Karen H. Timmons President and CEO Paul vanOstenberg, DDS Senior Executive Director of International Accreditation and

1. Accreditation: International Perspectives and Evolution of ProcessHospital Association Leadership Summit ● International Hospital Federation ● June 1-3, 2010 Karen H. Timmons President and CEO Paul vanOstenberg, DDS Senior Executive Director of International Accreditation and Standards Joint Commission International

2. Accreditation—Its Evolution

3. The Hippocratic Oath:To Do No Harm

4. Florence Nightingale:“The Lady with the Lamp”

5. Ignaz Semmelweis:“The Savior of Mothers”

6. Ernest A. Codman: End Result Theory • “So I am called eccentric for saying in public that hospitals, if they want to be sure of improvement, • Must find out what their results are. • Must analyze their results, to find their strong and weak points. • Must compare their results with those of other hospitals. • Must welcome publicity not only for their successes, but for their errors.”1

7. 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.”

8. ACS: The Minimum Standard • Organized medical staff • Physicians and surgeons are licensed, competent, and ethical • With the governing body, the medical staff adopts rules, regulations, and policies governing the organization’s professional work • Accurate, complete, and accessible medical records • Competently supervised diagnostic and therapeutic facilities are available

9. Accreditation: A World Trend • U.S., Canada, and Australia have the oldest accreditation systems • Germany, France, Ireland, and Spain have new accreditation systems • Japan, Jordan, Korea, Malaysia, and Thailand have new systems, with a government role • The WHO, World Bank, and development banks recognize the accreditation model

10. Accreditation – A Definition Usually a voluntaryprocess by which a government or non-government agency grants recognition to health care institutions which meet certain standards that require continuous improvementin structures, processes, and outcomes.

11. Licensure – A Definition A process by which a governmental authority grants permission to an individual practitioner or health care organization to operate or to engage in an occupation or profession. Licensure regulations are generally established to ensure that an organization or individual meets minimum standards to protect public health and safety.

12. Certification – A Definition A process by which an authorized body, either a governmental or non-governmental organization, evaluates and recognizes either an individual or an organization as meeting pre-determined requirements or criteria.

13. Strengths of Accreditation Methodology • Offers external, objective evaluation • Uses consensus standards • Involves the health professions • Is proactive, not reactive • Is implemented organizationwide • Focuses on systems, not individuals • Stimulates quality culture in the organization • Provides periodic re-evaluation against standards

14. Necessary Elements for a Health Care Accreditation System

15. Commonalities Related to How Accreditation Methodology is Applied • Common goal: to improve the safety and quality of health care • Used to validate compliance with consensus standards • Increasingly using outcomes/indicators to assess compliance • Results are shared publicly, increasing public awareness of—and often demand for—quality • ISQua principles stimulate more commonality

16. Differences In How Accreditation Methodology is Applied • Some use accreditation to validate continuous quality improvement, others to effect organizational change • Some approaches involve providers and other key stakeholders in developing standards and other requirements; others do not • In some countries, accreditation is a government mandate; in others, it is not—“inspection” versus accreditation • In many cases, standards set country-specific norms

17. Differences (cont.) • Some approaches involve a self-assessment component that is validated in a shorter onsite visit • Some approaches require use of quality/safety measures, others do not • Some use volunteers in onsite evaluation process • Voluntary vs. mandatory

18. Other Methodologies • EFQM • Baldrige • ISO • Lean/Six Sigma • “Best Practices”—IHI, Premier, etc • Others

19. Accreditation—What Is the JCI Model?

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

21. Joint Commission International • Global knowledge disseminator of quality improvement and patient safety • 346 accredited organizations in 41 countries • ISQua-accredited • WHO Collaborating Centre for Patient Safety Solutions

22. Mission Work at Three Levels • Individual organizations • Country-level efforts to assist Ministries of Health and Governmental Agencies to strengthen the role of quality oversight at the country level • International level as a consensus builder and vehicle for sharing new knowledge on quality and safety in health care

23. WHO Collaborating Centre for Patient Safety Solutions • Developed Nine Patient Safety Solutions • High 5s Project Collaboration between the Centre and WHO Patient Safety Programme • Offers proactive solutions for patient safety based on empirical evidence, hard research and best practice • Advances the entire continuum of patient safety • System design and redesign • Product safety • Safety of services • Environment of care Facts about the Centre 23

24. Joint Commission International Accreditation International Accreditation Philosophy • Maximum achievable standards • Patient-centered • Culturally adaptable • Process stimulates continuous improvement

25. JCI’s Accreditation Tools • Standards • Evaluation Methodology • Patient Safety Goals and Tools • Data on Performance and Benchmarks • Education

26. JCI Standards A system framework Address all the important managerial and clinical functions of a health care organization Focus on patients in context of their family A balance of structure, process, and outcomes standards Set optimal, achievable expectations Set measurable expectations

27. JCI Evidence Gathering Onsite • Standards have multiple dimensions and thus have multiple sources of evidence • Policy – document review • Knowledge – staff training logs, interviews with staff • Practice – clinical observation, patient interviews • Documentation of practice – open and closed record review • A good standard permits a convergent validity scoring process – all surveyors evaluating all types of evidence and reaching one score

