jcia outline by dr.mahboob ali khan phd

JCIA Outline

Dr.Mahboob ali khan Phd

Renowned Healthcare Quality

Consultant

Objectives

Upon the completion of this presentation audience will be able to:

Acknowledge the importance of team work to achieve

JCIA

Define the following terms: accreditation, standard.

List the JCI-Patient-Centered Standards

List the JCI-Health Care Organization Management Standards

Slide 2

Definitions

JCI Accreditation: Determination by the Joint Commission International (JCI) accrediting body that an eligible health care organization complies with applicable JCI standards.

Standard: A statement that defines the performance expectations, structures, or processes that must be in place for an organization to provide safe and high-quality care, treatment, and service.

Slide 3

Once upon a time there wasWerean(A)Arabianand(B) rowing team s

أ و ب

Slide 5

Arabian(A)

team and(B)Japanteam agreed to do an annual rowing race. Each team should contain 8 men.

)أ( )ب(

Both teams worked really hard to get in the best shape.

The day the race started both teams were in similar

condition. ....Teamthe Japanese(B) won by 1 mile.

....

ال )ب( يرف ق

Slide 8

FINISHالنهاية

Slide 9

The mood in the Arabian(A) team was really close to the freeze

point. The top management decided to win the race next year. So they established a team of analysts to observe the situation and recommend an appropriate solution.

)أ(

....

Slide 10

After several detailed analysis the team found out that

(B)Japaneseteam had 7 rowers and only one captain.

)ب( 7

Slide 12

(B )

Team

Slide 13

Of course the Arabian(A) team had 7 captains but only one rower.

)أ( 7

Slide 14

(A ) Team

Slide 15

After several months the consultants came up with

the conclusion that there were too many captains and

too few rowers in the Arabian)A( team. A solution

was proposed based on this analysis: the structure of

the Arabian)A( team has to be changed!

)أ(

)أ(

Slide 17

As of today there will be only 4 captains in the team led by 2

managers, one top-manager and one rower. Besides that, they

suggested to improve the rower’s working environment and to give

him higher competencies.

4

Slide 18

(A ) Team

Slide 19

Next year theTeamJapanese)B( won by 2 miles.

)ب( 2

Slide 20


Slide 21

The Arab)(ian team immediatelly displaced the rower from the team based on his unsatisfactory performance.

)أ(

Slide 22

But the bonus award was paid to the

management for the strong motivation the the

team showed during the preparation phase.

Slide 23

The consulting company prepared a new analysis,

which showed that the strategy was good, the

motivation was O.K. but the used tool has to be

improved.

Slide 24

Currently the Arabian)( team is designing a new boat.

)أ(

Slide 25


Slide 26

JCI-Patient-Centered Standards

International Patient Safety Goals (IPSG)

Access to Care and Continuity of Care (ACC)

Patient and Family Rights (PFR)

Assessment of Patients (AOP)

Care of Patients (COP)

Anesthesia and Surgical Care (ASC)

Medication Management and Use (MMU)

Patient and Family Education (PFE)

Slide 28

1. International Patient Safety Goals

(IPSG)

The International Patient Safety Goals (IPSG) promote specific improvements in patient safety. The goals highlight problematic areas in health care and describe evidence- and expert-based consensus solutions to problems related to patient safety. Recognizing that sound system design is intrinsic to the delivery of safe, high-quality health care, the goals generally focus on system wide solutions, whenever possible.

29

International Patient Safety Goals

(IPSG)

Goal 1: Identify Patients Correctly

Goal 2: Improve Effective Communication

Goal 3: Improve the Safety of High-Alert Medications

Goal 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery

Goal 5: Reduce the Risk of Health Care–Associated infections

Goal 6: Reduce the Risk of Patient Harm Resulting from Falls

Armed Forces Hospital, Southern Region

Policies

Policy Policy Title

No.

