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JCI Accreditation – International Standards of

Excellence for Primary Care

John Sweeney, Director HCI

Partner, Ireland

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1910

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1. Each hospital should have a medical staff.

2. The members of the medical staff should be

chosen based on graduation from medical

school, competency, and character.

3. There should be regular staff meetings to

review cases.

Ernest Codman

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4. Medical records should be written and filed

for all cases.

5. Each hospital should have a clinical

laboratory and radiology section.

Ernest Codman

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Waldorf Astoria New York

89 of 692

Burned

Unable to demonstrate Quality of Care

No framework for what that is ….

50 years….

Ernest Codman

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Today

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Building Control Authority Environmental Protection Agency Radiological Protection Institute of Ireland

Health & Safety Authority of Ireland Food Safety Authority of Ireland (EHO's)Pharmaceutical Society of

Ireland Health Services Executive CORU - Health and Social Care Professionals HIQA - Infection

Control Mental Health Commission National Disability Authority Clinical Indemnity Scheme Irish Medical

Council An Bord Altranais Opticians Board Dental Council Irish Medicines Board Irish Blood Transfusion

Service Royal College of Physicians in Ireland Faculty of Occupational Medicine Faculty of Paediatrics

Faculty of Public Health Medicine Institute of Obstetricians & Gynaecologists Royal College of Surgeons

in Ireland Faculty of Dentistry Faculty of Radiologists Irish College of Anaesthetists Irish College of

General Practitioners in Ireland Irish College of Psychiatrists Irish College of Ophthalmologists Irish

Society of Chartered Physiotherapists National Treatment Private Health Insurance Purchase Fund

Joint Assessment Group (GI )HIQA Pre-Hospital Emergency Care Council Fire Officers Excellence

Ireland National Standards Authority of Ireland Joint Commission International CHKS Accreditation

Centre for the Development of Nursing Policy and Practice, University of Leeds Irish National

Accreditation Board Clinical Pathology Accreditation (UK) Academy of Medical Laboratory Science

National Council for the Professional Development of Nursing and Midwifery NERA - National

Employment Rights Authority

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Gaps?

2006 – 75%

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9

Voluntary Process

Centers of Excellence

Framework for Clinical Care +

Demonstrable Evidence of Quality (VHI)

Not for all – NH – 3 of 700+

Accreditation – A Definition

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10

JCI

• Quality, Risk and Regulation• Ireland and Australia• Team of 20 MD including R&D• Compliance– HIQA, IMB, ISO, ACHS• Founded in 2005

Health Care Informed (HCI)

JCI

Transforming patient safety and quality of

care

• Leading accrediting body for health care institutions in the US

• Founded in 1951• >19,000 accredited institutions

The Joint Commission

• JCI is the international arm of the Joint Commission• Framework for Centers of Excellence• Work with health care orgs, NGOs, and governments• 400+ JCI accredited organizations – 85 Countries• Ireland 1999

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Mayo Clinic - Cleveland Clinic – John Hopkins -

Mount Sinai Medical Center – Mass. Gen Hospital

Ireland (22 +)– Mater Private, Hermitage Clinic, Blackrock,

Bon Secours, Galway Clinic, St Vincent’s UH, VHI Homecare, Ambulance Services, LTC….

Primary Care – Spain, Brazil, UAE, Singapore

JC Accreditation

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12

Community Involvement and Integration

Management of the Processes of Care

Patient and Family Rights

Assessment of Patients

Care of Patients

Patient and Family Education

Management Structure and Leadership

Primary Care Accreditation

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13

Management of Information

Facility Management and Safety

Staff Qualifications and Education

Surveillance, Prevention, and Control of Infection

Quality Improvement and Patient Safety

Adverse Event Identification, Analysis, and

Prevention

Primary Care Accreditation

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14

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International Patient Safety Goals

1. Identify Patients Correctly

2. Improve Effective Communications

3. Improve the Safety of High-Alert, High Risk Medications

4. Eliminate Wrong-side, Wrong-patient, Wrong-procedure

Surgery

5. Reduce the Risk of Health Care-acquired Infections

6. Reduce the Risk of Patient Harm Resulting from Falls

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Measures for Improvement

Clinical Measure: associated with the delivery of health care; may be diagnosis or procedure specific

Health Status Measure: addresses the functional well-being of specific populations

Patient Satisfaction Measure: focus on the delivery of clinical care from the patient’s, family’s or caregiver’s perspective

Financial/Administrative Measures: addresses organisational structure, utilization rates, operations or financial management

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Tracer Evaluation

An effective way to assess a healthcare

organization’s performance of care and the

services provided as viewed or

experienced by the patient.

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JCI Network

Communication - Newsletters

Education and Support

Network Meetings

Leadership Seminar – Patient Safety

Information Exchange

Quality Initiatives

Promotion

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What does it Accomplish?

Improves Patient Care – Peer Review

Continuous – Centres of Excellence

Increase efficiency/reduce costs

Improve the management of business services

Enhance staff recruitment and retention

Public Confidence - Reputation

Other Stakeholders - Reputation

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Does it Work?

“A better way of structuring how we

provide care and run our business”

Nicky Jermyn, CEO St Vincent’s University

Hospital

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Tomorrow ..