1. Joint Commission International
Association of Companies Health Insurance Funds 13 March 2009 Prague, Czech Republic Joint Commission International Standards and Survey Process
David Jaimovich, MD
Chief Medical Officer
Joint Commission International

2. Objectives Identify and describe the JCI Accreditation process
Describe and review tracer methodology
Discuss a hospital’s preparation for the JCI Accreditation process
Describe global standardization of healthcare services through the process of accreditation
Accreditation as part of a systems focus

3. JCI Standards System framework
Checklist of all the important managerial and clinical functions or activities
Focus on patient perspective in context of their family
A balance of structure, process and outcomes standards
Optimal but achievable expectations
Measurable
In developing standards, need to review the healthcare organization as a system-examining all the inputs/outputs and all the interdependencies of various processes.
Should include all of the major managerial/clinical functions of a healthcare organization.
Standards should focus on our common goal – to improve care provided to patients. So Standards should be written to focus on patients.
Balance between structure/process/outcomes.
Again, a very important element is that standards be realistic and achievable. Will they fit the healthcare system they are designed for? So the desired state as reflected in the standards is realistic, given the resources of the setting.
Also, can the standards be measured? Is it understood how an organization must comply with standards. Need for transparency.

4. Accreditation Represents a Risk Reduction Strategy
That an organization is doing the right things and doing them well;
Thereby significantly reducing the risk of harm in the delivery of care; and
Optimizing the likelihood of good outcomes.

5. Strengths of Accreditation
External, objective evaluation
Uses consensus standards
Involves the health professions
Proactive not reactive
Organization wide
Focus on systems not individuals
Stimulates quality culture in the organization
Periodic re-evaluation against standards
Strengthens public’s confidence

6. Accreditation Can Help:
Enhance staff recruitment, retention and satisfaction
Improve or expand sources of payment for patient care
Increase chances to enter networks and new provider arrangements
Provide greater independence from government oversight

7. Accreditation Can Help:
Build a quality measurement database
Provide comparison with self, others, and best practices
Provide a framework to improve patient safety

8. Quality Improvement and Patient Safety Programs
Are leadership driven
Seek to change the ethos of the organization
Proactively identify and reduce risk and variation
Use data to focus on priority issues
Seek to demonstrate sustainable improvement
Measurable Elements of QPS.1.2
1. The leaders set priorities for monitoring activities.
2. The leaders set priorities for improvement and patient safety activities.
3. The priorities include the implementation of PSG.1 through PSG.6.
I would imagine that the numbers for the PSG will change.

9. Accreditation as Part of Continuous Quality Improvement
Accreditation is a milestone on the continuous journey of improvement
Accreditation Standards provide a common quality language and common set of expectations to point the way forward
Establishing a permanent organizational culture of safe, quality care is essential for sustaining improvement
The effort is for your patients, not the certificate

10. Starting to Prepare Available Resources:
JCI Accreditation Standards for Hospitals, 3rd Edition
Survey Process Guide (electronic version)
Web-based training on introduction to the international accreditation process (ISAS)
Newsletters and publications
print and electronic (e.g. Getting Started)
JCI Practicum four times a year
(Annual JCI Executive Briefings – networking opportunity with accredited organizations)

11. Begin with Education Organizational leaders and managers
Introduction to accreditation philosophy and approach
Accreditation as a quality improvement and risk reduction strategy
Review of the standards and measurable elements
Discussion of the survey process and what to expect
Project planning and next steps

12. Baseline Assessment
Conduct a detailed baseline assessment of current adherence to the Standards and each Measurable Element:
Use knowledgeable and credible evaluators (either internal or external consultants) who will critically and objectively assess each area
Consider using ISAS as guide
Include all areas of the organization in the assessment

13. Baseline Assessment cont.
Collect and analyze baseline quality data as required by the quality monitoring standards
Examples: medication errors, hospital-associated infection rates, antibiotic usage, surgical complications.
Establish an ongoing monitoring system for data collection to identify problem areas and track progress in improvement
Set frequency of data collection
Analyze data

