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

2. 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.

3. 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)

4. 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)

5. 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.

6. 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.

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

8. 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)

9. 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)

10. 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

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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