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Joint Commission International

Standards and Survey Process

Mahboob Ali Khan MHA,CPHQ

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Objectives

Identify and describe the JCI Accreditation process

Describe and review tracer methodology

Discuss a hospital’s preparation for the JCI Accreditation process

Describe global standardization of healthcare services through the process of accreditation

Accreditation as part of a systems focus

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JCI Standards System framework

Checklist of all the important managerial and clinical functions or activities

Focus on patient perspective in context of their family

A balance of structure, process and outcomes standards

Optimal but achievable expectations

Measurable

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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.

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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

Strengthens public’s confidence

Strengths of Accreditation

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Accreditation Can Help:

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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Accreditation Can Help:

Build a quality measurement database

Provide comparison with self, others,

and best practices

Provide a framework to improve patient

safety

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Quality Improvement and Patient

Safety Programs

Are leadership driven

Seek to change the ethos of the organization

Proactively identify and reduce risk and variation

Use data to focus on priority issues

Seek to demonstrate sustainable improvement

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Accreditation as Part of

Continuous Quality Improvement

Accreditation is a milestone on the continuous journey of improvement

Accreditation Standards provide a common quality language and common set of expectations to point the way forward

Establishing a permanent organizational culture of safe, quality care is essential for sustaining improvement

The effort is for your patients, not the certificate

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Starting to Prepare

Available Resources:

JCI Accreditation Standards for Hospitals, 5TH

Edition

Survey Process Guide (electronic version)

Web-based training on introduction to the international accreditation process (ISAS)

Newsletters and publications

print and electronic (e.g. Getting Started)

JCI Practicum four times a year

(Annual JCI Executive Briefings – networking opportunity with accredited organizations)

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Begin with Education

Organizational leaders and managers

Introduction to accreditation philosophy and

approach

Accreditation as a quality improvement and risk

reduction strategy

Review of the standards and measurable elements

Discussion of the survey process and what to

expect

Project planning and next steps

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Baseline Assessment

Conduct a detailed baseline assessment of

current adherence to the Standards and each

Measurable Element:

Use knowledgeable and credible evaluators (either

internal or external consultants) who will critically and

objectively assess each area

Consider using ISAS as guide

Include all areas of the organization in the assessment

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Baseline Assessmentcont.

Collect and analyze baseline quality data as

required by the quality monitoring standards

Examples: medication errors, hospital-associated

infection rates, antibiotic usage, surgical complications.

Establish an ongoing monitoring system for data

collection to identify problem areas and track

progress in improvement

Set frequency of data collection

Analyze data

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Action Planning

Using the findings of the baseline assessment,

develop a detailed project plan with assigned

responsibilities, deliverables, and time frames.

Start with priority areas established by leadership

Example: Revise informed consent policy, develop a new

informed consent statement, educate staff - to be completed

in two months (specify exact date)

If available, use a software program such as MS

Project or Excel to confirm project plan in writing

Hold leaders and staff accountable to the plan

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Team Approach

Assign oversight of each chapter of standards to

a respected champion/leader who will identify

team members from throughout the hospital

Also include those who may be skeptical of the

process

Look for good people skills, time management

skills, and consensus building skills

Be prepared to change as new champions

emerge, and some leaders drop out

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Policies and Procedures

Compile a list of all required policies and

procedures that will need development and

revision

Hint: look for list in Survey Guide 2008

These may take some time to get revise or develop,

undergo organizational review, and obtain final

approval

Be certain that your policy reflects your actual

practice, as this is one of the yardsticks the

surveyors will use to evaluate your performance

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Mid-Point Strategies

Continue to monitor your progress in meeting the

standards

Ex. Use a mini-evaluation of each chapter at regular

intervals (e.g quarterly)

Don’t be afraid to adjust your project plan to be

more realistic – change often takes longer than

one expects

Continue to involve as many staff as possible in

the process – make it an organizational quality

goal that you are striving to achieve together

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Strategies That Have Worked

Importance of physician commitment to the accreditation process cannot be overstated

They should see accreditation standards as framework by which hospital processes will be improve

Care will ultimately be of higher quality and safer for their patients

Reassure physicians that accreditation is not intended to tell them how to practice medicine!

But it does compel them to look collectively at their own practices and evaluate their own results

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Strategies That Have WorkedCont.

