JOINT COMMISSION INTERNATIONAL ACCREDITATION(JCIA)

• Presented By:-MANOJ.P142803008

ACCREDITATION• Accreditation is a process in which an entity, separate & distinct from

the health care organization ,usually non governmental• assesses the healthcare organization to determine if it meets a set of

requirements (standards) designed to improve the safety and quality of care .

• Accreditation is usually voluntary.• It has gained world wide attention as an effective quality evaluation

and management tool.

BENEFITS OF ACCREDITATION• Improve public trust

• Provide a safe and efficient work environment

• Negotiate with sources of payment

• Listen to patients & their families ,respect their rights & involve them in the care process as partners

• Create a culture that is open to learning

• Establish collaborative leadership & continuous leadership

Introduction to JCI

• Joint Commission International (JCI) was founded in the late 1990s to survey hospitals outside of the United States. • JCI, which is also not-for- profit, currently accredits

facilities in Asia, Europe, the Middle East, and South America.• A count of JCI-accredited hospitals worldwide (as

listed on the JCI website till 2015) shows 820 hospitals in 47 & above countries. • 21 hospitals in India

JCIA Global Presence JCI team:

World headquarters in North America

Regional offices in Asia-Pacific, Europe, and the Middle East

More than 200 international consultants and accreditation surveyors

WHAT IS JCI?HOW IS IT GOOD FOR US ?

• JCI stands for JOINT COMMISSION INTERNATIONAL.

• It is US based , not for profit accreditation body , which sets & addresses standards for the healthcare providers level of performance in key functional areas , such as patient rights , patient treatment & infection control

• JCI’S mission is to improve the quality of healthcare in the international community by providing worldwide accreditation services

• JCIA is an initiative designed to respond to a growing around the world for standards – based evaluation in health care.

HOW WILL IT HELP US?• JCI standards would lead us to improved patient care, safety & path of

continuous quality improvement .

• This would strengthen patient , third party and insurer confidence and would provide us a competitive edge

• JCI accreditation is the gold standard for quality as it reflects the provision of the highest level of patient care & patient safety

• JCI ACCREDITATION. JCI accredits 8 types of healthcare programs:-• 1.hospitals• 2.academic medical center hospitals• 3.ambulatory care facilities • 4.clinical laboratories• 5.home care facilities • 6.long term care facilities • 7.medical transport organizations• 8.primary care centers

JCI 5TH Edition• Effective from 1st April 2014• Consists of four sections Section 1 consists of accreditation participation requirements APRSection 2 Patient centered standards • 1.IPSG• 2. ACC (Access to care and continuity of care)

JCI 5th Edition • 3. PFR (Patient and Family Rights)• 4. AOP (Assessment Of Patients)• 5. COP (Care Of Patients) ambulatory• 6. ASC (Anesthesia and Surgical Care)• 7. MMU (Medication Management and Use)• 8. PFE (Patient and Family Education)

JCI 5TH edition Section 3 consists of Health care organization management standards• 9. QPS (Quality improvement and Patient Safety)• 10. PCI (Prevention and Control of Infections) laboratory• 11. GLD (Governance, Leadership and Direction) for hospitals and

academic medical institutions

JCI 5th edition

• 12.FMS (Facility Management and Safety)• 13.Staff qualification and education SQE• 14.Management of Information MOISection 4 academic medical center hospitals

standards• 15.Medical profession education MPE• 16.Human subjects research Programs HRP

JCI 5th edition 5th edition of the Hospital Standards contains • 285 Standards• 1160 Measurable Elements

4thEdition of the Hospital Standards• Contains 320 standards• Over 1200 criteria measured during the survey/evaluation

process

REVISION OF STANDARDSThe standards will be revised and published at least every 3 years

JCI survey methodology

Thorough survey process becomes Operational:

Typical survey team consists of a physician, nurse, and administrator

Surveyors evaluate various units within an organization and meet to discuss their finding

Surveys conduct a complete system analysis on integration and coordination of care processes

ACCREDITATION SURVEYS• Interview with staff & patients & other verbal information• On-site observations of patient care process by surveyors• Policies, procedures, clinical practice guidelines, and other documents

provided by the organization

Jci accreditation process timeline

CONTINUOUS QUALITY IMPROVEMENT JOURNEY

6-9 MONTHS PRIOR TO TRIENNIAL DUE DATE

WITHIN 15 DAYS OF SURVEY

SURVEY DATES

2 MONTHS PRIOR TO SURVEY

4-6 MONTHS PRIOR TO SURVEY

6-9 MONTHS PRIOR TO SURVEY

12-24 MONTHS PRIOR TO SURVEY

JCI Accreditation survey occurs

Submit revised application & schedule triennial JCI accreditation re- survey

Receive Accreditation Decision & Official Accreditation findings report from JCI

JCI Survey team leader contacts your organization to determine survey agenda

Receive & complete JCI survey Contract & Travel Instructions Form

Submit application for survey to JCI, & schedule survey dates with JCI

Obtain JCI standards manual & begin preparing for JCI accreditation.

Scoring the Survey Results

• Each standard must have a scoring of at least 5• Each chapter must have a score of at least 8

• All standards must together average for at least 9• All measurable elements are averaged to obtain the score for the

standard

Scoring survey results• Each Measurable Element (ME) is scoredMet (10) Partially Met (5) Not Met (0)

• All Standards are averaged to obtain the score of the chapter• All Chapters are averaged to obtain the overall score

IPSGINTERNATIONAL PATIENT SAFETY GOALS GOAL 1• Identify patients correctlyGOAL 2• Improve effective communication GOAL 3 Improve the safety of high alert medicationsa. IV potassium chloride = or > 2meq concentrationb. Sodium chloride >0.9%c. Magnesium sulphate =or >50% concentration d. Potassium phosphate = or > 3mmol/ml concentration

GOAL 4• Ensure correct site , correct procedure & correct patient surgery GOAL 5 • Reduce the risk of healthcare associated infectionGOAL 6• Reduce the risk of patient harm resulting from falls

PIPELINE CARRYING COLOR CODES

As per BIS(Bureau of Indian Standards) :-• Oxygen –yellow line & white strips • Vacuum - blue & black strips • Air – blue & white & black strips • Nitrous oxide – yellow line with dark blue strips • Dry nitrogen – yellow with light green strips • ENTONX – blue & white strips • Carbon dioxide – yellow with ash strips • Calibration gas – white & red strips