Introduction to JCI Standards & Accreditation Processes Thalassemia Quality Office Prepared by : Samah Darwazeh

DOHMS has signed a two year consultancy agreement with Joint Commission International in November 2005, with the aim of acquiring the status of accreditation for Rashid, Dubai and Al-Wasl hospitals by early 2008.

Project Duration: The duration of the consultancy agreement is two years commenced on the 1st day of December 2005 and shall end on the 30th day of November 2007. Phase I: Accreditation Preparation Program (ongoing for approximately 24 months)

1st on site consultation: 4th-22nd February 2006 ( reports about the hospitals ) 2nd on site consultation: 4th- 22nd November 2006 Phase II: Final Mock Survey and Action Planning PHASE III: Accreditation Survey (Targeted for 2007)

What is accreditation? is a process whereby an outside agency assesses the healthcare organization to determine if it meets a set of fix standards designed to improve quality of care and safety.

What exactly do we mean by" standards”? Standards address the organizations level of performance in specific areas…not simply what it has but what it actually does. Standards set for the performance expectations for activities that affect the quality of care. Standards ask two kinds of questions: Is the organization doing the right things? And is it doing them well? Standards also specify requirements to ensure that care is provided in a safe environment.

JCI standards 11 Chapters, 368 Standards, 1008 M.E. 5 Chapters on Patient-centered standards 6 Chapters on Health Care Management standards

Patient-Centered Standards Access to Care and Continuity of Care (ACC) Patient and Family Rights (PFR) Assessment of Patients (AOP) Care of Patients (COP) Patient and Family Education (PFE)

Health Care Management Standards Quality Improvement and Patient Safety (QPS) Prevention and Control of Infection (PCI) Governance, Leadership and Direction (GLD) Facility Management and Safety (FMS) Staff Qualification and Education (SQE) Management of Information (MOI)

Scoring the Standards Each standard is measured by a number of measurable elements ( 1,032 M Es) Each measurable element is scored : 0= Non compliance 5= partial compliance 10= full compliance Core standards ( the bold ) MUST ALL be met Non core standards 70% must be met AUB website

Accreditation: Does it Make a Difference? Accredited hospitals report significant improvements in: Leadership Medical records management Infection control Reduction in medication errors Staff training and professional credentialing Improved quality monitoring

International Accreditation Programs Medical Transport Organizations (2002) Clinical Laboratories (2003) Care Continuum (2003) Ambulatory Care (2005) Disease or Condition-Specific Certification (2005)

Ambulatory Care Accreditation 1st edition of Joint Commission International Standards for Ambulatory Care published in August 2005 Strongly modeled on JCI hospital standards that have been adapted for an outpatient context

Who is Eligible for Accreditation? International healthcare organizations that address care in ambulatory care environments, such as: Free-standing outpatient clinics Dialysis facilities Ambulatory surgery centers Endoscopy centers Imaging centers Clinics or treatment programs for management of chronic diseases such as diabetes

Differences between Hospital and Ambulatory Care Accreditation Depending on scope of services, some standards in the AC manual may not apply (e.g. standards addressing pre-operative services would not apply in an outpatient dialysis center) Standards have been adapted as needed to reflect outpatient context, such as modification of the hospital standard addressing withdrawal of life-sustaining care Length of survey is shorter, depending on number and volume of services offered; typical survey is two days Hospital Vs. Ambulatory care

Overview of the Hospital Survey Process-Key Elements of a Survey Document Review Session Interviews with Hospital Leaders Visits to Patient Care Settings & tracers Function Interviews Other Assessment Activities Feedback Sessions Post Survey Activities

Tracer Methodology Patient-centered evaluation approach that will be introduced and tested with international surveys in 2006 JCAHO (in US) surveyors now use this approach during the on-site accreditation survey Follows or “traces” patients through the organization’s processes and services and then branches out to assess how well standards were met Uses both patient tracers as well as system tracers

Tracer Visits May Include Observation of direct care Observation of medication process Quality improvement discussion Staff interviews Patient interviews Observation of infection control practices and environment of care Review of open clinical records Review of policies as needed

Example of a Patient Tracer Activity Patient with diagnosis of heart failure, CAD, and cardiac catheterization Hospital areas visited and evaluated during the tracer exercise: Telemetry unit, where patient is currently Emergency department, through which patient admitted Radiology, where patient had chest X-ray Cardiac catheterization lab Intensive care unit Pharmacy Physical therapy/Rehabilitation services Home care services

Sample Points of Discussion in the Tracer Activity Telemetry Unit Post-catheterization assessment and care Process for handling verbal orders Medication process Screening for fall and nutritional risk Competency of nursing staff in telemetry Pain assessment process Patient education process and materials Discharge planning

Sample Points of Discussion in the Tracer Activity Emergency Department Triage process Patient assessment Communication with ICU prior to patient transfer Medication process, including for high risk concentrated medications and IV solutions Communication needs for hard-of-hearing elderly patients Competency of medical and nursing staff in emergency management

Introduction to JCI Standards & Accreditation Processes Thank you Thalaseemia Quality Office