14. Action Planning
Using the findings of the baseline assessment, develop a detailed project plan with assigned responsibilities, deliverables, and time frames.
Start with priority areas established by leadership
Example: Revise informed consent policy, develop a new informed consent statement, educate staff - to be completed in two months (specify exact date)
If available, use a software program such as MS Project or Excel to confirm project plan in writing
Hold leaders and staff accountable to the plan

15. Team Approach
Assign oversight of each chapter of standards to a respected champion/leader who will identify team members from throughout the hospital
Also include those who may be skeptical of the process
Look for good people skills, time management skills, and consensus building skills
Be prepared to change as new champions emerge, and some leaders drop out

16. Policies and Procedures
Compile a list of all required policies and procedures that will need development and revision
Hint: look for list in Survey Guide 2008
These may take some time to get revise or develop, undergo organizational review, and obtain final approval
Be certain that your policy reflects your actual practice, as this is one of the yardsticks the surveyors will use to evaluate your performance

17. Mid-Point Strategies
Continue to monitor your progress in meeting the standards
Ex. Use a mini-evaluation of each chapter at regular intervals (e.g quarterly)
Don’t be afraid to adjust your project plan to be more realistic – change often takes longer than one expects
Continue to involve as many staff as possible in the process – make it an organizational quality goal that you are striving to achieve together

18. Strategies That Have Worked
Importance of physician commitment to the accreditation process cannot be overstated
They should see accreditation standards as framework by which hospital processes will be improve
Care will ultimately be of higher quality and safer for their patients
Reassure physicians that accreditation is not intended to tell them how to practice medicine!
But it does compel them to look collectively at their own practices and evaluate their own results

19. Strategies That Have Worked Cont.
Learn from what others have done well and adapt the experience to the needs of your organization
Ask JCI for clarification with standards interpretation – don’t waste time going down the wrong path
Take advantage of resources (e.g. download electronic example policies and plans and adapt to your organization)

20. Pitfalls to Avoid
Top leaders “support” the process, but are totally unrealistic in what it will take to achieve it in terms of time and resources
Staff end up feeling that accreditation is extra work for which they are not rewarded or recognized
Over-eager managers using the standards as a threat rather than as a goal – can make entire accreditation process feel punitive and inspecting rather than motivating

21. Final Mock Survey
Plan for a final “mock” or practice survey about 6-8 months in advance of the target date of the actual accreditation survey
Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organization with a fresh and objective eye
Plan final actions and corrections based on the findings of the final mock survey

22. JCI Hospital Standards 3rd Ed.
Standards in two sections:
Patient-Centered Standards
Healthcare Organization Management Standards

23. JCI Hospital Standards 3rd Ed. Cont.
Patient-Centered Standards
Access to Care and Continuity of Care
Patient and Family Rights
Assessment of Patients
Care of Patients
Anesthesia and Surgical Care
Medication Management and Use
Patient and Family Education

24. Anesthesia and Surgical Care
Organization and Management
Sedation Care
Anesthesia Care
Surgical Care

25. Medication Management and Use
Organization and Management
Selection and Procurement
Storage
Ordering and Transcribing
Preparing and Dispensing
Administration
Monitoring

26. JCI Hospital Standards 3rd Ed. Cont.
Healthcare Organization Management Standards
Quality Improvement and Patient Safety
Prevention and Control of Infections
Governance, Leadership, and Direction
Facility Management and Safety
Staff qualifications and Education
Management of Communications and Information

27. Staff Qualifications and Education
Planning
Orientation and Education
Medical Staff
Nursing Staff
Other Health Professional Staff

28. Management of Communication and Information
Communication with the Community
Communication with Patients and Families
Communication Between Providers Within and Outside the Organization
Leadership and Planning
Patient Clinical Record
Aggregate Data and Information

29. Standards Content Each JCI standard contains three components:
The standard represents the principle
The intent describes the rationale of the standard
The measurable elements are the detailed requirements from the standard and intent that are scored

30. Standards Content (sample)

31. International Patient Safety Goals
Identify patients correctly at risk points
Improve effective communication of critical information
Improve safety of high-alert medications
Ensure correct-site, correct-patient, correct-procedure surgery
Reduce the risk of healthcare-associated infection
Reduce the risk of patient harm from falls

