JCI Summary

Joint Commission International: An Overview
Karen H. Timmons President and Chief Executive Officer Joint Commission International Association of Companies Health Insurance Funds 13 March 2009 Prague, Czech Republic
Copyright, Joint Commission International
Mission of Joint Commission International

To improve the safety and quality of care in the international community through the provision of education, publications, consultation, evaluation, and accreditation services
Ernest A. Codman: End Result Theory

So I am called eccentric for saying in public that hospitals, if they want to be sure of improvement, Must find out what their results are. Must analyze their results, to find their strong and weak points. Must compare their results with those of other hospitals. Must welcome publicity not only for their successes, but for their errors.[1]
The American College of Surgeons described the need for standardization of hospitals through accreditation as the need to:
Encourage those which are doing the best work, and to stimulate those of inferior standard to do better.
The Joint Commission

An independent, non-profit, nongovernmental agency Accredits over 15,000 health care organizations in the United States
Why International Standards?

The Joint Commission standards: Are filled with U.S. and state laws and regulations Include many political considerations such as requirements for an organized medical staff Use American jargon such as advanced directives Rely on National Fire Protection Association requirements for facility reviewno international version of these requirements Have a U.S. cultural overlay for patient rights
Standards Subcommittee: How We Get Stakeholder Input

Brazil Czech Republic Germany Italy Poland Portugal P.R. of China Republic of South Africa Saudi Arabia U.S.A.
JCI Hospital Standards Translations

Arabic Brazilian Portuguese Chinese Czech Danish European Portuguese German Greek/Cyprus Italian Korean Japanese Spanish Turkish
International Structure
International Board of Directors International Accreditation Committee International Standards Committee Regional Advisory Councils Four International Offices International translations of many products
Offices
Headquarters
Oak Brook, IL, USA
International
Europe Ferney-Voltaire, France (edge of Geneva) Milan, Italy (Project Office) Middle East Dubai Health Care City Asia Pacific Singapore
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Regional Advisory Councils

Asia-Pacific Europe Middle East Provide advice and counsel to JCI management about standards and patient safety initiatives Guidance on regional or cultural adaptations
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European Regional Advisory Council

BQS Danish Institute for Patient Safety Danish Institute for Quality and Accreditation in Healthcare (IKAS) European Parliament European Society for Quality in Healthcare (ESQH) Fundacin Acreditacin Desarrollo Asistencial Georgian Alliance for Patient Safety Haute Autorit de Sant (HAS) Health Care Quality Indicator Project HOPE (European Hospital Federation) International Hospital Federation International Pharmaceutical Federation (FIP) The Karolinska Institute Ministry of Health, State of Israel Ministry of Health, Turkey National Patient Safety Agency Socialstyrelsen Swedish Medical Injury Insurance WHO
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JCI Today
Global knowledge disseminator of quality improvement and patient safety Non-profit affiliate of the Joint Commission 236 accredited organizations in 35 countries Commitment to partnering with NGOs, HCOs, etc. ISQua-accredited WHO Collaborating Centre for Patient Safety Solutions
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International Accreditation Programs
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Accredited Hospitals in Czech Republic

Central Military Hospital Institute of Hematology and Blood Transfusion Na Homolce Hospital
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Accreditation A Definition
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 Usually a voluntary process
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Accreditation: A World Trend

The U.S., Canada, and Australia have the oldest accreditation systems In Europe, Germany, France, Ireland, and Spain have new accreditation systems In Asia, China, Thailand, and Malaysia are developing national accreditation programs The WHO, World Bank, and development banks recognize and endorse the accreditation model The International Society for Quality in Health Care (ISQua) accredits accrediting bodies
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Common Core of Health Care Accreditation Around the World

Administered by a recognized body
Establishes and publishes standards Conducts objective on-site evaluations Publishes accreditation decision Consensus on standards of quality and safety Professionals serve as the external evaluators
Professional involvement
Focus is on continuous improvement

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What is Accreditation Intended to Accomplish?

