Module 5- The Joint Commission and JCI Accrreditation.pptx
- 2. Introduction • The Joint Commission (TJC) is a United States-based nonprofit tax-exempt organization • It accredits more than 21,000 health care organizations and programs in the USA till 2015. 2
- 3. History 3 • Ernest Amory Codman, M.D., (December 30, 1869 – November 23, 1940) Promoted hospital reform based on outcomes management in patient care: – "End Result Cards“ – and “End Result System”, – “End Result Hospital” and – “A Study of Hospital Efficiency- 1917”, (123 Error)”.
- 4. History • Codman’s efforts led to the founding of the American College of Surgeons and its Hospital Standardization Program. 4
- 5. History • In 1951, the Joint Commission on Accreditation of Hospitals (JCAH) was created by merging the Hospital Standardization Program with similar programs run by: – American College of Physicians – American Hospital Association – American Medical Association – Canadian Medical Association 5
- 6. History • In 1987, the company JCAH was renamed the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, pronounced "Jay-co") to expand its services. 6 • In 2007, the Joint Commission on Accreditation of Healthcare Organizations underwent a major rebranding and simplified its name to The Joint Commission (TJC).
- 7. Joint Commission International (JCI) 7 • Private, not-for-profit established in 1994 as a division of Joint Commission Resources Inc. (JCR) and The Joint Commission.
- 8. Joint Commission International (JCI) 8 • Publish the first comprehensive set of international standards on 2000 and present its first award.
- 9. The Joint Commission International (JCI) 9 • Working in five continents and in more than 90 countries. • 20 % annual growth in the number of accredited organizations
- 10. JCI Mission 10 • The mission of JCI is to improve the safety and quality of care in the international community through the provision of education, publications, consultation, and evaluation services.
- 11. Serial Name History of Joint Commission • The Joint Commission on Accreditation of Hospitals (JCAH) (1951) • the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (1987) • The Joint Commission International (1994) • The Joint Commission (2007) 11
- 12. JCI Pathway 12
- 13. The Ten Steps towards JCI • There are10 steps that healthcare facility typically follow toward achieving accreditation success. • The average duration for the cycle is 18-24 months. 13
- 14. JCI Pathway to Accreditation 14 Phase Process Duration START UP Become Familiar with JCI Standards and Survey Process 2 – 3 Month PLAN Conduct gap analysis and build an action plan 2– 3 month PROCESS Update policies and Procedures 2 month FOCUS Target improvement when needed 2-3 month FIX BARRIERS Work with staff to overcome obstacles 2-3 month READINESS Assess your readiness at the midpoint 2-3 month TRAINING Continue training for sustainable changes 2-3 month Monitor & Adjust Evaluate and refine process 2-3 month Mock Survey Use mock survey to assess your readiness 2-3 month Final Stage Make final modification 6-7 month
- 15. 1- Start Up Become Familiar with JCI Standards and Survey Process 15
- 16. Start Up • Become familiar with JCI Polices and Procedures 16
- 17. Start Up • Review JCI Hospital Accreditation Manual 5th Ed. (US $130- 175) 17
- 18. Start Up • Review JCI Survey Process Guide 5th Ed ($75 -100) 18
- 19. Start Up • Excite your Leadership PDF File online: How JCI Accreditation Can Benefit Your Organization DISCUSSION POINTS: • Achieve Strategic Plan • Improve Quality of Service • Clinical Improvement • Meet Client needs • Take a role in the market • ….. 19
- 20. Start Up • Share Start up information with your team 20
- 21. 2- PLAN Conduct gap analysis and build an action plan 21
- 22. PLAN • Do the Self- Assessment • Perform a Baseline assessment of your hospital performance against the JCI Standards 22
- 23. Helpful Questions to Ask When Assessing Compliance 23 • Which patients or units are affected by the standard or a measurable element?
- 24. Helpful Questions to Ask When Assessing Compliance 24 • Is evidence of the measurable element present or absent?
