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Getting Started How to pursue accreditation and how JCI can help you

Getting Started How to pursue accreditation and how JCI can help you. Dr. Prabhu Vinayagam Managing Director Asia Pacific Office. Accreditation Preparation Process. Organizational Assessment

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Getting Started How to pursue accreditation and how JCI can help you

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  1. Getting StartedHow to pursue accreditation and how JCI can help you Dr. Prabhu Vinayagam Managing Director Asia Pacific Office

  2. Accreditation Preparation Process Organizational Assessment Evaluate your current performance against the standards and create plans and structures to drive improvement JCIA Survey Start Create New Processes Develop and implement new policies, plans, and procedures

  3. Organizational Assessment: Assess Current Compliance Determine your 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. • Cite specific findings and recommendations. • Include all areas of the organization in the assessment • Assess your organizational quality and patient safety “culture” Compile and analyze currently available baseline quality data as required by the quality monitoring standards (QPS).

  4. Organizational Assessment:Action Planning • Use the findings of the organizational assessment to develop a detailed project plan. • Include: • Assigned responsibilities • Deliverables • Timeframes • Hold leaders and staff accountable to plan.

  5. Organizational Assessment:Action Planning Tips • Think structure-process-outcome • Implement those requirements that will take the longest to make fully functional • E.g., the quality monitoring system for the QPS indicators. • Do not forget the “track record” or “performance history” requirement • 4 months on the first survey.

  6. Accreditation Preparation Process 18-24 Months Policy & Procedure Development Develop new polices and procedures that comply with JCI standards Organizational Assessment Evaluate your current performance against the standards and create plans and structures to drive improvement JCIA Survey Start Create New Processes Develop and implement new policies, plans, and procedures

  7. Policy and Procedure Development • Developing policies and procedures that meet the JCI standards is one of the most time consuming parts of the preparation process • Start by compiling all of your policies and procedures • Make sure that all of these documents are in one place. • Be certain that your existing policies reflects your actual practice. This is how surveyors will evaluate your organization. • Compile a list of all required policies and procedures that will need development or revision.

  8. Policy and Procedure Development • Revise your policies and procedures • It may take more time than you think to write, review, and approve policies • Educate your staff on your new policies • Test understanding and compliance • Make sure that policy = practice • Create, refine and/or test your document management system (Policy on Policies)

  9. Accreditation Preparation Process 18-24 Months Policy & Procedure Development Develop new polices and procedures that comply with JCI standards Organizational Assessment Evaluate your current performance against the standards and create plans and structures to drive improvement Document Review Assess your plans, policies, and procedures for compliance with JCI standards JCIA Survey Start Create New Processes Develop and implement new policies, plans, and procedures

  10. Document Review • Have an objective pair of “fresh-eyes” review your new policies and procedures to make sure: • They meet the JCI standards • They can be clearly understood by your staff • They can be followed by your staff • The survey will assess if your policies and procedures meet the standards and if your staff is actually following them.

  11. Accreditation Preparation Process Policy & Procedure Development Develop new polices and procedures that comply with JCI standards Organizational Assessment Evaluate your current performance against the standards and create plans and structures to drive improvement Document Review Assess your plans, policies, and procedures for compliance with JCI standards JCIA Survey Start Create New Processes Develop and implement new policies, plans, and procedures Monitor Progress and Adjust Evaluate effectiveness of processes and refine as necessary

  12. Monitoring Progress • Continue to monitor your progress in meeting the standards • Keep staff motivated. • Involve as many staff as possible • Make accreditation a goal that you are striving to achieve together. • Use the evaluation methods your JCI surveyor will use • Use the results of these evaluations to show progress or focus efforts

  13. Accreditation Preparation Process Policy & Procedure Development Develop new polices and procedures that comply with JCI standards Organizational Assessment Evaluate your current performance against the standards and create plans and structures to drive improvement Document Review Assess your plans, policies, and procedures for compliance with JCI standards Technical Assistance Use experts to address persistent or difficult problems JCIA Survey Start Create New Processes Develop and implement new policies, plans, and procedures Monitor Progress and Adjust Evaluate effectiveness of processes and refine as necessary