32. Approach and Philosophy to the On Site Survey
A Survey is not intended to be punitive, a “got you” exercise, or an inspection
Tracer Methodology is a process of identifying imperfections, flaws, or broken systems
Surveyors will “drill down” or focus on areas where a potential risk area is identified
Based on common problem areas in many hospitals
High risk or high volume services
They have identified a vulnerable area

33. On-Site Evaluation Process
Opening conference
Orientation
Document review
Leadership session
Assessment activities
Tracer activities – patient
Tracer activities – systems
Facility tour
Special interview / issue resolution
Feedback sessions
Daily briefings
Leadership exit conference

34. Tracer Methodology
Is an effective evaluation method that is used to assess a healthcare organization’s performance of care and the services provided as viewed or experienced by the patient

35. Objectives of Tracer Activity
Follow entire course of care and services provided to the patient
Assess relationships among disciplines and important functions
Evaluate performance of processes provided to the patient

36. Types of Tracers Patient Tracer – Follows the patient
System Tracer – Follows the system
Data use
Medication management
Infection Control

37. Conducting Tracers Selection of patients Procedures Selection of units
Diagnoses
High volume
Procedures
High risk
Low volume
Selection of units
Diagnoses/procedures
Special care
Now that we’ve completed that form, we use it to select:
High volume diagnoses
High volume procedures
High risk procedures
Low volume procedures
Based on that, the units we need to go to help guide us.

38. Sample Patient Tracer Hospital Setting
Patient – Mr. Ramponi
Cardiac-surgery related diagnosis (cardiac bypass surgery)
Pulmonary complications (pneumonia)
Surveyor
Reviews patient record
Notes what services and transfers occurred

39. Surveyor Reviews Medical Record
72-year old man presented to ER with chest pain
An electrocardiogram showed signs of sinus tachycardia
Staff administered aspirin and drew blood
Mr. Ramponi
Treated for diabetes and hypertension
Recently quit smoking after 33 years
Sent to cardiac catheterization lab for an angiogram, which revealed
5 blockages
Put on IV heparin, nitroglycerin and beta-blocker
Transferred to ICU
Hypertension was an issue. So medications were adjusted to lower his blood pressure
Surgery for a coronary artery bypass graft was scheduled for the
next morning

40. At Emergency Department
Communication, assessment, performance improvement, and medication management issues.
Step 1
Surveyor speaks with ED Staff
“A little over 2 weeks ago, Mr. Ramponi came into the ED with chest pains and a history of hypertension and diabetes. What processes were followed for triaging and treating him?”
“I see that a cardiac catheterization was necessary; how was informed consent obtained from Mr. Ramponi?”
“You’ve said that like many heart attack victims, Mr. Ramponi delayed seeking help after experiencing the first symptoms. Has your ED conducted any performance improvement projects to decrease the time to begin treatment?”

41. Surveyor reviews Medical Record
Antibiotics were begun at the time of surgery
Sent to ICU with ventilator which was removed 5 hours later
Developed pneumonia within 2 days
IV antibiotic was changed, but history of smoking has weakened his lungs
Placed on ventilator
Wean from ventilator within 6 days
Received pulmonary treatment regimen of nebulizer treatments, incentive spirometry, and assisted cough
Transferred to a general medical unit with telemetry after 3 days
Scheduled to be discharged for continued outpatient rehabilitation

42. Emergency Department points of discussion
Triage process
Patient assessment
Communication prior to patient transfer
Medication process, including for high risk concentrated medications and IV solutions
Communication needs for elderly patients
Competency of medical and nursing staff in emergency care

43. At Cardiac Catheterization Lab
Verbal orders, assessment and emergency care issues
Step 2
Surveyor talks with Staff Nurse and Cardiologist
“What communication took place between the catheterization lab and the ED before Mr. Ramponi arrived for his procedure?”
“What process was used for ensuring medical equipment safety?”
“How did you make certain Mr. Ramponi had no allergies to the contrast medium being used for the procedure?”