Maximize quality/minimize safety risk Improve patient care processes and outcomes Enhance patient safety Strengthen the confidence of patients, professionals, and payors about the organization Improve the management of health services Enhance staff recruitment, retention, and satisfaction Provide education on better/best practices
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Increasing Requests for Ensuring Quality and Safety for Medical Travel
International Medical Travel Association issued position paper advocating that international health care organizations be held to high standards set by recognized accreditation authorities1 American Medical Association adopted guiding principles on medical tourism2
Outline steps for care abroad for consideration by patients, employers, insurers, and third parties Require patients to be made aware of their legal rights and have access to physician licensing and facility accreditation
Increasing exposure in international trade journals highlighting the need to research quality when considering medical travel3 Deloitte study mentions JCI in particular in reference to patients increasing concerns about quality in international hospitals4
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Accreditation
Assesses the capability of an organization to provide good results
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Joint Commission International Accreditation

International Accreditation Philosophy Maximum achievable standards Patient-centered Culturally adaptable Process stimulates continuous improvement
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The Accreditors Tools

Standards Evaluation Methodology Patient Safety Goals and Tools Data on Performance and Benchmarks Education
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Standards
A system framework Address all the important managerial and clinical functions of a health care organization Focus on patients in context of their family A balance of structure, process, and outcomes standards Set optimal, achievable expectations Set measurable expectations
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Standards are Continually a Work in Progress

The heart of any accreditation program is the standards upon which all else is based the evaluation methodology, decision process, evaluator training, and other operational elements Thus, a standard must be good, not just on the day the standard is written, but on a continuing basis
25
Evidence of Performance is Available

Standards have multiple dimensions and thus have multiple sources of evidence Policy document review Knowledge staff training logs, interviews with staff Practice clinical observation, patient interviews Documentation of practice open and closed record review A good standard permits a convergent validity scoring process all surveyors evaluating all types of evidence and reaching one score
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Joint Commission International Standards

Organized Around Important Functions
Patient-Centered Standards Access to Care and Continuity of Care Patient and Family Rights Assessment of Patients Care of Patients Anesthesia and Surgical Care Medication Management and Use Patient and Family Education
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JCI Standards, continued

Organized Around Important Functions
Organization Management Standards Quality Improvement and Patient Safety Prevention and Control of Infections Governance, Leadership, and Direction Facility Management and Safety Staff Qualifications and Education Management of Communication and Information
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Patient Tracer: Systems Analysis

Set of components that work together toward common goal Evaluation of how - and how well - the organizations systems function Addresses interrelationships of elements Translates standards compliance issues into potential vulnerabilities as far as patient quality and safety
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International Patient Safety Goals and Tools

Represent proactive strategies to reduce risk of medical error and reflect good practices proposed by leading patient safety experts Incorporating these new tools into our accreditation requirements is a significant step Organizations taking responsibility for using the IPSG to foster an atmosphere of continuous improvement is even more important
30
JCI International Patient Safety Goals

1. 2. 3. 4. 5. 6. Identify patients correctly Improve effective communication Improve the safety of high-alert medications Ensure right-site, right-patient, right-procedure surgery
Reduce the risk of health care-associated infections Reduce the risk of patient harm from falls
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JCIs Measurement Strategy

Accreditation is continuous Accreditation status publicly disclosed Complements existing standards requirements International comparisons Meets needs of multiple stakeholders Develop and identify measures that address clinical and managerial dimensions Need for and rigor of data validation Measurement system supported by IT platform JCI currently has 20 performance measurement requirements
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International Cardiac Surgery Benchmarking (ICSB) Project

Pilot program addressing international clinical cardiac indicators Enables hospitals to evaluate the current status of their coronary artery bypass graft (CABG) and valverelated surgery risk-adjusted mortality rates Encourages hospitals to implement and measure rates of improvement using the New York State Department of Health (NYSDOH) Cardiac Surgery Reporting System (CSRS) as a model
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ICSB Project Objectives

