Mahboob Ali Khan

,MHA,CPHQ

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

Section I :

International

Patient Safety

Goals (IPSG)

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–Associated

Infections

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 Harm

Resulting 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.

Patient and

Family Rights

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.

Care of

Patients

(COP)

Food and Nutrition

TherapyA 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

PatientsPatients 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

Medication

Management

and Use

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.

Medication effects on patients are

monitored.

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

Those responsible for governing and managing the organization participate in planning and measuring a quality improvement and patient safety program.

Design of Clinical and Managerial Processes

Data Collection for Quality Measurement

Analysis of Measurement Data

Improvement

Prevention and

Control of

Infections

One or more individuals oversee all

infection prevention and control activities.

This individual(s) is qualified in infection

prevention and control practices through

education, training, experience, or

certification.

The organization designs and implements

a comprehensive program to reduce the

risks of health care–associated infections

in patients and health care workers.

The organization provides barrier

precautions and isolation procedures

that protect patients, visitors, and staff

from communicable diseases and

protects immunosuppressed patients

from acquiring infections to which they

are uniquely prone.

Gloves, masks, eye protection, other

protective equipment, soap, and

disinfectants are available and used

correctly when required.

The organization provides education on

infection prevention and control

practices to staff, physicians, patients,

families, and other caregivers when

indicated by their involvement in care.

Governance,

Leadership, and

Direction

Governance responsibilities and accountabilities are described in bylaws, policies and procedures, or similar documents that guide how they are to be carried out.

A senior manager or director is responsible for operating the organization

One or more qualified individuals provide direction for each department or service in the organization.

Facility

Management

and Safety

The organization complies with relevant laws, regulations, and facility inspection requirements.

The organization plans and implements a program to provide a safe and secure physical environment.

The organization has a plan for the inventory, handling, storage, and use of hazardous materials and the control and disposal of hazardous materials and waste.

The organization develops and

maintains an emergency management

plan and program to respond to likely

community emergencies, epidemics,

and natural or other disasters.

The organization plans and implements

a program to ensure that all occupants

are safe from fire, smoke, or other

emergencies in the facility.

The organization plans and implements a program for inspecting, testing, and maintaining medical equipment and documenting the results.

Potable water and electrical power are available 24 hours a day, seven days a week,

The organization educates and trains all staff members about their roles in providing a safe and effective patient care facility.

Staff

Qualifications

and Education

Organization leaders define the desired education, skills, knowledge, and other requirements of all staff members.

Organization leaders develop and implement processes for recruiting, evaluating, and appointing staff as well as other related procedures identified by the organization.

The organization uses a defined process to ensure that nonclinical staff knowledge and skills are consistent with organization needs and the requirements of the position.

All clinical and nonclinical staff members are oriented to the organization, the department, or unit to which they are assigned and to their specific job responsibilities at appointment to the staff.

The organization uses an ongoing standardized process to evaluate the quality and safety of the patient services provided by each medical staff member.

The organization has an effective process to gather, to verify, and to evaluate the nursing staff ’s credentials (license, education, training, and experience).

The organization has a standardized procedure to gather, to verify, and to evaluate other health professional staff members’ credentials (license, education, training, and experience).

Management of

Communication

and

Information

Communication with the Community

Communication with Patients and

Families

Communication Between Practitioners

Within and Outside of the Organization

Patient Clinical Record

The organization initiates and maintains a

clinical record for every patient assessed or

treated.

Thank you

………………..