ACC.1 Improving Patient Identification

AOP.1 Verbal and Telephone Orders

AOP.2 Reporting of Critical Results

ACC.2 Hand Off Communication

MMU.1 Improving Safety of High-Alert Medications

ASC.1 Surgical Invasive Procedure Site Verification, Marking and Time out

PCI.1 Improving Hand Hygiene to Prevent Health Care-Associated

Infections

AOP.3 Adult Falls Assessment and Prevention Plan

AOP.4 Pediatric Falls Assessment and Prevention Plan

Slide 31

2. Access to Care and Continuity of Care (ACC)

These standards address which patient needs can be met by the hospital, the efficient flow of services to patients, and the appropriate transfer or discharge of patients to their home or to another care setting.

32

Access to Care and Continuity of Care (ACC)

Screening for Admission to the Hospital

Admission to the Hospital

Continuity of Care

Discharge, Referral, and Follow-Up

Transfer of Patients

Transportation

Slide 33

Armed Forces Hospital, Southern

Region Policies

Policy Policy Title

No.

ACC.3 Access to Armed Forces Hospital, Southern Region Services and

Out Patient Registration

ACC.4 Standard Screening and Diagnostic Tests

ACC.5 Responsibility of Patient Care and Managing Patients when there is

a Delay for Diagnostics and Treatment Services

ACC.6 Reduction of Barriers to Access and Delivery of Services

ACC.7 Elective Admission of Patients

ACC.8 Emergency Admission of Patients

ACC.9 Intensive Care Unit Admission, Discharge and Transfer Criteria

ACC.10 Pediatric Intensive Care Unit Admission, Discharge and Transfer

Criteria

ACC.11 Coronary Care Unit Admission, Discharge and Transfer Criteria

Slide 34


Region Policies

Policy Policy Title

No.

ACC.12 Neonatal Intensive Care Unit Admission, Discharge and Transfer

Criteria

ACC.13 Renal Transplant Unit Admission, Discharge and Transfer Criteria

ACC.14 Continuity and Coordination of Patient Care Services

ACC.15 Outpatient Medical Care Profile

ACC.16 Patient Referral, Discharge Planning and Discharge Process

ACC.17 Discharge Summary

ACC.18 Patient Transfer within the Hospital

ACC.19 Patient Transfer to another Healthcare Facility

Slide 35

3. Patient and Family Rights (PFR)

These standards address issues such as promoting consideration of patients’ values, recognizing the hospital’s responsibilities under law, and informing patients of their responsibilities in the care process. Standards regarding patient rights with respect to informed consent, resolution of complaints, and confidentiality are also included.

36

General Consent

Informed Consent

Organ Donation

Slide 37


Region Policies

Policy Policy Title

No.

PFR.1 Patient’s and Family Rights and Responsibilities

PFR.2 Improving Patient and Families Participation in Care Process

PFR.3 Informed Consent

PFR.4 Patient Right of Refusal or Discontinuing of Treatment

PFR.5 Do Not Resuscitate DNR

PFR.6 Patient and Family Complaint

PFR.7 Organ and Tissue Procurement

PFR.8 Safe Keeping of Patient Belongings

PFR.9 Identification and Reporting of Adult or Child Abuse and Neglect

PFR.10 General Consent

Slide 38

4. Assessment of Patients (AOP) These standards addresses patient assessment at all

points of care within the hospital. Assessment includes collecting information and data on the patient’s physical and psychosocial history, analyzing the data and information to identify the patient’s health care needs, and developing a plan of care to meet those identified needs. It also includes standards that address laboratory services and diagnostic imaging and radiology services.

39


Region Policies

Policy Policy Title

No.

AOP.5 Outpatients Assessment and Reassessment

AOP.6 Inpatients Assessment and Reassessment

AOP.7 Triage Process and Emergency Patients Assessment

AOP.8 Pre Anesthesia/ Sedation Assessment and Reassessment

AOP.9 Skin Care Assessment

AOP.10 Nutritional Screening, Initial Assessment and Reassessment

PFR.11 Patient Social Assessment and Reassessment

PFR.12 Initial Physiotherapy Assessment and Reassessment of Patients

PFR.13 Obstetric Patients Assessment and Management in Emergency

Room

AOP.14 Assessment and Reassessment of Dialysis Patients

Slide 40


Region Policies

Policy Policy Title

No.