Participating hospitals will get information to help them improve quality of care and assess a patients risk factors before cardiac surgery Multi-site and multi-country use of the ICSB assessment and reporting tool to guide organized quality improvement and benchmarking efforts Long-term goalto improve the outcomes of cardiac surgical procedures in participating organizations
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Speak Up
Help Prevent Errors in Your Care Help Avoid Mistakes in Your Surgery Information for Living Organ Donors Five Things You Can Do to Prevent Infection Help Avoid Mistakes With Your Medicines What You Should Know About Research Studies Planning Your Follow-up Care Help Prevent Medical Test Mistakes Know Your Rights Understanding Your Doctors and Other Caregivers What You Should Know About Pain Management
36
Sentinel Event Database

Sentinel Event database collects data from accredited organizations on errors that have occurred Information in database led to the publication of Sentinel Event Alert, published by The Joint Commission Sentinel Event Alerts highlight significant risk areas in care Offer suggestions and recommendations for mitigating risk Latest Alert focuses on information technology
37
Sentinel Event Experience to Date

Of 5632 sentinel events reviewed by the Joint Commission, January 1995 through December 2008:
741 698 631 492 442 341 218 212 189 175 132 113 86 85 85 992 Events of wrong site surgery Inpatient suicides Operative/post op complications Events relating to medication errors Deaths related to delay in treatment Patient falls Assault/rape/homicide Retained foreign objects Deaths of patients in restraints Perinatal death/injury Transfusion-related events Infection-related events Deaths following elopement Anesthesia-related events Fires Other
= 5632 RCAs
Client name/ Presentation Name/ 12pt - 38
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Accreditation Represents a Risk Reduction Strategy

That an organization is doing the right things and doing them well; Thereby significantly reducing the risk of harm in the delivery of care; and Optimizing the likelihood of good outcomes.
39
The Value and Impact of Accreditation
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Impact of Accreditation
What is the evidence that Accreditation improves quality and safety of care? High quality lowers cost of health care? The cost of implementing accreditation standards is worth the achievable benefit?
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Impact of Accreditation (contd)

The process of Joint Commission International accreditation has set many of the fundamental principles that guide health care organizations today Many of these principles are routine in health care today but were revolutionary in their time
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Impact of Accreditation: Some Examples

Medical Records First required in 1917, many considered the medical record unnecessary Today the medical record is inarguably the central point of information gathering for treatment decisions, research, patient monitoring, outcomes measurement, and even billing
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Infection Control Programs In the mid-1950s, patients, especially surgery patients and newborns, acquired infections in epidemic proportions In the 1950s, hospitals were required to appoint infection control committees to direct activities aimed at curbing epidemics of infections Infection control programs were created that reduced the spread of devastating infectious agents
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Fire Safety
Non-smoking standards for hospitals were developed due to the adverse effects of passive non-smokers and significant fire hazards
Advance Directives
Protects patients from a life or death they would not have wished Requires organizations to establish Do-Not-Resuscitate (DNR) standards and request an advance directive from each patient so the individuals wishes can be documented in the patient chart In the 1980s only 20% of hospitals addressed this issue; since the implementation of the standard, nearly 100% of accredited organizations are in compliance with the standard
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Accreditation: The Value Equation

JCI has conducted descriptive research with a sample of accredited hospitals to determine the value of accreditation Accredited hospitals report significant improvements in: Leadership Medical records management Infection control Reduction in medication errors Staff training and professional credentialing Improved quality monitoring
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Recent Studies Support the Value of Joint Commission Accreditation

Longo study showed that accreditation is a significant factor in whether facilities engaged in actions widely recognized to improve patient safety; advocates accreditation as a means for improving health care5 Health Affairs report indicated that Joint Commission accreditation requirements influenced hospitals efforts toward implementing patient safety initiatives6 Study in Hospital Topics found accreditation to be effective in driving efforts to reduce errors7
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to address the problem of patient safety worldwide

