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Understanding JCIA
By:
Team Healthcare Consulting
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Accreditation
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.
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Accreditation Accomplishes:
1. Stimulate continuous improvement inpatient care processes and outcomes
2. Increase efficiency/reduce costs
3. Strengthen the public confidence
4. Improve the management of healthservices
5. Provide education on better or bestpractices
6. Provide recognition for excellence
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JCIA
A subsidiary of Joint Commission onAccreditation of Healthcare Organizations
(JCAHO) now called THE JOINT
COMMISSION).
Mission:
To improve the quality of health care in the
international community through provisionof accreditation, consultation, and
education services.
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JCIA Today
3rd edition will be issued June 2007
effective for survey Jan. 2008
120+ hospitals and other healthcare
organizations are accredited around the
world as of Dec. 2007.
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JCIA Standards
International Patient Safety Goals
Section I: Patient Centered Standards:
1. Access to Care and Continuity of Care (ACC)
2. Patient and Family Rights (PFR)
3. Assessment of Patients (AOP)
4. Care of Patients (COP)
5. Anesthesia and Surgical Care (ASC)
6. Medication Management and Use (MMU)
7. Patient and Family Education (PFE)
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Section II: Healthcare Organization
Management Standards
8. Quality Improvement & Patient Safety(QPS)
9. Governance, Leadership, and Direction
(GLD)10. Facility Management & Safety (FMS)
11. Staff Qualifications & Education (SQE)
12. Prevention & Control of Infections (PCI)13. Management of Communication and
Information (MCI)
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Structure of Standards
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PATIENT SAFETY GOALS
The purpose of the International Patient Safety Goalsis to promote specific improvements in patient safety.
The goals highlight problematic areas in health careand describe evidence- and expert-based consensussolutions to these problems.
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GOALS
Goal 1
Identify Patients Correctly
Requirement of Goal 1
The organization develops an approach to
improve accuracy of patient identifications.
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Measurable Elements of Goal 1
Require the use of two patient identifiers, notincluding the use of the patients room number orlocation.
Patients are identified before: administering medications,
blood, or blood products.
taking blood and other specimens for clinical testing.
providing treatments and procedures.
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Goal 2
Improve Effective Communication
Requirement of Goal 2
The organization develops an approach to
improve the effectiveness of
communication among caregivers.
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Measurable Elements of Goal 2 The complete verbal and telephone order or testresult is:
written down by the receiver
read back by the receiver
The order or test result is confirmed by the
individual who gave the order or test result. (signed)
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Goal 3Improve the Safety of High-Alert Medications
Requirement of Goal 3The organization develops an approach to
improve the safety of high-alert medications.
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Measurable Elements of Goal 3 Concentrated electrolytes are not present inpatient care units unless clinically necessary and
actions are taken to prevent inadvertent
administration in those areas where permitted by
policy.
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Goal 4
Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery
Requirement of Goal 4The organization develops an approach to
ensuring correct-site, correct-procedure, and
correct-patient surgery.
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Measurable Elements of Goal 4mark for surgical site identification involves the patient in the marking process.
verify that all documents and equipment
needed are on hand, correct, and functional. use checklist and time-out procedure just
before starting a surgical procedure.
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Goal 5Reduce the Risk of Health CareAssociatedInfections
Requirement of Goal 5The organization develops an approach to reduce
the risk of health careassociated infections.
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Measurable Elements of Goal 5 adapted currently published and
generally accepted hand hygiene
guidelines. implements an effective hand hygiene
program.
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Goal 6
Reduce the Risk of Patient Harm Resulting fromFalls
Requirement of Goal 6The organization develops an approach to reduce
the risk of patient harm resulting from falls.
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Measurable Elements of Goal 6implements a process for the initial assessmentof patients for fall risk
reassessment of patients when indicated by achange in condition, medications, etc.
Measures are implemented to reduce fall riskfor those assessed to be at risk.
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Patient Centered Standards:
(ACC)
Overview:
Information is essential to match the
patients health care needs with the
services available.
Coordinate the services provided by the
organization.
Plan for discharge and follow-up
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Patient Centered Standards:
(PFR)
Overview:
Identify, protect, and promote patient rights
Inform patients of their rights
Include the patients family in patient care
decisions
Obtain informed consent
Educate staff about patient rightsEstablish an ethical framework.
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Patient Centered Standards:
(AOP)Overview:
A effective assessment process results in decisions aboutthe immediate and continuing treatment needs. Patientassessment is ongoing, dynamic, and multidisciplinary
process:1.Collecting information and data on patients physical,psychological, social status, and health history.
2.Analyzing data and information to identify the patientshealth care needs.
3.Developing a plan of care to meet the patients identifiedneeds.
4.Performed by qualified individuals.
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Patient Centered Standards:
(COP)
Overview:
1. Plan and deliver uniform care to all patients
especially frail and elderly
2. Make care seamless through effectivecommunication
3. Provide safe care of high risk patients
4. Use medications safely5. Support patient nutrition needs
6. Pain management and care of the dying
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Patient Centered Standards:
(ASC) Overview:
The use of anaesthesia, sedation and surgicalintervention are common and complex processes
They require complete and comprehensive patientassessment
Integrated care planning
Continuous monitoring of patients
And criteria to determine transfer to another level of careor discharge
Managing patient at risk of complications The standards are applicable for all areas where surgical
and invasive procedures, anaesthesia and sedation areused within the organization
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Patient Centered Standards
(MMU)Overview:
MMU Important component of patient care
Encompasses systems and processes toprovide pharmaceutical care to patients
Multidisciplinary and coordinated efforts tomanage medication use by: Process design
Implementation and improvement
Selection of medication Procurement, storing, ordering/prescribing,
transcribing, distribution, preparing, administering,documenting and monitoring of medication therapies.
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Patient Centered Standards:
(PFE)
Overview:
1. Assessment of educational needs
2. Education includes: Medication, medicalequipment, interaction between food &
medication, nutritional guidance, and
rehabilitation techniques.
3. Staff have appropriate knowledge and
skills
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Healthcare Organization Management
Standards: (QPS)
Overview:
1. Governance and leadership participation
2. Comprehensive approach3. A framework for: Designing processes,
implementing and sustaining changes
that result in improvement.
4. PI plan and indicators.
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Healthcare Organization Management
Standards: (PCI)
Overview:
1. Understand infection risks in the entire
organization
2. Plan and implement surveillance and
prevention strategies
3. Integrate the program with quality
management and improvement
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Healthcare Organization Management
Standards: (GLD)
Overview:
1. Identify governance structure and
responsibility
2. Provide collaborative leadership
3. Provide responsible leadership at
department and service level
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Healthcare Organization Management
Standards: (FMS)
Overview:
1. Reduce and control hazards and risks
2. Prevent accidents and injuries
3. Maintain safe conditions
4. Plan space, equipment, and resources
5. Educate staff to reduce risks and report
incidents6. Use data to monitor performance
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Healthcare Organization Management
Standards: (SQE)Overview:
1. Mix of skills to fulfill hospital mission
2. Managerial and clinical leaders identify the numberand types of staff needed
3. Recruiting, evaluating, and appointing staff are bestaccomplished through a coordinated uniform process
4. Documented skills, knowledge, education, andexperience
5. Review of credentials of medical and nursingpersonnel
6. Provide staff with the required education to updatetheir competencies
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Management of Communication
and Information (MCI)
Overview:
Assure that Organizations are effective in:
Identifying information needs
Designing and information management system
Defining and capturing data and information
Analyzing data and transforming it into
information And integrating and using information
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Thank YouQuestions?