when surveyors need

To resolve outstanding issues identified during survey Additional time to evaluate or obtain information for a specific topic To revisit an area To visit additional patient care settings that were not scheduled Review additional patient records or documents

May be scheduled in survey agenda or agenda may be


modified to include a special interview/issue resolution

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Assessment of Complaints
Any complaint about the organization received prior to the
survey will be assessed by the survey team

Survey team provided with specific complaint information

Surveyors address issues identified in the complaint during


the survey

During scheduled activities or in special sessions, as appropriate Team leader will share pertinent information with the CEO at an appropriate time and reports assessment findings Findings included in the survey report to JCI

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Feedback Sessions: Daily Briefings


Daily Briefings

Conducted each survey morning except on the first day Provides senior leaders with pertinent observations from previous days activities

Allows organization to be proactive in clarifying issues or providing additional needed documents for consideration

Review agenda for upcoming day

Modify, as needed

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Identification of Immediate Threat to Public or Patient Safety


If identified during survey

Immediate notification of the hospitals CEO and JCI JCI will decide to continue or stop survey and determine need to inform relevant public authorities

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Feedback Sessions: Leadership Exit Conference


Surveyors confer with
organizations CEO and other leaders at end of survey Provides strictly preliminary information about findings

A written preliminary report may be provided

Depends on number of recommendations and Time allowed for integration and preparation of report

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Survey Process
Post-Survey Activities

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Accreditation Decision Process


Survey Team Leader submits
preliminary report and supporting documentation to JCI JCI Executive Staff review report for accuracy Report submitted to JCI Accreditation Committee for decision Official Accreditation Decision Report mailed

Usually within 60 days


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Survey Process
2003 Changes in Process

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2003 Survey Process Changes


Track record required for scoring full compliance

Initial Surveys

4 month track record

Triennial Surveys

12 month track record

Revised List of Documents


Some documents added because of new or revised standards Changes in selected documents required to be in English

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2003 Survey Process Changes


New standards, such as sedation, pain management,
end of life-care, incorporated in appropriate survey activities

Document review Visits to patient care settings Patient record review Function interviews

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2003 Survey Process Changes


Revised tools

Staff qualifications and education review

Clarification of elements

Patient record review form

Sequence of criteria Clarification of some criteria Additional criteria to reflect new standards

Total of 31 criteria rather than 26

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2003 Survey Process Changes


Application for Survey updated Survey Process Guide refined

More detailed description of each survey activity

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2007 changes in the process


The use of Tracer Methodology for surveying
The introduction of patient safety goals

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Top Compliance Issues


Standards compliance tracked to identify
challenges to

Allow organizations to benchmark their performance in safety and quality issues covered in JCI standards against the cumulative data from all JCI-accredited organizations Identify issues to address in own quality improvement activities

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Top Compliance Issues From Through July 2003


Challenging standards addressed in this presentation are those
which many hospitals have compliance issues related to a particular standard.

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Listing of 9 Challenging Standards


PCI.3 Procedures and processes associated with risk of

infection MOI.2.2 Patient clinical record review AOP.3 Reassessment of Patients SQE.8 Process for authorization of treatment MOI.1.5.3 Patient record entries COP.2.1 Plan of care SQE.3.1 Evaluation of staff performance SQE.9 Process for quality improvement activity QPS. 4.2 Analysis of quality improvement data
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Procedures and Processes Associated with Risk of Infection


PCI.3 The organization identifies the
procedures and processes associated with the risk of infection and implements strategies to reduce the infection risk.

Survey method is primarily through direct observations made by all members of survey team Compliance issues included

handling of clean and contaminated equipment, linen, and supplies used in patient care; and storage of blood

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Patient Clinical Record Review


MOI.2.2 As part of its performance improvement
activities, the organization regularly assesses patient clinical record content and the completeness of patient clinical records.

Survey methods include discussion in the Patient Record Interview and review of written documents

such as minutes of the reporting of results and improvement activities identified through the review process Lack of participation in review by all disciplines authorized to make entries in or manage patient records; and Review not conducted regularly

Compliance issues included


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Reassessment of Patients
AOP.3 All patients are reassessed at appropriate
intervals to determine their response to treatment and to plan for continued treatment or discharge.

Survey methods include staff interviews; review of documents, such as policies and procedures describing reassessment activities in writing; and review of documentation in active and closed patient records. Compliance issues included poor policy development and implementation and inconsistent performance in accordance with policies.
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Process for Authorization of Treatment


SQE.8 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.

Survey methods include staff interviews ( Staff Qualifications and Education Interview) and review of individual medical staffs credential files. Compliance issues included absence of or incomplete documentation evident in individuals credential files
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Patient Record Entries


MOI.1.5.3 Every patient clinical record entry identifies its
author and when the entry was made in the record.
Survey methods include

Review of patient records Compliance issues included missing signatures of authors of entries

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Plan of Care
COP.2.1 The care provided to each patient is
planned and written in the patients record.
Survey methods include
review of documentation of plan and implementation of plan in patient records Compliance issues included Lack of/ inconsistent documentation of the plans of care and their implementation in the records

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Evaluation of Staff Performance


SQE.3.1 Each staff members ability to carry out the
responsibilities in his or her job description is evaluated at appointment to the staff and then regularly thereafter. Survey methods include

Review of documents, such as job description, initial and ongoing (at least annual) evaluations; Compliance issues included lack of initial evaluations and most frequent issue was poor compliance in conducting annual evaluations

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Process for Quality Improvement Activities


SQE.9 The organization has an effective process for medical staff
participation in the organizations quality improvement activities, including evaluating individual performance, when indicated, and for periodically reevaluating the performance of all medical staff members. Survey methods include review of selected documents, such as credential files and quality improvement findings (minutes, reports) Compliance issues included lack of evidence of medical staff participation and/or lack of a process for gathering individual performance data

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Analysis of Quality Improvement Data


QPS.4.2 Data are intensively assessed when significant
unexpected events and undesirable trends and variation occur. (Previously was QMI.4.2 prior to Jan.1, 2003) (41.6%) Survey methods include review of documents, such as analysis of data for certain events and reports to leadership on findings and actions, when taken. Compliance issues included lack of evidence of a process to conduct intensive analysis, failure to clearly define and communicate definitions of certain events to be reported and reviewed

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