1. JCIA Update (April – May 2011)

2. KFSH&RC Mission JCIA accreditation is designed to create that culture. KFSH&RC provides the highest level of specialized healthcare in an integrated education and research setting. It is important to have a culture of : Quality Patient safety Continuous Improvement

3.  2008 JCIA survey visit findings  Standards Changes  Medical Quality Directors Role Objectives

4. 4 2008 JCIA Survey visit findings

5.  H&P form (Admission Notes) use.  Procedural Sedation Assessment form completion (Endoscopy).  Pain documentation.  D4 Chronic Patients Weekly Assessment. 2008 JCIA Survey visit findings Documentation

6.  Authentication of telephone orders.  PRN order for Restraint.  Inconsistency in ASA score documented for the same patient.  Renewed orders completion (e.g. cont fentanyl) 2008 JCIA Survey visit findings Documentation

7.  Consultants co-signature on Residents entries as hospital policy states  Date documentation in the progress notes  Significant Medical Record Documentation issues: Timeliness, Eligibility, Completeness 2008 JCIA Survey visit findings Documentation

8.  ASA Score of III accepted for procedural sedation in Outpatient w/o explanation  Inconsistency in the location of documenting site marking (tooth) in dental clinic  Patient discharged from post anesthesia unit w/o physician order 2008 JCIA Survey visit findings Practice & Documentation

9. Quality Management is currently working with concerned departments and staff to implement the required policies & processes for the standards changes Standards Changes

10. Heart Failure (HF) Stroke (STK) Children’s Asthma Care (CAC) Hospital-Based Inpatient Psychiatric Services (HBIPS) Perinatal Care (PC) Pneumonia (PN) Surgical Care Improvement Project (SCIP) Venous Thromboembolism (VTE) Acute Myocardial infarction (AMI) Nursing Sensitive care (NSC) (International Library of Measures) At least 5 Clinical Measures should be chosen from International Library of Measures

11.  IPSG – stay the same but more emphasis on monitoring 1. Identify Patients Correctly 2. Improve Effective Communication 3. Improve the Safety of High-Alert Medications (IPP list) 4. Ensure Correct Site, Correct- Procedure, Correct – Patient Surgery 5. Reduce the Risk of Health Care Associated Infections 6. Reduce the risk of patient harm resulting from falls Standards Changes (International Patient Safety Goals (IPSG))

12. (High Alert Medication Policy)

14. Standards Changes  Patient’s right to seek a second opinion without fear  Consent is obtained in a language the patient can understand  Process to respond to patient’s request for additional information on the practitioner  The organization obtains informed consent from live donors Standards Changes (Patient and Family Rights – PFR)

15. Standards Changes  Patient’s right to seek a second opinion without fear  Consent is obtained in a language the patient can understand  Process to respond to patient’s request for additional information on the practitioner  The organization obtains informed consent from live donors Standards Changes (Patient and Family Rights – PFR)

16. Standards Changes (Access to Care and Continuity of Care – ACC)  Patients with emergent, needs are given priority for assessment and treatment.  The clinical records of outpatients receiving continuing care contain a summary of all significant diagnoses, drug allergies…etc  Follow-up process for patients who leave against medical advice.  Planning to meet the patients’ transportation needs.  Medication reconciliation upon admission. Standards Changes (Access to Care and Continuity of Care – ACC)

17. Standards Changes (Care Of Patient –COP)  The planned care is documented in the record in the form of measurable progress (goals) & updated based on assessment  The care planned is reviewed and verified by the responsible physician.

18. Standards Changes (Aesthesia & Surgical Care – ASC)  The post-surgical plan is documented by the responsible surgeon or verified by the responsible surgeon  The plans of care are documented within 24 hours of surgery.  The anesthesiologist are identified in the patient’s anesthesia record.

19. Standards Changes (Staff Qualification and Education-SQE)  Each medical staff member provides only those services that have been permitted by the organization.  Have a uniform process (defined by organization policy for ongoing professional practice evaluation & (at least) annual review on quality & safety of services

20. Standards Changes (Staff Qualification and Education-SQE)  Uses comparative data such as benchmarking to literature-based medicine.  Use conclusions of in-depth analysis of known complications as applicable.  Feedback to staff.

21. Reinforce the following to department members:  Patient Safety.  Safety reporting (SRS).  Applying Infection Control Measures.  Promote the Just culture. Your role as a Quality Director

22. Documentation : (Not documented, Not completely done !!)  Identify documentation compliance issues in your area (i.e. insufficient computers, training..etc ) and work with Chairman for solutions.  Review tracer reports & Quarterly documentation reports. Discuss results with the concerned staff. Your role as a Quality Director

23. Medical Staff files, Ensure that :  Staff privileges are up to date  Saudi Commission registration completed  Life Support certification is completed  Fire training completed  Evaluations Your role as a Quality Director Reference: Joint Commission International Accreditation Hospital Survey Process Guide Page 67

24. Departmental education on :  New JCIA standards  Hospital policies related to physicians. Your role as a Quality Director

25.  Help directors to provide JCIA visit update in departments’ meetings.  Provide Educational material for directors.  Prepare Readiness Tips. Quality Management Educational Role

26. Thank You