AOP.15 Respiratory Therapy Assessment and Reassessment of Patients

AOP.16 Assessment and Care of Patients at End of Life

AOP.17

AOP.18

AOP.19 Managing the Clinical Laboratory Services

AOP.20 Laboratory Quality Control Program

PFR.21 Laboratory Safety Program

PFR.22

PFR.23 Ordering Laboratory Tests

AOP.24 Laboratory Turnaround Times

Slide 41


Region Policies

Policy Policy Title

No.

AOP.25 Guideline for Evaluating the Laboratory Reagents

AOP.26 Collection and Identification of Specimens

AOP.27 Laboratory Specimens Handling: Receiving, Tracking, Storage,

Recording and Disposal

AOP.28 Laboratory Proficiency Testing

AOP.29 Managing the Radiology and Diagnostic Imaging Services

AOP.30 Radiology Quality Control Program

PFR.31 Radiation Safety Program

PFR.32 Laboratory and Radiology Equipment and Medical Technology

Management Program

PFR.33 Reassessment of Non-Acute Inpatients

Slide 42

5. Care of Patients (COP) These standards discusses activities basic to patient

care, including processes for planning and coordinating care, monitoring results, modifying care, and conducting follow-ups. It also includes high-risk care services, nutrition care, pain management, and end-of-life care.

43


Region Policies

Policy Policy Title

No.

COP.1 Law, Regulation and Uniform Patient Care

COP.2 Physician Orders

COP.3 Recognition and Management of Anaphylactic Reactions

COP.4 Code Blue Protocol

COP.5 High Risk Services and High Risk Patients

COP.6 Care of Comatose Patients

COP.7 Care of Patient on Ventilator

COP.8 Use of Patient Restraints

COP.9

COP.10 Care of Patients Receiving Dialysis

Slide 44


Region Policies

Policy Policy Title

No.

COP.11 Care of Patients Receiving Chemotherapy

COP.12 The Handling, Use, and Administration of Blood and Blood Products

COP.13 Pain Assessment and Management

COP.14 Kidney Transplant Program

COP.15 Rapid Response Team

COP.16 Breastfeeding

COP.17 Caesarian Section Guidelines

COP.18 Guideline for the Management of ST-Elevation Myocardial Infarction

COP.19 Guideline for the Management of Patients With Non–ST-Elevation

Acute Coronary Syndromes

COP.20 Clinical Practice Guidelines for the Management of Hypertension in

Adults

Slide 45


Region Policies

Policy Policy Title

No.

COP.21 Clinical Guidelines for Management of Community Acquired

Pneumonia in adult

COP.22 Clinical Guidelines for Management of Asthma in Children

Slide 46

6. Anesthesia and Surgical Care

(ASC)

Slide 47

Anesthesia and Surgical Care (ASC)

These standards addresses sedation and anesthesia use and surgical care. Topics include procedures for preparing, monitoring, and planning for aftercare for patients who received sedation or anesthesia and/or who had surgery.

48


Region Policies

Policy Policy Title

No.

ASC.2 Procedural Sedation Patient Care Guidelines

ASC.3 Anesthesia Patient Care Guidelines

ASC.4 Criteria for Recovery and Discharge from Sedation and Anesthesia

ASC.5 Special Consideration for Surgical Care Including Implanting of a

Medical Device

ASC.6 Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery

ASC.7 Risk of Surgical Fires

Slide 49

7. Medication Management and Use

(MMU)

Slide 50

Medication Management and Use

(MMU)

These standards addresses systems and processes for selecting, procuring, storing, ordering/prescribing, transcribing, distributing, preparing, dispensing, administering, documenting, and monitoring medication therapies.

51


Region Policies

Policy Policy Title

No.

MMU.2 Medication Organization and Management

MMU.3 Hospital Formulary and Medication Procurement

MMU.4 Storage of Medication and Nourishment

MMU.5 Emergency Medication and Crash Cart Management

MMU.6 Medication Recall

MMU.7 Medication Ordering, Appropriateness Review and Administration

MMU.8 Medication Samples

MMU.9 Patient's Own Medication Brought to the Hospital

MMU.10 Monitoring Medication Effect on patients and Adverse Drug Effects

MMU.11 Medication Errors and Near Misses Prevention and Reporting

MMU.12 Antibiotic Control

Slide 52

8. Patient and Family Education (PFE) These standards address the

effectiveness of education that is provided to patients and families and the modalities employed to successfully educate these individuals. It also examines patients’ readiness to learn by considering their language needs and learning preferences.

