How Hospital Accreditation facilitates health care quality and patient safety

1. Color Palette How Hospital Accreditation facilitates health care quality and patient safety Healthcare Quality Improvement and Patient Safety Forum 12-13 Dec 2008 Kaohsiung, Taiwan Dr Paul Chang, MBBS, MPH, CPHQ Managing Director, Asia Pacific Joint Commission International

2. Organizational Base • Joint Commission International (JCI) is the international arm of The Joint Commission (TJC). • Established 1997 • TJC and JCI are independent, non-profit, non- governmental agencies

3. Mission of Joint Commission International • To improve the safety and quality of care in the international community through the provision of education, publications, consultation, evaluation, and accreditation services

4. International Accreditation and Certification Programs • Hospitals (1999) – 3rd Edition (2007) • Laboratories (2002) * • Medical Transport (2002) • Care Continuum (2003) • Ambulatory Care (2005) * • Disease Condition-Specific Certification (2005) * • Primary Care (July 2008) * To be revised in 2009

5. JCI European Office Ferney-Voltaire, France JCI Headquarters Chicago, USA JCI Middle East Office Dubai, UAE JCI Asia-Pacific Office Singapore JCI Accredited Organizations Demark Ireland Germany Cz. R. Aus Swz. Italy Spain Turkey S. Korea China Lebanon Jordan Bermuda Pakistan Taiwan Egypt Qatar India Mexico UAE Saudi Arabia Bangladesh Hong Kong Thailand Philippines Barbados Costa Rica Ethiopia Malaysia Singapore Indonesia Brazil Chile To date, more than 200 in 28 countries

6. Accredited Organizations in Asia-Pacific Region 1 1 1 3 1 2 2 4 1 13 1

7. Accreditation – A Definition • Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standards that require continuous improvement in structures, processes, and outcomes. • Usually a voluntary process • Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions • Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standards

8. Accreditation – A Definition • Accreditation is often confused with: • Licensure-governmental activity that sets minimum standards to protect the public • Certification- evaluates special capability or unique skills/ability

9. Need for Accreditation In 1918, the American College of Surgeons described the need for standardization of hospitals through accreditation as the need to: “Encourage those which are doing the best work, and to stimulate those of inferior standard to do better.”

10. 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.

11. How safe is healthcare? Safe (<1/100K) Dangerous (>1/1000) Risky 100,000 Healthcare Regular air transport Driving 10,000 Deaths / year 1000 Mountain climbing Chemical industry European railways 100 10 Charter flights Bungee jumping Nuclear power 1 Contacts / 1 death

12. “Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous.” Sir Cyril Chantler, former Dean Guy’s, King and St. Thomas’s Medical and Dental School, Lancet 1999

13. Accreditation - A World Trend • The U.S., Canada, and Australia have the oldest accreditation systems • In Europe, Germany, France, Ireland and Spain have new accreditation systems • In Japan, Korea, Malaysia, and Thailand there are new systems with government role • The WHO, World Bank and development banks recognize and endorse the accreditation model

14. Potential Returns on Accreditation • Improved care – fewer complications • Better reputation -- increased number of new patients • More satisfied staff – better retention and lower recruitment and training costs • More efficient, cost effective work processes

15. Potential Returns on Accreditation • Better preventive maintenance program – longer life of biomedical equipment • Special recognition from payment sources and insurance companies • Greater clarity to leadership structure and quality oversight • Better safety management, and risk reduction – reduced liability exposure

16. Questions to Ask • How does accreditation lead to enhancement of patient and staff safety? • Is it a result of compliance of standards? • Or is it a function of the survey methodology? • Do you have the data to prove what you aretelling us?

17. Joint Commission International Standards • Set optimum, achievable expectations • Focus on the patient • Designed to be interpreted/surveyed within the local culture and legal framework • Stimulates continuous improvement

18. Diverse Sources of Input for Standards • Scientific literature • Research findings • Survey compliance data • Input from field experts and key stakeholders • Regional Advisory Councils • JCI staff and surveyors

19. Rigorous Review and Approval Process • Consensus of the Standards Subcommittee (12 members) • Review by individual experts or expert panels • Focus groups on select areas • Internet review by as many international users as possible • Final approval by Accreditation Committee and the Board of JCI

20. Questions to Ask • How does accreditation lead to enhancement of patient and staff safety? • Is it a result of compliance of standards? • Or is it a function of the survey methodology? • Do you have the data to prove what you aretelling us?