Learn from what others have done well and

adapt the experience to the needs of your

organization

Ask JCI for clarification with standards

interpretation – don’t waste time going down

the wrong path

Take advantage of resources (e.g.

download electronic example policies and

plans and adapt to your organization)

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Pitfalls to Avoid

Top leaders “support” the process, but are totally unrealistic in what it will take to achieve it in terms of time and resources

Staff end up feeling that accreditation is extra work for which they are not rewarded or recognized

Over-eager managers using the standards as a threat rather than as a goal – can make entire accreditation process feel punitive and inspecting rather than motivating

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Final Mock Survey

Plan for a final “mock” or practice survey about 6-8 months in advance of the target date of the actual accreditation survey

Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organization with a fresh and objective eye

Plan final actions and corrections based on the

findings of the final mock survey

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Standards in two sections:

Patient-Centered Standards

Healthcare Organization Management Standards

JCI Hospital Standards 3rd Ed.

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JCI Hospital Standards 3rd Ed.

Cont.

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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Anesthesia and Surgical Care

1. Organization and Management

2. Sedation Care

3. Anesthesia Care

4. Surgical Care

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Medication Management and Use

1. Organization and Management

2. Selection and Procurement

3. Storage

4. Ordering and Transcribing

5. Preparing and Dispensing

6. Administration

7. Monitoring

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JCI Hospital Standards 3rd Ed.Cont.

Healthcare 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 Communications and Information

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Staff Qualifications and Education

1. Planning

2. Orientation and Education

3. Medical Staff

4. Nursing Staff

5. Other Health Professional Staff

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Management of Communication

and Information

1. Communication with the Community

2. Communication with Patients and Families

3. Communication Between Providers Within and Outside the Organization

4. Leadership and Planning

5. Patient Clinical Record

6. Aggregate Data and Information

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Standards Content

Each JCI standard contains three

components:

The standard represents the principle

The intent describes the rationale of the

standard

The measurable elements are the detailed

requirements from the standard and intent

that are scored

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Standards Content (sample)

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International Patient Safety Goals

Identify patients correctly at risk points

Improve effective communication of critical information

Improve safety of high-alert medications

Ensure correct-site, correct-patient, correct-procedure surgery

Reduce the risk of healthcare-associated infection

Reduce the risk of patient harm from falls

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Approach and Philosophy

to the On Site Survey

A Survey is not intended to be punitive, a “got you” exercise, or an inspection

Tracer Methodology is a process of identifying imperfections, flaws, or broken systems

Surveyors will “drill down” or focus on areas where a potential risk area is identified Based on common problem areas in many hospitals

High risk or high volume services

They have identified a vulnerable area

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On-Site Evaluation Process

Opening conference

Orientation

Document review

Leadership session

Assessment activities Tracer activities – patient

Tracer activities – systems

Facility tour

Special interview / issue resolution

Feedback sessions Daily briefings

Leadership exit conference

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Tracer Methodology

Is an effective evaluation method that

is used to assess a healthcare

organization’s performance of care

and the services provided as

viewed or experienced by the

patient

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Objectives of Tracer Activity

Follow entire course of care and

services provided to the patient

Assess relationships among disciplines

and important functions

Evaluate performance of processes

provided to the patient

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Types of Tracers

Patient Tracer – Follows the patient

System Tracer – Follows the system

Data use

Medication management

Infection Control

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Conducting Tracers

Selection of patients

Diagnoses

High volume

Procedures

High volume

High risk

Low volume

Selection of units

Diagnoses/procedures

Special care

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Sample Patient Tracer

Hospital Setting

Patient – Mr. Ramponi

Cardiac-surgery related diagnosis (cardiac bypass

surgery)

Pulmonary complications (pneumonia)

Surveyor

Reviews patient record

Notes what services and transfers occurred

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72-year old man presented to ER with chest pain

An electrocardiogram showed signs of sinus tachycardia

Staff administered aspirin and drew blood

Mr. Ramponi

Treated for diabetes and hypertension

Recently quit smoking after 33 years

Sent to cardiac catheterization lab for an angiogram, which revealed

5 blockages

Put on IV heparin, nitroglycerin and beta-blocker

Transferred to ICU

Hypertension was an issue. So medications were adjusted to lower his blood pressure

Surgery for a coronary artery bypass graft was scheduled for the

next morning

Surveyor Reviews Medical Record

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Communication, assessment, performance improvement, and

medication management issues.

Surveyor speaks with ED Staff

At Emergency Department

“You’ve said that like many

heart attack victims, Mr.

Ramponi delayed seeking

help after experiencing the

first symptoms. Has your ED

conducted any performance

improvement projects to

decrease the time to begin

treatment?”

Step 1

“I see that a cardiac catheterization was

necessary; how was informed consent obtained

from Mr. Ramponi?”

“A little over 2 weeks ago, Mr. Ramponi came

into the ED with chest pains and a history of

hypertension and diabetes. What processes

were followed for triaging and treating him?”