53

JCI-Health Care Organization

Management Standards

Quality Improvement and Patient Safety (QPS)

Prevention and Control of Infections (PCI)

Governance, Leadership, and Direction (GLD)

Facility Management and Safety (FMS)

Staff Qualifications and Education (SQE)

Management of Information (MOI)

Slide 54

Organization Functions

The chapters in the third section of the manual examine the benefits of the hospital’s management system for

patients, focusing on core processes that support good management. Examples of core processes include

leadership requirements, infection prevention and control, and the qualifications and education of staff.

55

9. Quality Improvement and Patient

Safety (QPS)

The standards in this chapter identify the structure, leadership, and activities to support the data collection,

analysis and improvement for the identified priorities—hospitalwide and department- and service-specific.

This includes the collection and analysis of data on, and response to, hospitalwide sentinel events, adverse

events, and near-miss events. The standards also describe the central role of coordinating all the quality

improvement and patient safety initiatives in the hospital and providing guidance and direction for staff

training and communication of quality and patient safety information. The standards do not identify an

organizational structure, such as a department, as this is up to each hospital to determine.

56


Region Policies

Policy Policy Title

No.

QPS.1 Guiding and Managing Effective Program of Continuous Quality

Improvement, Patient Safety and Risk Management

QPS.2 Internal Data Validation Process

QPS.3 Sentinel Event, Near Misses and Root Cause Analysis

QPS.4 Data Analysis

QPS.5 Failure Mode and Effect Analysis

Slide 57

10. Prevention and Control of

Infections (PCI)

These standards address the methods a hospital uses to design and implement a program to identify and

reduce the risk of patients and staff acquiring and transmitting infections. Areas covered in this chapter

include the process for reporting infections and the types of ongoing surveillance activities that are in place.

58


Region Policies

Policy Policy Title

No.

PCI.2 Respiratory Hygiene and Cough Etiquette

PCI.3 Ventilator-Associated Pneumonia Prevention and Reduction

PCI.4 Catheter-Associated Urinary Tract Infections Prevention and

Reduction Program

PCI.5 Intravascular Catheter-Associated Infections Prevention and

Reduction Program

PCI.6 Surgical Site Infection Prevention and Reduction

PCI.7 Epidemiologically Significant Organisms Prevention and Reduction

PCI.8 MERS-Novel Coronavirus

PCI.9 Work Practice Controls

PCI.10 Employee Infectious Disease Prevention Program

Slide 59


Region Policies

Policy Policy Title

No.

PCI.11 Reuse of Disposables (Single-use) and Management of Expired

Supplies

PCI.12 Needles and Sharps Management

PCI.13 Infectious and General Waste Management

PCI.14 Management of Multi and Single-Dose Vials/Ampule Solutions

PCI.15 Care of Refrigerators and Freezers

PCI.16 Kitchen Sanitation and Food Preparation and Handling

PCI.17 Linen Management

PCI.18 Toy Selection, Cleaning and Storage Guidelines

PCI.19 Operation of the Mortuary

PCI.20 Cleaning and Decontaminating Spills of Blood or Other Body Fluids

Slide 60


Region Policies

Policy Policy Title

No.