- 25. Helpful Questions to Ask When Assessing Compliance • If a requirement is an activity that must be performed or accomplished within a particular time frame: – Is that time frame being met? – Is there evidence of this? 25
- 26. Helpful Questions to Ask When Assessing Compliance • Is the requirement in a measurable element being met: – Completely, – Effectively, – and Appropriately? • Is practice consistent with policy? 26
- 27. Assign staff responsibilities 27 • Assign Primary Contact for the accreditation • File in the JCI Electronic Application (E-App) • Action Plan: – WHO? – will DO What? – And When?
- 28. Build Accreditation Action Plan 28
- 29. Build Accreditation Action Plan • The Action Plan respond to the gaps in the self-assessment and comply with the standards 29
- 30. 3- Process Update Polices and Procedures 30
- 31. Assess Current Policies and Procedures 31 • Use Accreditation Preparation Requirements (APRs) listed in the E- App and the JCI Hospital Accreditation Manual
- 32. Develop a process to create JCI compliant Policy • Unclear, wordy, difficult to understand policy • Too general or confusing • Poorly designed or difficult to navigate • Difficult to find or locate 32 Avoid the Followings:
- 33. 4- FOCUS • Target Improvement when Needed 33
- 34. Examine challenges • Start with the International Patient Safety Goals (IPSGs) 34
- 35. Cure challenges without delay 35 • Prioritize high risk and problem-prone issues to start with
- 36. Assess hospital risk for adverse event 36 • Create Reporting System to report any adverse event or medical error
- 37. 5- FIX BARRIER: Work with Staff to Overcome Obstacles 37
- 38. Explain how to achieve a Safety Culture • Acknowledge mistakes • Learn from mistakes • Take action to correct mistakes • Maintain excellence • Responsibility for excellence 38
- 39. Train staff on New Procedure 39
- 40. Involve physician leaders 40 • To undercover issues • To involve in finding solutions and Implement them • To motivate their staff
- 41. Break time 41
- 42. Back to Work 42
- 43. 6- READINESS: Assess your readiness at the mid-point 43
- 44. 6- Assess your readiness at the mid-point 44 • Prepare your Staff for Mock Survey • Conduct Patient Tracer • Communicate the result of finding with your staff
- 45. 45 7- TRAINING: CONTINUE TRAINING FOR SUSTAINABLE CHANGES
- 46. Educate Staff 46 • Educate all staff on Accreditation concept and philosophy • Inspire and motivate staff to commit to accreditation process
- 47. Keep Essential Documents Ready 47 1) List of priority improvement 2) List of measures for department and services 3) Clinical practice guidelines 4) Healthcare facility map
- 48. Keep Essential Documents Ready • Sample of medical records • Organizational plans e.g.: – Facility Management Plan – Safety Plan • Policies, procedures, documents and bylaws 48
- 49. 8- Monitor & Adjust: Evaluate and Refine Process 49
- 50. 8- Evaluate and Refine Process 50 1. Use accreditation, multidisciplinary team to spot deficiencies 2. Encourage staff to make correction 3. Build a cohesive spirit from the leadership to the frontline staff
- 51. 9- MOCK SURVEY: Use a Mock Survey to Assess Your Readiness 51
- 52. 9- Use a Mock Survey to Assess Your Readiness 52 1. Conduct final mock Survey 2. Spot necessary improvements 3. Plan corrections
- 53. 10- FINAL SURVEY: Make your Final modifications 53
- 54. Make final preparation for final survey 54 • Complete the E-App • Communicate with JCI coordinator • Communicate with JCI Surveyors • Complete your “Ready to Go” List of Documents.
- 55. Conduct your JCI Survey 55 1. Opening Conference 2. Leadership interview 3. Staff qualifications and educations review 4. Facility tour 5. Leadership conference 6. Other interactions …..
- 56. Congratulations: Display proudly the Gold Seal 56
- 57. Join World Hospital Search 57 • Once Accredited, the healthcare facility can now join the World Hospital Search: http://www.worldhospitalsearch.org/ • It is a complete online directory of all JCI Accredited Organizations