  14. Technical Assistance • Every accreditation preparation effort reveals persistent problems. • JCI is available to help: • Standards Interpretation & Clarification (free) • Make sure that the standard really requires the element that is causing you difficulty. • Compliance Assistance (for fee) • Let JCI help you develop solutions to your persistent problems, based upon our experience helping other organizations address similar problems

  15. Accreditation Preparation Process Policy & Procedure Development Develop new polices and procedures that comply with JCI standards Organizational Assessment Evaluate your current performance against the standards and create plans and structures to drive improvement Mock Survey Reassess current performance 6 months prior to survey to allow you enough time to make last minute adjustments Document Review Assess your plans, policies, and procedures for compliance with JCI standards Technical Assistance Use experts to address persistent or difficult problems JCIA Survey Start Create New Processes Develop and implement new policies, plans, and procedures Monitor Progress and Adjust Evaluate effectiveness of processes and refine as necessary

  16. Mock Survey • The “Mock Survey” helps you see what standards still need improvement before your survey. • Conduct at least 6 months before your survey • Use objective evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation. • Plan revisions and corrections based on the findings of the mock survey.

  17. Scheduling Your Accreditation Survey • At about the same time as your mock survey, you should schedule your “real” survey. • Request an application from JCI at least 6 months or longer in advance of target dates for survey. • Once your application is completed, a surveyor team will be assigned and dates confirmed. • A survey team leader will be in contact to coordinate an agenda and plans for the survey.

  18. Accreditation Preparation Process 18-24 Months Policy & Procedure Development Develop new polices and procedures that comply with JCI standards Organizational Assessment Evaluate your current performance against the standards and create plans and structures to drive improvement Mock Survey Reassess current performance 6 months prior to survey to allow you enough time to make last minute adjustments Document Review Assess your plans, policies, and procedures for compliance with JCI standards Technical Assistance Use experts to address persistent or difficult problems JCIA Survey Start Create New Processes Develop and implement new policies, plans, and procedures Monitor Progress and Adjust Evaluate effectiveness of processes and refine as necessary

  19. Two Pieces of Advice from Accreditation Leaders

  20. 1. Honestly Address Resistors • Many staff members may not see the value of JCI Accreditation.

  21. Common Sources of Resistance “JCI is too expensive.” Although JCI is expensive, the quality improvement activities and patient safety techniques that accreditation preparation requires can lead to significant cost savings for an organization.

  22. Brandeis Value and Impact Study • Brandeis University examined this question in a forthcoming pilot study • Three study hospitals matched with three control hospitals • Designed to control for the changes within a country that may influence standards compliance

  23. Value and Impact Study • Early analysis suggests significant findings: Metric Savings • Reduced rate of return to ICU within 24 hours • Staff turnover • $34,000 per year • $53,000 per year

  24. Common Sources of Resistance “JCI only helps staff members in clinical departments. There’s nothing in it for me.” Achieving JCI’s gold seal can have a profound impact on a hospital’s business operations.

  25. Marketing • JCI is globally recognized as the preeminent international accrediting body. • JCI accreditation is increasingly seen as the mark of an organization’s commitment to quality and patient safety.

  26. Common Sources of Resistance “We don’t want JCI telling us what to do.” JCI asks you to decide which processes, practices, and policies will lead to the best outcomes for your patients. We believe that your organization and your healthcare professionals are best suited to make these decisions. We do not evaluate clinical decisions.

  27. A Final Note About Resistors • Vocal resistors who are willing to share their concerns will help you understand the concerns of those that are silently resistant. • Their input is critical in crafting a strategy that helps address the concerns of everyone in your organization.

  28. 2. Don’t try to memorize the standards • There is no need to memorize all 287 standards and 1,146 measurable elements. • Most people only need to know the few standards applicable to their job. • Everyone should be familiar with the organization of the standards manual, so they can find the standards that may apply to new situations.

  29. JCI in SummaryOur Mission and our Activities Our Mission Our Activities • Create global accreditation standards that provide a roadmap for organizations seeking a rigorous approach to safety and quality. • To improve the safety and quality of care in the international community • Encourage organizations to meet our accreditation standard as a way of structuring their continuing improvement. • Assist organizations to achieve their safety and quality goals through consulting, education, and publications.

  30. Thank You

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