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Surveyor reviews Medical Record

Antibiotics were begun at the time of surgery

Sent to ICU with ventilator which was removed 5 hours later

Developed pneumonia within 2 days

IV antibiotic was changed, but history of smoking has weakened his lungs

Placed on ventilator

Wean from ventilator within 6 days

Received pulmonary treatment regimen of nebulizer treatments, incentive spirometry, and assisted cough

Transferred to a general medical unit with telemetry after 3 days

Scheduled to be discharged for continued outpatient rehabilitation

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Emergency Department

points of discussion

Triage process

Patient assessment

Communication prior to patient transfer

Medication process, including for high risk concentrated medications and IV solutions

Communication needs for elderly patients

Competency of medical and nursing staff in emergency care

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Verbal orders, assessment and emergency care issues

Surveyor talks with Staff Nurse and CardiologistStep 2

At Cardiac Catheterization Lab

“What communication took place between

the catheterization lab and the ED before

Mr. Ramponi arrived for his procedure?”“How did you make certain Mr. Ramponi

had no allergies to the contrast medium

being used for the procedure?”

“What process was used for ensuring

medical equipment safety?”

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Catheterization Lab

points of discussion Pre-procedural patient assessment

Patient identification process

Informed consent

Patient privacy and confidentiality

Infection control

Patient monitoring during and after procedure

Use and maintenance of equipment

Sedation and anesthesia use and safety

Frequency of cancellation of procedures and

reasons (Quality Improvement project)

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Medication use, anesthesia care, informed consent, site verification,

emergency care issues and infection control.

Step 3

Surveyor also requests credentialling files for the

anesthesiologist and cardiac surgeon.

Surveyor talks to the

Staff, Circulating Nurse,

Anesthesiologist

At Operating Room

“What assessments had been

performed and what

information did you receive

before Mr. Ramponi arrived in

the OR?”

“Can you explain the process to

obtain informed consent for Mr.

Ramponi for this surgery?”

“What processes do you

follow to verify that you had

the correct patient and

procedure before you

started Mr. Ramponi’s

surgery?”

“During open-heart surgery, concentrated

potassium was used. How is access to

this undiluted concentrated electrolyte

controlled?”

“Patients undergoing bypass

surgery are at increased risk

of developing a surgical site

infection. What preventive

measures did you take to help

reduce that risk for the

patient?”“How was the placement

of Mr. Ramponi’s

pulmonary artery catheter

confirmed?”

“How do you maintain this

equipment? How were you

trained to use it?”

“What do you do in the event of fire?”

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At OR Recovery Area

Verbal orders, clinical practice guidelines and equipment management

Step 4

At Recovery Room

“Following Mr. Ramponi’s surgery,

he started on an IV infusion pump

for pain management. What

checks did you perform on the

equipment before starting him on

the pump?”

“Who made the decision to discharge Mr.

Ramponi from the Recovery, OT?”

“What guidelines did you follow for post-

anesthesia monitoring of Mr. Ramponi?”

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Communication, assessment, clinical practice guidelines,

credentialling, infection control, equipment management and

medication management

Surveyor talks with attending Physician, ICU Nurse,

Respiratory Therapist, Infection Control PractitionerStep 5

At Cardiac ICU

“Was Mr. Ramponi restrained while on

ventilator? How was the decision made to

remove Mr. Ramponi from the ventilator?”“How did the OR communicate what

procedures took place when Mr.

Ramponi was transferred to the ICU?

“Mr. Ramponi was receiving IV pain medication

following surgery. Can you show me where you

documented Mr. Ramponi’s pain assessment,

treatment and reassessment?”

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Cardiac ICU

points of discussion

Communications received from Recovery Room

Patient assessment and monitoring

Patient privacy and confidentiality

Infection control

Use and maintenance of equipment, especially clinical alarm systems

Staff competency based on patient populations cared for in ICU

End-of-life issues

Medication management

Handling of verbal orders

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Equipment management, patient education, rights & ethics,

discharge planning, continuum of care.

Step 6 Surveyor talks to Staff Nurse, Cardiac Rehab Nurse,

Respiratory Therapist, Nutritionist, Patient Educator

At Medical - Surgical Unit

“I see that Mr. Ramponi was on telemetry. How would

you know if the equipment is working? Can you explain how the

patient is monitored on this

system?”

“What process was followed for ordering

respiratory therapy for Mr. Ramponi?”

“Can you describe Mr. Ramponi’s medication protocols?”

“How was nutrition and weight management

education provided to the patient?”

“What is your plan for Mr.

Ramponi’s discharge?”

Surveyor reviews patient education materials.

Speaks with Mr. Ramponi and his wife about ongoing

education, informed consent process and the care

provided.