44. Catheterization Lab points of discussion
Pre-procedural patient assessment
Patient identification process
Informed consent
Patient privacy and confidentiality
Infection control
Patient monitoring during and after procedure
Use and maintenance of equipment
Sedation and anesthesia use and safety
Frequency of cancellation of procedures and reasons (Quality Improvement project)

45. Surveyor talks to the Staff, Circulating Nurse, Anesthesiologist
At Operating Room
Medication use, anesthesia care, informed consent, site verification, emergency care issues and infection control.
“Patients undergoing bypass surgery are at increased risk of developing a surgical site infection. What preventive measures did you take to help reduce that risk for the patient?”
“What processes do you follow to verify that you had the correct patient and procedure before you started Mr. Ramponi’s surgery?”
Step 3
Surveyor talks to the Staff, Circulating Nurse, Anesthesiologist
“What assessments had been performed and what information did you receive before Mr. Ramponi arrived in the OR?”
“During open-heart surgery, concentrated potassium was used. How is access to this undiluted concentrated electrolyte controlled?”
“Can you explain the process to obtain informed consent for Mr. Ramponi for this surgery?”
Surveyor also requests credentialling files for the anesthesiologist and cardiac surgeon.
“How was the placement of Mr. Ramponi’s pulmonary artery catheter confirmed?”
“What do you do in the event of fire?”
“How do you maintain this equipment? How were you trained to use it?”

46. At Recovery Room
Verbal orders, clinical practice guidelines and equipment management
Step 4
“Following Mr. Ramponi’s surgery, he started on an IV infusion pump for pain management. What checks did you perform on the equipment before starting him on the pump?”
At OR Recovery Area
“What guidelines did you follow for post-anesthesia monitoring of Mr. Ramponi?”
“Who made the decision to discharge Mr. Ramponi from the Recovery, OT?”

47. At Cardiac ICU
Communication, assessment, clinical practice guidelines, credentialling, infection control, equipment management and medication management
Step 5
Surveyor talks with attending Physician, ICU Nurse, Respiratory Therapist, Infection Control Practitioner
“Mr. Ramponi was receiving IV pain medication following surgery. Can you show me where you documented Mr. Ramponi’s pain assessment, treatment and reassessment?”
“Was Mr. Ramponi restrained while on ventilator? How was the decision made to remove Mr. Ramponi from the ventilator?”
“How did the OR communicate what procedures took place when Mr. Ramponi was transferred to the ICU?

48. Cardiac ICU points of discussion
Communications received from Recovery Room
Patient assessment and monitoring
Patient privacy and confidentiality
Infection control
Use and maintenance of equipment, especially clinical alarm systems
Staff competency based on patient populations cared for in ICU
End-of-life issues
Medication management
Handling of verbal orders

49. At Medical - Surgical Unit
Equipment management, patient education, rights & ethics, discharge planning, continuum of care.
“What written information will Mr. Ramponi receive about his medications when he is discharged this afternoon? Does the patient know about his medications? When did you educate him? How?”
“Can you describe Mr. Ramponi’s medication protocols?”
“What process was followed for ordering respiratory therapy for Mr. Ramponi?”
Step 6
Surveyor talks to Staff Nurse, Cardiac Rehab Nurse, Respiratory Therapist, Nutritionist, Patient Educator
“How was nutrition and weight management education provided to the patient?”
“What is your plan for Mr. Ramponi’s discharge?”
“I see that Mr. Ramponi was on telemetry. How would you know if the equipment is working?
Can you explain how the patient is monitored on this system?”
Surveyor reviews patient education materials.
Speaks with Mr. Ramponi and his wife about ongoing education, informed consent process and the care provided.

50. Patient Tracer Summary
Surveyor visits areas within the organization where the tracer patient was physically treated.
Wherever the surveyor is, he/she is assessing numerous standards.
Surveyor might also tour other areas, e.g., laboratory and pharmacy to explore issues such as diagnostics and medication management.
Surveyor could theoretically visit any location in the organization if it related to the care provided to the patient, including registration, dietary dept, physical therapy, outpatient pharmacy, etc.

