I ntroduction to JCI Standards & A ccreditation Processes

1. Introduction to JCI Standards & Accreditation Processes Thalassemia Quality Office Prepared by : Samah Darwazeh

2. DOHMS has signed a two year consultancy agreement with Joint Commission International in November 2005, with the aim of acquiring the status of accreditation for Rashid, Dubai and Al-Wasl hospitals by early 2008.

3. Project Duration: • The duration of the consultancy agreement is two years commenced on the 1st day of December 2005 and shall end on the 30th day of November 2007. • Phase I: Accreditation Preparation Program (ongoing for approximately 24 months)

4. 1st on site consultation: 4th-22nd February 2006 ( reports about the hospitals ) • 2nd on site consultation: 4th- 22nd November 2006 • Phase II: Final Mock Survey and Action Planning • PHASE III: Accreditation Survey (Targeted for 2007)

5. What is accreditation? • is a process whereby an outside agency assesses the healthcare organization to determine if it meets a set of fix standards designed to improve quality of care and safety.

6. What exactly do we mean by" standards”? • Standards address the organizations level of performance in specific areas…not simply what it has but what it actually does. • Standards set for the performance expectations for activities that affect the quality of care. • Standards ask two kinds of questions: Is the organization doing the right things? And is it doing them well? • Standards also specify requirements to ensure that care is provided in a safe environment.

7. JCI standards • 11 Chapters, 368 Standards, 1008 M.E. • 5 Chapters on Patient-centered standards • 6 Chapters on Health Care Management standards

8. Patient-Centered Standards • Access to Care and Continuity of Care (ACC) • Patient and Family Rights (PFR) • Assessment of Patients (AOP) • Care of Patients (COP) • Patient and Family Education (PFE)

9. Health Care Management Standards • Quality Improvement and Patient Safety (QPS) • Prevention and Control of Infection (PCI) • Governance, Leadership and Direction (GLD) • Facility Management and Safety (FMS) • Staff Qualification and Education (SQE) • Management of Information (MOI)

10. Scoring the Standards • Each standard is measured by a number of measurable elements ( 1,032 M Es) • Each measurable element is scored : • 0= Non compliance • 5= partial compliance • 10= full compliance • Core standards ( the bold ) MUST ALL be met • Non core standards 70% must be met AUB website

11. Accreditation:Does it Make a Difference? • Accredited hospitals report significant improvements in: • Leadership • Medical records management • Infection control • Reduction in medication errors • Staff training and professional credentialing • Improved quality monitoring

12. International Accreditation Programs • Medical Transport Organizations (2002) • Clinical Laboratories (2003) • Care Continuum (2003) • Ambulatory Care (2005) • Disease or Condition-Specific Certification (2005)

13. Ambulatory Care Accreditation • 1st edition of Joint Commission International Standards for Ambulatory Carepublished in August 2005 • Strongly modeled on JCI hospital standards that have been adapted for an outpatient context

14. Who is Eligible for Accreditation? • International healthcare organizations that address care in ambulatory care environments, such as: • Free-standing outpatient clinics • Dialysis facilities • Ambulatory surgery centers • Endoscopy centers • Imaging centers • Clinics or treatment programs for management of chronic diseases such as diabetes

15. Differences between Hospital and Ambulatory Care Accreditation • Depending on scope of services, some standards in the AC manual may not apply (e.g. standards addressing pre-operative services would not apply in an outpatient dialysis center) • Standards have been adapted as needed to reflect outpatient context, such as modification of the hospital standard addressing withdrawal of life-sustaining care • Length of survey is shorter, depending on number and volume of services offered; typical survey is two days Hospital Vs. Ambulatory care

16. Overview of the Hospital SurveyProcess-Key Elements of a Survey • Document Review Session • Interviews with Hospital Leaders • Visits to Patient Care Settings & tracers • Function Interviews • Other Assessment Activities • Feedback Sessions • Post Survey Activities

17. Tracer Methodology • Patient-centered evaluation approach that will be introduced and tested with international surveys in 2006 • JCAHO (in US) surveyors now use this approach during the on-site accreditation survey • Follows or “traces” patients through the organization’s processes and services and then branches out to assess how well standards were met • Uses both patient tracers as well as system tracers

18. Tracer Visits May Include • Observation of direct care • Observation of medication process • Quality improvement discussion • Staff interviews • Patient interviews • Observation of infection control practices and environment of care • Review of open clinical records • Review of policies as needed

19. Example of a Patient Tracer Activity • Patient with diagnosis of heart failure, CAD, and cardiac catheterization • Hospital areas visited and evaluated during the tracer exercise: • Telemetry unit, where patient is currently • Emergency department, through which patient admitted • Radiology, where patient had chest X-ray • Cardiac catheterization lab • Intensive care unit • Pharmacy • Physical therapy/Rehabilitation services • Home care services

20. Sample Points of Discussion in the Tracer Activity • Telemetry Unit • Post-catheterization assessment and care • Process for handling verbal orders • Medication process • Screening for fall and nutritional risk • Competency of nursing staff in telemetry • Pain assessment process • Patient education process and materials • Discharge planning

21. Sample Points of Discussion in the Tracer Activity Emergency Department • Triage process • Patient assessment • Communication with ICU prior to patient transfer • Medication process, including for high risk concentrated medications and IV solutions • Communication needs for hard-of-hearing elderly patients • Competency of medical and nursing staff in emergency management

22. Introduction to JCI Standards & Accreditation Processes Thank you Thalaseemia Quality Office