PCI.21 Handling Contaminated Uniforms/Street Clothing

PCI.22 Transporting Laboratory Specimens

PCI.23 Blood and Body Fluid Exposure Evaluation and Follow-up

PCI.24 Prevention and Control of Infection Risk Assessment

PCI.25 Processing Endoscopes

PCI.26 Operating department Practice to Prevent Healthcare Associated

Infection in Patients

PCI.27 Personal Protective Equipments, Standard Precaution and Surface

Disinfection

PCI.28 Infectious Patients and Isolation Precautions

PCI.29 Immunocompromised Population

PCI.30 Prevention and Control of Infection Education Program

Slide 61

11. Governance, Leadership, and

Direction (GLD)

Effective leadership depends on successfully performing the following processes:

Planning and designing services—defining a clear mission, including a vision of the future and the values that underlie day-to-day activities

Directing services—developing and maintaining policies, providing an adequate number of staff, and determining their qualifications and competence

Integrating and coordinating services—identifying and planning the clinical services required and integrating and coordinating those services within and between departments

Improving performance—leaders’ critical roles in initiating performance and maintaining a hospital’s performance improvement activities

The GLD chapter has been greatly expanded in the fifth edition standards, focusing even more importance on the role of leadership in a hospital’s safe and effective operation.

62


Region Policies

Policy Policy Title

No.

GLD.1 Hospital Governance, Leadership and Organization Chart

GLD.2 Contracts and Agreements Monitoring

GLD.3

GLD.4 Ethical Management Framework

GLD.5 Plan of Services and Staffing Plan

GLD.6 Standardization of Clinical Care Processes

Slide 63

12. Facility Management and Safety

(FMS)

These standards measure the hospital’s maintenance of a safe, functional, and effective environment for patients, staff members, and other individuals. Areas addressed include emergency preparedness, security, safety, life safety, medical equipment, utility systems, hazardous materials, and waste management.

64


Region Policies

Policy Policy Title

No.

FMS.1 Safety Orientation Program

FMS.2 No Smoking Policy

FMS.3 Environment of Care Rounds

FMS.4 Laser Safety

FMS.5 Restriction the Cellular Phones use in Critical Areas

FMS.6 Use of Adaptors and Extension Cords

FMS.7 Interim Life Safety Measures (ILSM)

FMS.8 Lost and Found Items

FMS.9 Violent Patients or Personnel (Code Gray)

FMS.10 Newborn, Infant, And Child Security (Code Pink)

Slide 65


Region Policies

Policy Policy Title

No.

FMS.11 Communication with Military Police

FMS.12 Bomb Threat (Code White)

FMS.13 Hazardous Material Spill (Code Orange)

FMS.14 Handling of Compressed Gases

FMS.15 Medical Equipment Tagging, Repair, Removal from Service and

Recall

FMS.16 Hazardous Chemical and Radioactive Waste Management

Slide 66

13. Staff Qualifications and

Education (SQE)

This chapter includes sections on human resources planning; staff orientation, training, and education; staff competence assessments; handling staff requests; and credentialing and privileging of licensed independent practitioners, nurses, and other practitioners.

67


Region Policies

Policy Policy Title

No.

SQE.1 Job Description

SQE.2 Personnel Files

SQE.3 Hospital Staffing Strategy

SQE.4 Credentialing of Healthcare Providers and Appointment of Medical

Staff

SQE.5 Granting of Medical Staff Privileges

SQE.6 Professional Practice Evaluation and Annual Review of Healthcare

Providers

SQE.7 Staff Health and Safety and Workplace Violence

Slide 68

14. Management of Information (MOI)

Formerly named Management of Communication and

Information (MCI), these standards have been focused

to address how well the hospital obtains, manages, and

uses information to provide, coordinate, and integrate

services. The principles of good information

management apply to all methods, whether paper-based

or electronic, and JCI standards are equally compatible

with either method:

Information Management

Management and Implementation of Documents

Patient Clinical Record

69


Region Policies

Policy Policy Title

No.

MOI.1 Information Privacy, Confidentiality and Security

MOI.2 Medical Record Accessibility and Confidentiality of Patient’s

Information

MOI.3 Medical Record and Data Retention

MOI.4 Policies and Procedures Development and Maintenance

MOI.5 Hospital Programs Development and Maintenance

MOI.6 Approved Abbreviations

MOI.7 Documentation Guidelines

Slide 70

What is next ?

Every staff has a role in the accreditation process regardless of his/her position, it requires collaborative efforts and team work!

Think were you want to belong?

Slide 71

(A ) (A ) Team

Team

Slide 72

(B )

Team

Slide 73

Questions? Comments?

Slide 74