21. The JCI Evaluation Process • Covers all portions of an organization and all systems of care and management • Is focused on what happens to patients – patient tracers used • Is proactive – evaluates the likely quality and safety of patient care in the future

22. Tracer Methodology Tracers provide the methodology to assess an organization’s systems and processes by; • Following the treatment path an individual patient has taken in the hospital, or • Following a process in the hospital from a beginning to an endpoint. • It is about areas for improvement

23. The Transparent JCI Process Accreditation Decision Rules On-site Evaluation of Standards Accreditation Certificate International Standards

24. Questions to Ask • How does accreditation lead to enhancement of patient and staff safety? • Is it a result of compliance of standards? • Or is it a function of the survey methodology? • Do you have the data to prove what you aretelling us?

25. Decreases in Medication Errors

26. Reduction of Complications at American Hospital, Dubai, UAE • During preparation for re-accreditation: • Emphasis on prevention of hospital associated infections • New Clinical guidelines introduced N/100 device days

27. Reduction of Ventilator-Associated Pneumonia at

28. Reduction in VAP Rates– National University Hospital, Singapore Target ________ NNIS ------------

29. Reduction of Complications at “Istituto Giannina Gaslini”NI/PICU * Mortality (%) from hosp acq. Infections ** Hosp acq. Infections (per 1000 pt days) *** Hosp acq. Pneumonia (per 1000 pt days)

30. Improved Patient Safety Indraprastha Apollo Hospital, New Delhi, India

31. Unscheduled Returns to ICU Rates (Q1 2002 to Q4 2004) in National University Hospital, Singapore Comparison With Project-Wide & S'pore Public Hospital Rates

32. Handwashing – Pt Safety

33. Patient Falls (%) Apollo Hospitals INDIA touching lives Indraprastha Apollo Hospital, New Delhi, India

34. Needlestick Injuries – Changi General Hospital, Singapore The rate of needlestick injuries per 1000 healthcare workers was reduced from 7.91 in 2003 to 3.48 in 1st 6 months of 2005, an improvement of 127%

35. So Far So Good • These are individual reports, dealing with segments of hospital operations – Anecdotal accounts • To study it systematically, • One ME hospital embarked on a study of the effect of the process, not of the outcome, before and after JCI accreditation

36. Study Details • 400 bed Government Hospital in ME • Accredited in 2007 • Studied before start of project to comply with JCI standards • Repeat study 15 months later (before survey) • Perceptions of stakeholders studied by questionnaires • 100 point indices Hassan, DK & Kanji, GK: Measuring Quality Performance in Healthcare 2007. Kingsham Press, Chichester, UK

37. Findings of Study • All stakeholder groups reported improvement in every dimension measured • Overall improvement: 49% over baseline Main Areas of Improvement Leadership & management Quality improvement Patient safety Pt satisfaction & “delight” Ethical performance Documentation Organizational learning Organizational excellence Areas of Lesser Improvement Corporate structure Human resources management Staff satisfaction

38. Accreditation:Does it Make a Difference? • Joint Commission International has conducted descriptive research with a sample of accredited hospitals to determine the value of accreditation • Accredited hospitals report significant improvements in: • Leadership • Medical records management • Infection control • Reduction in medication errors • Staff training and professional credentialing • Improved quality monitoring

39. Dear Dr. Paul, I was meeting with Dr. Chatree yesterday and he wanted me to share with you what we have just discovered about the Disease Specific Process. Even though we have not completed the process of Disease Specific certification the programs have been in place for months as we adjust and improve the pathways. Dr. Chatree presides over the monthly meeting to review the CSI report (Customer Satisfaction Index). As you know our CSI scores are quite high, however this month there was a significant and remarkable jump in the scores of the sections affiliated with the pathways - stroke, heart, and cancer. No one would have predicted it this soon and no one expected it. But the results told the story.

40. Other benefits • Recognition by Payers, Governmental Agencies and Vendors • Marketing tool • Increased patient volumes • Increased organizational efficiencies • Decreased wastage

41. Conclusion • JCI accreditation assists organizations in enhancing quality and safety in their organization through: • Internationally accepted, maximum achievable standards that are regularly reviewed • Transparent, objective survey methodology that emphasises frontline, on-the-ground practices for demonstrating compliance • Focus on fostering a culture of leadership, accountability and drive for continuous improvement that will support sustained improvements in the organization.

42. Thank You. Arigato Grazie. Sukran Shukran Obrigado Danke Xie Xie Do jeh Tak tesekkür ederim Komawoyo