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Accreditation: How to improve efficiency and

quality in the hospital

Global GS1 Healthcare ConferenceGeneva, Switzerland, 22-24 june 2010

Carlo Ramponi, MD, MBA, Managing Director JCI EuropeFerney-Voltaire, FranceMilano, Italy

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JCI

•Non-profit affiliate of TJC•Quality and safety innovations •Accreditation resources•Quality and safety risk areas• Founded 1986

JCR

A quick overview of our organization

Transforming patient safety and quality of

care

• Leading accrediting body for health care institutions in the US

• Founded 1951•>15,000 accredited institutions

The Joint Commission

• Improving the quality and safety of patient care and achieve peak performance in the international community

•Work with Health Care org’s, NGO’s and Government

•300+ Accredited organizations

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We’ve worked in over 70 countries

Head office

Countries with current JCI accredited organizations

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JCI Accreditation Update

Middle East (99)

Asia (68)Europe (114)

Other (40)

HOSP (27)AMB (5)CCPC (2)CC (3)LAB (2)MED TRANS (1)PRI CARE (0)

HOSP (83)AMB (9)CCPC (2)CC (1)LAB (5)MED TRANS (0)PRI CARE (0)

HOSP (83)AMB (14)CCPC (1)CC (8)LAB (5)MED TRANS (2)PRI CARE (1)

HOSP (48)AMB (4)CCPC (16)CC (0)LAB (0)MED TRANS (0)PRI CARE (0)

Regional Distribution of Accredited/Certified Programs (1 Jan 10)

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5

International Structure

– International Board of Directors (of JCR)

– International Accreditation Committee

– International Standards Committee

– Regional Advisory Councils – Four International Offices– International translations of

many products

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Essentials: Validated achievement in self-assessment and improvement

Certification of excellent programs in uniquecapabilities

Accreditation: Accreditation of the full organization

High Performance Organizations

The JCI Roadmap

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– A voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standards that require continuousimprovement in structures, processes, and outcomes.

Accreditation – JCI Definition

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JCI Accreditation SystemPatient Centered STD

1. Access to Care and Continuity of Care

2. Patient and Family Rights3. Assessment of Patients4. Care of Patients5. Anesthesia and Surgical Care6. Medication Management and

Use7. Patient and Family Education

Organization centered STD

1. Quality Improvement and Patient Safety

2. Prevention and Control of Infections

3. Governance, Leadership, and Direction

4. Facility Management and Safety

5. Staff Qualifications and Education

6. Management of Communication and Information

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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

Standards

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ASC.5.1 The risks, benefits, and alternatives of anesthesia are discussed with the patient, his or her family, or those who make decisions for the patient.

Intent of ASC.5.1The anesthesia planning process includes educating the patient, his or her

family, or decision maker on the risks, benefits, and alternatives related to the planned anesthesia and postoperative analgesia. This discussion occurs as part of the process to obtain consent for anesthesia (including moderate and deep sedation) as required in PFR.6.4, ME 2. An anesthesiologist or a qualified individual provides this education.

Measurable Elements of ASC.5.1 1. The patient, family, and decision makers are educated on the risks, benefits,

and alternatives of anesthesia. (Also see PFR.6.4, ME 2)2. The anesthesiologist or another qualified individual provides the education.

An example of standard

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What is Accreditation Intended to Accomplish?

– Involve Patient and Family in his/her care– Stimulate continuous improvement in patient care – Increase efficiency/reduce costs– Strengthen the public’s confidence– Improve the management of health services– Enhance staff recruitment and retention– Improve or expand sources of payment– Provide less government oversight– Provide comparison of performance

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What is it found in JCI Accredited Organizations?

– A culture of patient rights, quality, safety and transparency

– An integrated management structure– Qualified staff– Lower risks and data on the risks– Quantifiable outcomes of care– Up-to-date science used by Medical staff

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Accreditation Standards and Performance Measures Are Complementary

Complex interrelationships exist among any given standard and an array of relevant

performance measures

Standards

PerformanceMeasures

100%

Stan

dard

s Dep

ende

nt100%

Measure D

ependent

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Clinical Monitoring

• aspects of patient assessment•aspects of laboratory services•aspects of radiology and diagnostic imaging services •aspects of surgical procedures•aspects of antibiotic and other medication use •the monitoring of medication errors and near misses.•aspects of anesthesia and sedation use•aspects of the use of blood and blood products•aspects of availability, content, and use of patient records•aspects of infection control, surveillance, and reporting•aspects of clinical research

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Managerial monitoring•aspects of the procurement of routinely required supplies and medications essential to meet patient needs •aspects of reporting of activities as required by law and regulation•aspects of risk management•aspects of utilization management•aspects of patient and family expectations and satisfaction •aspects of staff expectations and satisfaction•aspects of patient demographics and clinical diagnoses•aspects of financial management•aspects of the prevention and control of events that jeopardize the safety of patients, families, and staff, including the International Patient Safety Goals.

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Reduction in Radiology Film Costs in Hospitals in Qatar

0

1

2

3

4

5

6

Hosp A Hosp R

Q1 2006Q2 2006

%

Percentage of Radiology films needing repeat

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Improved Patient Service in Qatar

0102030405060708090

MRI delay US Biopsy delay

Q1 2006Q2 2006D

ays

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Reduction of Complications at “Istituto Giannina Gaslini” NI/PICU

27.2

4.92.6

03.6

0.90

5

10

15

20

25

30

2006 2007

******

* Mortality (%) from hosp acq. Infections** Hosp acq. Infections (per 1000 pt days)*** Hosp acq. Pneumonia (per 1000 pt days)

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Postoperative mortality rate (Mexico)The following chart reflects the percentage rate of patientsdeceased (line) within 48 hours of a surgical procedure(associated with surgical complications) per total number ofsurgical patients (bars) from January 2007 to June 2008. Totalnumber of surgical patients during the period described: 21,184

0

0.001

0.002

0.003

0.004

0.005

0.006

0.007

Jan-07

F M A M J J A S O N D Jan-08

F M A M J

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Recent Studies Support the Value of Accreditation

– 1. Longo D.R., Hewett J.E., Ge B., Schubert S.: Hospital Patient Safety: Characteristics of Best-Performing Hospitals. J Healthc Manag. 52(3):188-204, May-June 2007.

– 2. Devers K.J., Pham H.H., Liu G: What is driving hospitals’ patient-safety efforts? Health Affairs 23(2):103-115, 2004.

– 3. Hosford S.B.: Hospital progress in reducing error: The impact of external interventions. Hospital Topics 86(1):9-19, 2008.

– 4 Groene O, Klazinga N, Walshe K, Cucic C, Shaw CD, Suñol R Learning from MARQUIS: future direction of quality and safety in healthcare in the European Union. Qual Saf Health Care 2009; 18 (Suppl 1): i69-i74. doi:10.1136/qshc.2008.029447

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– Accreditation is the most comprehensive and powerful tool for quality improvement

– Accreditation has been found to be effective in many cultures and countries with very different systems

– International Accreditation is the appropriate answer to increasing needs of quality and safety in a global society

Conclusion

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Thank youFor more information:

• On JCR products and services• www.jcrinc.com• +1630-268-7400

• On JCI accreditation and advisory services• www.jointcommissioninternational.org• +1630-268-4800

• WHO Collaborating Centre for Patient Safety Solutions• http://www.ccforpatientsafety.org/• +1630-268-7467

• Carlo Ramponi, MD JCI Europe• cramponi@jcrinc.com• +393477295364 • +334 5042 6082