Mahidol U. Thailand 22/01/2552 Joint Commission International (JCI) ศ. นพ. ประสิทธิ์ วัฒนาภา มหาวิทยาลัยมหิดล

Mahidol U. Thailand P Watanapa The U.S., Canada, and Australia have the oldest accreditation systems In Europe, Germany, France, Ireland and Spain have new accreditation systems In Japan, Korea, Malaysia, and Thailand there are new systems with government role The WHO, World Bank and development banks recognize and endorse the accreditation model Accreditation : A World Trend

Mahidol U. Thailand P Watanapa The Joint Commission International (JCI) Is a Major Subsidiary of Joint Commission Accreditation of Healthcare Organizations (JCAHO) To Improve the Safety and Quality of Care in the International Community Through the Provision of Education, Publications, Consultation and Evaluation Services Mission of JCI About JCI

Mahidol U. Thailand P Watanapa JCAHO - History 1910 – 1913 : Concerned for the Quality of Hospital Care in the U.S.A : Ernest A Codman Focused on Results 1918 : American College of Surgeons Began a Hospital Standardization Program 1951 : Joint Commission on Accreditation of Hospitals Formed to Continue the Challenge

Mahidol U. Thailand P Watanapa Joint Commission on Accreditation Non-profit Affiliate of JCAHO Separate Board with International Members Accreditation Committee with International Members Advisory Structure with International Members International Division Is Known As Joint Commission International (JCI)

Mahidol U. Thailand P Watanapa Origin and Content of JCI Standards

Mahidol U. Thailand P Watanapa International Hospital Standards International Principles and Standards Development Task Force Formed February 1998 First Meeting of the Task Force in June 1998 Meeting Held in Chicago, Budapest, Barcelona in 1998 and 1999 Publication of Standards in October 1999

Mahidol U. Thailand P Watanapa Standards Subcommittee Members Brazil China Czech Republic Germany Ireland (pending) Italy Poland Portugal (pending) Republic of South Africa Saudi Arabia

Mahidol U. Thailand P Watanapa ACCREDITA TION Benefits and Characteristics

Mahidol U. Thailand P Watanapa Benefits for the Hospital Improves Care and Enhances Public Confidence Stimulates Continuous Improvement Demonstrates Commitment to Quality Care Raises Community Confidence Comparison with Self and Other Similar Organization

Mahidol U. Thailand P Watanapa Benefits for the Medical & Nursing Staff Improves Professional Staff Development Provides Education on Consensus Standards Provides Leadership for Quality Improvement within Medicine and Nursing Increases Satisfaction with Working Conditions, Leadership and Accountability

Mahidol U. Thailand P Watanapa Benefits for Hospital Employees Values Employee Opinions Measures Employee Satisfaction Involvement in Quality Activities Improved Employee Safety and Security Clearer Lines of Authority and Accountability Promotes Teamwork

Mahidol U. Thailand P Watanapa Benefits for Patients Access to a Quality Focused Organization Rights Are Respected and Protected Understandable Education and Communication Satisfaction Is Evaluated Involvement in Care Decisions and Care Process Focus on Patient Safety

Mahidol U. Thailand P Watanapa Character istics Usually a VOLUNTARY Process by Which a Government or Non- Government Agency Grants RECOGNITION to Health Care Institutions Which Meet Certain STANDARDS That Require Continuous IMPROVEMENT in Structures, Processes, and Outcomes

Mahidol U. Thailand P WatanapaJCIA Definition of Standards Requirements That Define Performance Expectations with Respect to STRUCTURE, PROCESS, and OUTCOMES That Must Be Substantially in Place in an Organization to Enhance the Safety and Quality for Patient Care

Mahidol U. Thailand P Watanapa Performance Components STRUCTURE : Resources E.g. Adequate Staff, Supplies, Building PROCESS : Activities E.g. Patient Education, Nursing Assessment OUTCOMES : Results E.g. Infection Rates, Maternal Mortality

Mahidol U. Thailand P Watanapa Standar ds A System Framework (i.e. Policy, Procedures, Indicators, Monitor, Feed-Back) Address All the Important Managerial and Clinical Functions of a Healthcare Organization Focus on Patient in Context of Their Family A Balance of Structure, Process and Outcomes Standards Set Optimal, Achievable Expectations Set Measurable Expectations

Mahidol U. Thailand P Watanapa Components of Standards Development Multiple Information Sources Scientific Literature Survey Compliance Data Research Findings Individual Input from Field Experts and Key Stakeholders

Mahidol U. Thailand P Watanapa JCI Standards

Mahidol U. Thailand P Watanapa Patient-Centered Standards Access to Care and Continuity of Care (ACC) Patient and Family Rights (PFR) Assessment of Patient (AOP) Care of Patients (COP) Anesthetic and Surgical Care (ASC) Medical Management and Use (MMU) Patient and Family Education (PFE)

Mahidol U. Thailand P Watanapa Health Care Organization Management Standards Quality Improvement and Patient Safety (QPS) Prevention and Control of Infection (PCI) Government, Leadership & Direction (GLD) Facility Management & Safety (FMS) Staff Qualification & Education (SQE) Management of Information (MOI)

Mahidol U. Thailand P Watanapa Priority Focus Process Patient and Family Rights (PFR) Staff Qualifications & Education (SQE) Governance, Leadership, and Direction (GLD) PerformanceReview Management of Information (MOI) Driver System Results Cause - Effect Quality Improvement & Patient Safety (QPS) Facility Management & Safety (FMS) Prevention & Control of Infections (PCI) 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) Quality Improvement & Patient Safety (QPS) Facility Management & Safety (FMS) Prevention & Control of Infections (PCI) 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)

Mahidol U. Thailand P Watanapa 6. Process Management 3. Focus on Patients/Customers 5. Staff Focus (HR) 1. Leadership 1. Health Care Results 2. Patient and Other Customer-focused Results 3. Financial Results 4. Staff and Work System Results 5. Organizational Effectiveness Results 6. Governance and Social Responsibility Results 7. Health Promotion Results 2. Strategic Management 4. Information and Knowledge Management Driver System Results Cause - Effect 1. Risk, Safety, and Quality Management 2. Professional Governance 3. Physical Structure and Environment of Care 4. Prevention and Control of Infection 5. Medical Record System 6. Medication Management System 7. Diagnostic Investigation and Related Services 8. Disease and Health Hazard Surveillance 9. Working with Community 1. Entry 2. Patient Assessment 3. Planning of Care 4. Patient Care Delivery 5. Information and Empowerment 6. Discharge Planning & Continuity of Care

Mahidol U. Thailand P Watanapa 24 HA 2006JCIA 2008 Clinical Tracer of Quality HA-Thailand PSGs Tracer Methodology/DSC 2007 IPSGs

Mahidol U. Thailand P Watanapa