28. Accreditation: What Do We Know About the Link to Quality?

29. Summary of Studies on the Impact of Accreditation • Braithwaite et al: Accreditation performance significantly positively correlated with organizational culture and leadership but unrelated to organizational climate and consumer involvement • El Jardali et al: Lebanese study showed hospital accreditation is a good tool for improving quality of care from nurses’ perspective but there is a need to assess quality based on patient outcome indicators • Greenfield et al: Unannounced surveys and tracer methodology are effective but there is no empirical evidence in the literature to support their benefit in health care

30. Summary of Studies on the Impact of Accreditation, cont’d • Greenfield, Braithwaite: Summary of studies of effectiveness of accreditation on clinical outcomes, with consistent findings showing accreditation positively impacted promoting change and professional development but inconsistent findings related to professions’ attitudes toward accreditation, organizational impact, financial impact, quality measures, and program assessment • Pomey et al: Accreditation process is effective for introducing change but is subject to a learning cycle and learning curve

31. Summary of Studies on the Impact of Accreditation, cont’d • Salmon et al: Accredited hospitals significantly improved their average with accreditation standards while no appreciable increase was observed in non-accredited hospitals • Shaw: Too many variables to prove that inspection causes better clinical outcomes • Touati, Pomey: Accreditation has positive impacts in France and Canada but current trends in evolution of accreditation threaten purpose of the accreditation process

32. Summary of Studies on the Impact of Accreditation, cont’d • Wachter: Joint Commission’s NPSGs and use of tracer methodology are effective but ill-suited to drive progress in culture and communication • Walshe et al: Although external review systems are widely used to promote quality improvement, their effectiveness is little researched • Walshe, Shortell: Study results show consensus that health care regulation does have a significant impact by causing organizations to change their behavior, but less consensus about how beneficial impact was and whether it led to quality and PI

33. Sentinel Event Experience to Date 908 Events of wrong site surgery 804 Inpatient suicides 734 Operative/post op complications 580 Deaths related to delay in treatment 547 Events relating to medication errors 436 Patient falls 360 Retained foreign objects 256 Assault/rape/homicide 209 Perinatal death/injury 201 Deaths of patients in restraints 146 Transfusion-related events 145 Infection-related events 102 Fires 100 Anesthesia-related events 1254 “Other” Sentinel events reviewed by The Joint Commission: 1995 – 2010 = 6782 RCAs 33

34. Sentinel Event Alert

35. Impact of Accreditation: Some Examples Medical Records • First required in 1917, many considered the medical record unnecessary • Today the medical record is the central point of information gathering for treatment decisions, research, patient monitoring, outcomes measurement, and even billing

36. Impact of Accreditation:Some Examples Infection Control Programs • In the mid-1950s, patients, especially surgery patients and newborns, acquired infections in epidemic proportions • In the 1950s, hospitals were required to appoint infection control committees to direct activities aimed at curbing epidemics of infections • Infection control programs were created that reduced the spread of devastating infectious agents

37. Impact of Accreditation:Some Examples • Fire Safety • Non-smoking standards for hospitals were developed due to the adverse effects of passive non-smokers and significant fire hazards • Advance Directives • Protects patients from a life or death they would not have wished • Requires organizations to establish Do-Not-Resuscitate (DNR) standards and request an advance directive from each patient so the individual’s wishes can be documented in the patient chart • In the 1980s only 20% of hospitals addressed this issue; since the implementation of the standard, nearly 100% of accredited organizations are in compliance with the standard

38. Studies Supporting the Value of Joint Commission Accreditation • Devers, Pham, Liu: Accreditation requirements influenced hospitals’ efforts toward implementing patient safety initiatives, and hospital leaders ranked Joint Commission as most important driver of patient safety • Hosford: Accreditation is effective in driving efforts to reduce errors • Longo et al: Accreditation Improves Patient Safety

39. Value and Impact of Accreditation Study • Conducted with JCI-accredited and non-accredited hospitals in Jordan • Pilot collected and analyzed data related to 6 managerial and economic quality indicators • Results show statistically-significant improvements in the JCI-accredited hospitals on 3 indicators: • Return to ICU within 24 hours of discharge • Staff turnover per year • Completeness of medical records Total annual savings per accredited hospital = $87,600

40. Completed Assessment of Inpatient Transfers Actual rate of recording of patient’s condition at assessment “Qualified Rate”= “Actual Rate” Clifford Hospital, Panyü, P.R. China

41. Ventilator Associated Pneumonia (VAP) Three JCI-accredited hospitals in India

42. Unscheduled Acute Care Readmissions % of unscheduled readmissions within 31 days for patients with primary Dx of heart failure or related condition Percentage Santa Chiara Hospital, Trento, Italy

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

44. Study Details • 400-bed Government Hospital • 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

45. 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

46. Accreditation: What Should The Future Look Like?

47. A Revolution in Health Care Delivery

48. What Should The Future of Accreditation Look Like? Should it be . . . • Flexible and performance-based? • Able to address issues related to coordination of care from one country to another? • Extended beyond organizations to focus on individual providers? • Able to provide reliable quality data? • Adaptable to improved technologies? • Sustainable?

49. Suggested Principles for Effective Regulation • Improvement focus • Responsiveness • Proportionality and targeting • Rigour and robustness • Flexibility and consistency

50. Suggested Principles for Effective Regulation, cont’d • Cost consciousness • Openness and transparency • Enforceability • Accountability and independence • Formative evaluation and review