51. Infection Control Assessment
Assess processes to identify, prevent & manage healthcare acquired infections throughout organization
Uses information obtained from other assessment activities
Facility tour
Tracer activities to inpatient / outpatient care areas
Tracer activities to diagnostic services
Document review
Open & closed record review activities
System tracers activities, e.g. Pharmacy

52. Infection Control System Tracer
Group discussion
Goals
Surveillance data
Analysis
Prevention & control strategies
Areas of concern & action
Outbreaks

53. Infection Control System Tracer Cont.
Focused tracer
Tracing infection control processes across the organization
Example 1: a TB patient admitted through Emergency to Medical Unit to Radiology to Medical Unit to Rehab
Example 2: an immuno-compromised patient admitted through Emergency to Oncology to Intensive Care Unit to Medical Unit to End-of -Life care unit.

54. Data System Tracer Group Discussion 20 Minute presentation – optional
Required measures and sustained improvements reviewed
Steps – selection, collection, analysis, dissemination/transmission, action, monitoring, sustained improvement
How data is used throughout the organization
Short surveys
Include medication management and infection control data issues

55. Benefits of Tracers For Patients For Staff For Organizations
Improves Safety and Quality of care
Improves patient flow
For Staff
Encourages team building
Creates systems thinkers
Creates a better understanding of roles
For Organizations
Reduces risk to patients
Increases patient satisfaction

56. Tracer Methodology
You can learn more in 8 hours of tracing than in 20 hours of chart review

57. Follow-up Process
Written report is required within 6 months for standards that require a plan, policy or procedure, or documentation
Focused survey is required within 6 months for standards that require surveyor observation, staff or patient interviews, or the inspection of the physical facility
If both are required, written report is reviewed at time of focused survey

58. Accreditation Denied
A required follow-up focused survey has not resulted in acceptable compliance with the applicable standards and/or International Patient Safety Goal requirements
JCI withdraws its accreditation for other reasons
Organization voluntarily withdraws from the accreditation process

59. After the Survey Celebrate the success! Let your patients know what
you have achieved
Take a week off and then start again
May need to work on areas for improvement and submit a follow-up progress report to JCI
Maintain the momentum from the survey – establish an ongoing system of standards compliance and survey readiness

60. The Globalization of Healthcare
Color Palette
The Globalization of Healthcare
JCI

61. Why International Standards?
JCAHO standards filled with U.S. and state laws and regulations
JCAHO standards contain many “political” considerations such as requirements for an organized medical staff
JCAHO standards use U.S. jargon such as “advanced directives”
JCAHO standards rely on NFPA requirements for facility review with no international version of those requirements
JCAHO standards have a U.S. cultural overlay for patient rights

62. JCI’s Commitment to Globalization
International Board Members Mandated
International Standards Committee
Regional Offices
Asia Pacific
Europe
Middle East
Regional Advisory Councils
WHO Collaborating Centre for Patient Safety Solutions
International Standards
International Patient Safety Goals
ISQua Accredited
International Surveyors
As Karen mentioned in her presentation, JCI is committed to globalization. We achieve this through . . .

63. Comparisons
International standards include all topics from Joint Commission standards including newer ones related to pain management, and care at the end of life
International standards contain many of the quality control and quality leadership ISO criteria
International standards include the criteria of the European (EFQM) and U.S. (Baldridge) quality award

64. JCI Standards Address Key Issues Relevant to Globalization
Truth in admission policies
Patients are admitted for care only if the organization can provide the necessary services and settings for care.
At admission patients and families are provided information on the proposed care, expected results of care, and expected costs.
There is an established framework for ethical management including marketing, admissions, transfer, and discharge, and disclosure of ownership and any professional conflicts that may not be in the patients’ best interests.

65. JCI Standards Address Key Issues Relevant to Globalization
Professional Competence
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.
The credentials of medical staff members are reevaluated at least every three years to determine their qualifications to continue to provide patient care services in the organization.

66. Accreditation as Part of a Systems Focus
Focusing on staff would mean reviewing the mistakes of individuals
A focus on systems examines conditions where staff work and targets strategy development to ensure that there are fewer errors and risk is reduced

67. Accreditation as Part of a Systems Focus
Errors need to be seen as consequences, not as causes
The best professionals can make the worst mistakes
Errors tend to have recurrent patterns
Organizations should review high reliability systems and anticipate the worst possibilities

68. Accreditation as Part of a Systems Focus
If systems are designed with the full understanding that we do mistakes, and nobody is perfect, errors should occur less frequently.
Furthermore, increasing the consistency of care provision will decrease the frequency of errors.