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WHO World Alliance for Patient Safety
World Alliance for Patient Safety: Ten Action Areas

Global Patient Safety Challenges : 1. Clean Care is Safer Care 2. Safe Surgery Saves Lives Patients for Patient Safety Solutions to improve patient safety High 5s
Research for Patient Safety
International Classification for Patient Safety (ICPS) Reporting & Learning
Special projects: - Education - Radiotherapy - Rewarding excellence - When things go wrong - Vincristine sulphate
Catalyse countries action to achieve safety of care
Technology for Patient Safety
Knowledge Management
Solutions for Patient Safety
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Clean Care is Safer Care
Copyright, Joint Commission Resources
51
Patients for Patient Safety

A patient engagement initiative Focus on individuals (champions), not organizations Links to other World Alliance strands Creation of regional groups
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Taxonomy for Patient Safety
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International Patient Safety Events Taxonomy Cornerstone of patient safety communications
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Reporting and Learning
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Research for Patient Safety

Canadian Adverse Event Study 2004 Harvard Practice Medical Study 1984 Danish Adverse Event Study 2001
Utah Colorado Study 1992
Adverse events in British Hospitals 1999-2001
French Adverse Event Study 2004

The Commonwealth Fund Survey 2005
Australian Quality in Healthcare Study 1992 Adverse Events in New Zealand Study 2002
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Technology for Patient Safety

To identify and clarify the role and objectives of technology in improving patient safety both in the developed and developing world, and future directions (research, education, implementation) for the alliance regarding technology for patient safety.
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High 5s Project Objective

To achieve significant, sustained, and measurable reduction in the occurrence of patient safety problems over 5 years in at least 7 countries and build an international, collaborative learning community that fosters the sharing of knowledge and experience in implementing innovative standardized operating protocols and evaluating their impact.
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High 5s Standardized Operating Protocols

Managing Concentrated Injectable Medicines (U.K.) Assuring Medication Accuracy at Transitions in Care (Canada) Performance of Correct Procedure at Correct Body Sites (U.S.) Improved Hand Hygiene to Prevent Health CareAssociated Infections (New Zealand) (deferred) Communication During Patient Care Handovers (Australia) (deferred)
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WHO Collaborating Centre for Patient Safety Solutions

Identify Current Regional Safety Problems and Solutions Available Understand Regional Barriers to Solutions Assess Risk of Solutions Adapt Solutions to Local/Regional Needs Develop/Disseminate Solutions
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Definition
A Patient Safety Solution is any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care.
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Topic Selection Process

Sentinel Event Topic Areas Expert Panels National Agencies and Governments Professional societies and organizations Patient and family advocacy organizations Field reviews Open solicitations
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Confusing drug names is one of the most common causes of medication errors and is a worldwide concern. With tens of thousands of drugs currently on the market, the potential for error created by confusing brand or generic drug names and packaging is significant. The recommendations focus on using protocols to reduce risks and ensuring prescription legibility or the use of preprinted orders or electronic prescribing.
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The widespread and continuing failures to correctly identify patients often leads to medication, transfusion and testing errors; wrong person procedures; and the discharge of infants to the wrong families. The recommendations place emphasis on methods for verifying patient identity, including patient involvement in this process; standardization of identification methods across hospitals in a health care system; and patient participation in this confirmation; and use of protocols for distinguishing the identity of patients with the same name. 64
Gaps in hand-over (or hand-off) communication between patient care handhandunits, and between and among care teams, can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient. The recommendations for improving patient handhand-overs include using protocols for communicating critical information; providing opportunities for practitioners to ask and resolve questions during the hand-over; and involving patients and families in the hand-over handhandprocess. 65
Considered totally preventable, cases of wrong procedure or wrong site surgery are largely the result of miscommunication and unavailable, or incorrect, information. A major contributing factor to these types of errors is the lack of a standardized preoperative process. The recommendations to prevent these types of errors rely on the conduct of a preoperative verification process; marking of the operative site by the practitioner who will do the procedure; and having the team involved in the procedure take a time out immediately before starting the procedure to confirm patient identity, procedure, and operative site. 66
While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions that are used for injection are especially dangerous. The recommendations address standardization of the dosing, units of measure and terminology; and prevention of mix-ups of specific concentrated mixelectrolyte solutions.
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Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient transition points. The recommendations address creation of the most complete and accurate list of all medications the patient is currently taking taking also called the home medication list; comparison of the list against the admission, transfer and/or discharge orders when writing medication orders; and communication of the list to the next provider of care whenever the patient is transferred or discharged. 68
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The design of tubing, catheters, and syringes currently in use is such that it is possible to inadvertently cause patient harm through connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route. The recommendations address the need for meticulous attention to detail when administering medications and feedings (i.e., the right route of administration), and when connecting devices to patients (i.e., using the right connection/tubing).
One of the biggest global concerns is the spread of Human Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles. The recommendations address the need for prohibitions on the reuse of needles at health care facilities; periodic training of practitioners and other health care workers regarding infection control principles; education of patients and families regarding transmission of blood borne pathogens; and safe needle disposal practices. 70
One of the biggest global concerns is the spread of Human Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles. The recommendations address the need for prohibitions on the reuse of needles at health care facilities; periodic training of practitioners and other health care workers regarding infection control principles; education of patients and families regarding transmission of blood borne pathogens; and safe needle disposal practices. 71
Next Set of Solutions

