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Hospital Accreditation and

Patient Safety

Dr. David Marx

Joint Commission International, IL, USA

Joint Accreditation Committee, Prague

3rd Medical Faculty, Charles University,

Prague

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How safe is health care ???

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10

100

1 000

10 000

100 000

1 10 100 1 000 10 000 100 000 1 000 000 10 000 000

Contacts/1 death

Dea

ths/

year

RiskyDangerous(>1/1000)

Safe(<1/100K)

Health care

Mountain climbing

Bungee Jumping

Driving

Chemical industry

Charter flights

Regular air transport

European railways

Nuclear power

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• Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standardsthat require continuous improvement in structures, processes, and outcomes.

Accreditation – A Definition

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• To improve the safety and quality of care in the international community through the provision of education, publications, consultation, and evaluation services

Mission of

Joint Commission International

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Organizational Base

• The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the USA accreditation agency, is the organizational parent of Joint Commission International (JCI)

• Both organizations are based outside Chicago, USA

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JCAHO - History

• 1910 to 1913 Concern for the quality of hospital care in the U.S.

• 1910 Ernest A. Codman, M.D., focus on results

• 1918 American College of Surgeons begins a Hospital Standardization Program

• 1951 Joint Commission on Accreditation of Hospitals formed to continue the task

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• The U.S., Canada, and Australia have the oldest accreditation systems

• In Europe, Germany, France, Ireland and Spain have new accreditation systems

• CEE countries – Czech Republic, Poland

• 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

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Joint Commission Resources, Inc.

• 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)

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• 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.

Accreditation Represents a Risk

Reduction Strategy

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International Accreditation Philosophy

Joint Commission International-

Accreditation

• Maximum achievable standards

• Patient-centered

• Culturally adaptable

• Process stimulates continuous improvement

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International Accreditation

Programs

• Hospitals (1999) – 2nd Edition 2003 • As of July 2004, more than 40 accredited hospitals in

� Turkey, Saudi Arabia, UAE, � Brazil, � Thailand, � Spain, Ireland, Germany, Italy, Denmark, Austria,

Portugal……..• Care continuum• Transport• Laboratories• Primary and Ambulatory Care

ACCREDITATION:

Characteristics and Benefits

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What is Accreditation Intended to

Accomplish?

• Stimulate continuous improvement in patient care processes and outcomes

• Increase efficiency/reduce costs

• Strengthen the public’s confidence

• Improve the management of health services

• Provide education on better/best practices

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What is Accreditation

Intended to Accomplish?

• Enhance staff recruitment, retention and satisfaction

• Improve or expand sources of payment for patient care

• Increase chances to enter networks and new provider arrangements

• Provide greater independence from government oversight

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What is Accreditation

Intended to Accomplish?

• Build a quality measurement database

• Provide comparison with self, others, and best practices

continued

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• External, objective evaluation

• Uses consensus standards

• Involves the health professions

• Proactive not reactive

• Organization wide

• Focus on systems not individuals

• Stimulates quality culture in the organization

• Periodic re-evaluation against standards

Strengths of Accreditation

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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 organizations

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Benefits for the Medical Staff

and 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

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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

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Benefits for Patients

• Access to a quality and safety focused organization

• Rights are respected and protected

• Understandable education and communication

• Satisfaction is evaluated

• Involvement in care decisions and care process

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Characteristics of

Excellent Hospitals

• Patient centered with good customer service• Coordinated and efficient care processes• Safe, low risk facility and environment• Staff with good skills and knowledge• Quality culture supported by leaders and

managers• Use standards and guidelines to continually

improve safety and quality of care and the environment

Origin and Content of JCI

Standards

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International Hospital Standards

• International Principles and Standards Development Task Force formed February 1998

• First meeting of the Task Force in June 1998

• Meetings held in Chicago, Budapest, Barcelona in 1998 and 1999

• Publication of standards in October 1999

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Hospital Task Force Members

• Saeed Almulla - United Arab Emirates• Rodolfo ArmasMerino, MD - Chile• Lluis Bohigas, PhD - Spain• Willis Goldbeck - United States• Ping Huang - Taiwan• Niek Klazinga, MD - The Netherlands• David Marx, MD - Czech Republic• Raphal Nizankowski, MD - Poland • Jose Noronha, MD - Brazil• Yazid Ohaly, MD - Saudi Arabia• Clive Ross, FDSRCS - New Zealand• Charles Shaw, MD - England• Christoph Straub, MD - Germany• Margretta Styles, EdD, MN,RN - United States• Stuart Whittaker, MD - South Africa

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Standards Subcommittee

Members - Countries

• Brazil• China• Czech Republic• Germany• Ireland (pending)• Italy• Poland• Portugal (pending)• Republic of South Africa• Saudi Arabia

International Accreditation

Standards

of

Joint Commission

International

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Definition of a Standard

• A standard is a statement of expectationthat defines the structures and processes that must be substantially in place in an organization to enhance the quality of care.

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Hospital Standards

• Organized around important functions• Focus on the patient• Designed to be interpreted/surveyed within the

culture and legal framework of a country• Set “core” or threshold standards that all

organizations must pass• Set “reach” or better practice standards for all to

achieve

Note: The standards in bold typeface are those “core” standards that all organizations must meet to be accredited.

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• Quality Improvement and Patient Safety (QPS)

• Prevention and Control of Infection (PCI)

• Governance, Leadership & Direction (GLD)

• Facility Management & Safety (FMS)

• Staff Qualifications & Management (SQE)

• Management of Information (MOI)

Section II: Health Care Organization

Management Standards

Accreditation Surveys

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• Tested survey methodologies – convergent validity

• Trained evaluator team of senior peers

• Score fundamentals, not symptoms

• Rule based processes for decisions

• Results set continuing improvement priorities

Valid and Reliable

Evaluation Process

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Overview of the Survey Process

• Pre-Survey Activities

• During Survey Activities

• Post-Survey Activities

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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

• The Joint Commission and others are working to advance accreditation around the world as we live in a global society

Conclusion