Dr.Ihab Nada,M.D Director of education MSKMC JOINT COMMISSION INTERNATIONALACCREDITATION STANDARDS FORHOSPITALS
MISSION • The mission of Joint Commission International (JCI) is to improve the safety and quality of care in the international community
JCI was created in 1998 as the international arm of The Joint Commission (United States) , The process of developing standards is actively overseen by an expert international task force, whose members are drawn from each of the world’s populated continents . JCI standards are the basis for accreditation and certification of individual health care facilities and programs around the world.
What is accreditation? • Accreditation is a process in which an entity, usually nongovernmental, assesses the health care organization to determine if it meets a set of requirements (standards) designed to improve the safety and quality of care.
What are the benefits of accreditation? • Accreditation has gained worldwide attention as an effective quality evaluation and management tool. • improve public trust that the organization is concerned for patient safety and the quality of care; • provide a safe and efficient work environment that contributes to worker satisfaction;
negotiate with sources of payment for care with data on the quality of care;
How frequently will the standards be updated? • the standards will be revised and published at least every three years.
Accreditation Surveys • • interview with staff and patients and other verbal information; • • on-site observations of patient care processes by surveyors; • • policies, procedures, clinical practice guidelines, and other documents provided by the organization
Goal 1: Identify Patients Correctly • using two patient identifiers, • before administering medications, blood, • before taking blood and other specimens or providing treatments
Goal 2: Improve Effective Communication • The complete verbal and telephone order or test result is written down , and is read back by the receiver of the order then it is confirmed by the individual who gave the order or test result.
Goal 3: Improve the Safety of High-Alert Medications • High-alert medications are those medications involved in a high percentage of errors • medications that carry a higher risk for adverse outcomes, • look-alike/sound-alike medications • example, concentrated electrolytes as potassium chloride 2 mEq/ml concentrated
How to improve safety • removing the concentrated electrolytes from the patient care unit to the pharmacy. • clearly labeled and stored in a manner that restricts access.
Goal 4: Ensure Correct-Site, Correct-Procedure,Correct-Patient Surgery • mark for surgical-site identification and involves the patient in the marking process • The organization uses a checklist to verify preoperatively the correct site, correct procedure, and correct patient and that all documents and equipment needed are on hand, correct, and functional.
The full surgical team conducts and documents a time-out procedure just before starting a surgical procedure.
Goal 5: Reduce the Risk of Health Care–AssociatedInfections • include catheter-associated urinary tract infections, blood stream infections, and pneumonia(often associated with mechanical ventilation). • Via effective hand-hygiene program.
Goal 6: Reduce the Risk of Patient HarmResulting from Falls • initial assessment of patients for fall risk • Measures are implemented to reduce fall risk for those assessed to be at risk.
Access to Care and Continuity of Care (ACC)
1-Admission to the Organization • To have a process for admitting inpatients and for registering outpatients. • Patients with emergent, urgent, or immediate needs are given priority • The organization considers the clinical needs of patients when there are waiting periods or delays for diagnostic and/or treatment services.
At admission as an inpatient, patients and families receive information on the proposed care, the expected outcomes of that care, and any expected cost to the patient for the care. • Admission or transfer to or from units providing intensive or specialized services is determined by established criteria.
2-Continuity of Care • During all phases of inpatient care, there is a qualified individual identified as responsible for the patient’s care.
3- Discharge, Referral, and Follow-Up • The organization cooperates with health care practitioners and outside agencies to ensure timely and appropriate referrals. • The clinical records of inpatients contain a copy of the discharge summary.
The clinical records of outpatients receiving continuing care contain a summary of all known diagnoses, drug allergies, current medications, and any past surgical procedures and hospitalizations. • Patients and, their families are given understandable follow-up instructions. • The organization has a process for the management and follow-up of patients who leave against medical advice.
4-Transfer of Patients • The transfer process addresses who is responsible during transfer and what supplies and equipment are required during transport. • The referring organization determines that the receiving organization can meet the needs of the patient to be transferred.
Patient clinical information or a clinical summary is transferred with the patient. • During direct transfer, a qualified staff member monitors the patient’s condition. • The transfer process is documented in the patient’s record.
5-Transportation • The transportation provided or arranged is appropriate to the needs and condition of the patient. • There is a process in place to monitor the quality and safety of transportation provided or arranged by the hospital, including a complaint process.
Respond to the patient’s requests related to religious beliefs • Care is respectful of the patient’s need for privacy. • Patients are protected from physical assault. • Patient information is confidential.
MSKMC will inform pts & family with diagnosis ,ttt plan , complications and consequences of refusing or discontinuing ttt The organization supports the patient’s right to respectful and compassionate care at the end of life.
Patient informed consent is obtained • The organization informs patients and families about how to gain access to clinical research, clinical investigation, or clinical trials involving human subjects. • Informed consent is obtained before a patient participates in clinical research, clinical investigation, and clinical trials.
Assessment of Patients (AOP)
Each patient’s initial assessment(s) includes an evaluation of physical, psychological, social, and economic factors, including a physical examination and health history. • Assessment findings are documented in the patient’s record and readily available to those responsible for the patient’s care.
All patients are reassessed at intervals based on their condition and treatment to determine their response to treatment and to plan for continued treatment or discharge. • Qualified individuals conduct the assessments and reassessments.
Laboratory Services • All equipment used for laboratory testing is regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities. • Procedures for collecting, identifying, handling, safely transporting, and disposing of specimens are followed. • A laboratory safety program is in place, followed, and documented.
Radiology and Diagnostic Imaging Services • Radiology and diagnostic imaging services are provided by the organization or are readily available through arrangements with outside sources. • Individuals with proper qualifications and experience perform diagnostic imaging studies, interpret the results, and report the results.
Food and Nutrition Therapy • A variety of food choices, appropriate for the patient’s nutritional status and consistent with his or her clinical care, is regularly available.
Pain Management • Patients are supported in managing pain effectively.
End-of-Life Care • Care of the dying patient optimizes his or her comfort and dignity.
Care Delivery for All Patients • Patients with the same health problems and care needs have a right to receive the same quality of care throughout the organization.
Anesthesia and Surgical Care
Anesthesia services (including moderate and deep sedation) are available to meet patient needs, • A qualified individual(s) is responsible for managing the anesthesia services • Each patient’s surgical care is planned and documented based on the results of the assessment. • Anesthesia & surgical care are documented in pts records
An appropriately licensed pharmacist, technician, or other trained professional supervises the pharmacy or pharmaceutical service. • An appropriate selection of medications for prescribing or ordering is stocked or readily available. • Medications are properly and safely stored.
Prescribing, ordering, and transcribing are guided by policies and procedures. • The organization identifies those qualified individuals permitted to prescribe or to order medications. • A system is used to dispense medications in the right dose to the right patient at the right time. • The organization identifies those qualified individuals permitted to administer medications.
Patient and Family Education (PFE)
The organization provides education that supports patient and family participation in care decisions and care processes. • Education and training help meet patients’ ongoing health needs. • Health professionals caring for the patient collaborate to provide education.
Section II: Health Care Organization Management Standards
Quality Improvement and Patient Safety