Preventing Central Line Infections Communicating Critical Test Results Recognizing and Responding to Deteriorating Patients Preventing Pressure Ulcers Preventing Harm from Patient Falls
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Next Set of Solutions (contd)

Prototype will target four audiences: 1. Government policy at ministry of health level 2. Health care organization at the CEO level 3. Clinician/provider levels 4. Patient and family level
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Joint Commission International: An Overview

Copyright, Joint Commission International

Mission of Joint Commission International

Copyright, Joint Commission International

Ernest A. Codman: End Result Theory

Copyright, Joint Commission International

Copyright, Joint Commission International

The Joint Commission

Why International Standards?

Copyright, Joint Commission International

Standards Subcommittee: How We Get Stakeholder Input

Copyright, Joint Commission International

JCI Hospital Standards Translations

Copyright, Joint Commission International

Copyright, Joint Commission International

Copyright, Joint Commission International

Regional Advisory Councils

Copyright, Joint Commission International

European Regional Advisory Council

Copyright, Joint Commission International

Copyright, Joint Commission International

International Accreditation Programs

Copyright, Joint Commission International

Accredited Hospitals in Czech Republic

Copyright, Joint Commission International

Accreditation: A World Trend

Copyright, Joint Commission International

Common Core of Health Care Accreditation Around the World

 Focus is on continuous improvement

What is Accreditation Intended to Accomplish?

Copyright, Joint Commission International

Copyright, Joint Commission International

Copyright, Joint Commission International

Joint Commission International Accreditation

Copyright, Joint Commission International

The Accreditors Tools

Copyright, Joint Commission International

Standards are Continually a Work in Progress

Copyright, Joint Commission International

Evidence of Performance is Available

Copyright, Joint Commission International

Joint Commission International Standards

Copyright, Joint Commission International

JCI Standards, continued

Copyright, Joint Commission International

Patient Tracer: Systems Analysis

Copyright, Joint Commission International

International Patient Safety Goals and Tools

Copyright, Joint Commission International

JCI International Patient Safety Goals

JCIs Measurement Strategy

Copyright, Joint Commission International

Copyright, Joint Commission International

International Cardiac Surgery Benchmarking (ICSB) Project

Copyright, Joint Commission International

ICSB Project Objectives

Copyright, Joint Commission International

Copyright, Joint Commission International

Sentinel Event Database

Copyright, Joint Commission International

Sentinel Event Experience to Date

Client name/ Presentation Name/ 12pt - 38

Copyright, Joint Commission International

Focus is on continuous improvement