“What written information will Mr. Ramponi receive about his medications

when he is discharged this afternoon? Does the patient know about his

medications? When did you educate him? How?”

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Patient Tracer

Summary

Surveyor visits areas within the organization where the tracer patient was physically treated.

Wherever the surveyor is, he/she is assessing numerous standards.

Surveyor might also tour other areas, e.g., laboratory and pharmacy to explore issues such as diagnostics and medication management.

Surveyor could theoretically visit any location in the organization if it related to the care provided to the patient, including registration, dietary dept, physical therapy, outpatient pharmacy, etc.

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Infection Control Assessment

Assess processes to identify, prevent & manage healthcare acquired infections throughout organization

Uses information obtained from other assessment activities

Facility tour

Tracer activities to inpatient / outpatient care areas

Tracer activities to diagnostic services

Document review

Open & closed record review activities

System tracers activities, e.g. Pharmacy

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Infection Control System Tracer

Group discussion

Goals

Surveillance data

Analysis

Prevention & control strategies

Areas of concern & action

Outbreaks

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Infection Control System TracerCont.

Focused tracer

Tracing infection control processes across the

organization

Example 1: a TB patient admitted through

Emergency to Medical Unit to Radiology to

Medical Unit to Rehab

Example 2: an immuno-compromised patient

admitted through Emergency to Oncology to

Intensive Care Unit to Medical Unit to End-of -

Life care unit.

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Data System Tracer

Group Discussion

20 Minute presentation – optional

Required measures and sustained improvements reviewed

Steps – selection, collection, analysis, dissemination/transmission, action, monitoring, sustained improvement

How data is used throughout the organization

Short surveys

Include medication management and infection control data issues

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Benefits of Tracers

For Patients

Improves Safety and Quality of care

Improves patient flow

For Staff

Encourages team building

Creates systems thinkers

Creates a better understanding of roles

For Organizations

Reduces risk to patients

Increases patient satisfaction

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Tracer Methodology

You can learn more

in 8 hours of tracing

than in 20 hours of

chart review

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Follow-up Process

Written report is required within 6 months for

standards that require a plan, policy or procedure,

or documentation

Focused survey is required within 6 months for

standards that require surveyor observation, staff

or patient interviews, or the inspection of the

physical facility

If both are required, written report is reviewed at

time of focused survey

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Accreditation Denied

A required follow-up focused survey has not

resulted in acceptable compliance with the

applicable standards and/or International Patient

Safety Goal requirements

JCI withdraws its accreditation for other reasons

Organization voluntarily withdraws from the

accreditation process

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After the Survey

Celebrate the success!

Let your patients know what

you have achieved

Take a week off and then start again

May need to work on areas for improvement and submit a follow-up progress report to JCI

Maintain the momentum from the survey –establish an ongoing system of standards compliance and survey readiness

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The Globalization of Healthcare

Color Palette

JCI

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Why International Standards?

JCAHO standards filled with U.S. and state laws and regulations

JCAHO standards contain many “political” considerations such as requirements for an organized medical staff

JCAHO standards use U.S. jargon such as “advanced directives”

JCAHO standards rely on NFPA requirements for facility review with no international version of those requirements

JCAHO standards have a U.S. cultural overlay for patient rights

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JCI’s Commitment to Globalization

International Board Members Mandated

International Standards Committee

Regional Offices Asia Pacific

Europe

Middle East

Regional Advisory Councils

WHO Collaborating Centre for Patient Safety Solutions

International Standards

International Patient Safety Goals

ISQua Accredited

International Surveyors

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Comparisons

International standards include all topics from Joint Commission standards including newer ones related to pain management, and care at the end of life

International standards contain many of the quality control and quality leadership ISO 9000 criteria

International standards include the criteria of the European (EFQM) and U.S. (Baldridge) quality award

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JCI Standards Address Key Issues

Relevant to Globalization

Truth in admission policies

Patients are admitted for care only if the organization can provide the necessary services and settings for care.

At admission patients and families are provided information on the proposed care, expected results of care, and expected costs.

There is an established framework for ethical management including marketing, admissions, transfer, and discharge, and disclosure of ownership and any professional conflicts that may not be in the patients’ best interests.

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JCI Standards Address Key Issues

Relevant to Globalization

Professional Competence

The organization has an effective process to authorize all medical staff members to admit and treat patients and provide other clinical services consistent with their qualifications.

The credentials of medical staff members are reevaluated at least every three years to determine their qualifications to continue to provide patient care services in the organization.

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Accreditation as Part of a

Systems Focus

Focusing on staff would mean reviewing

the mistakes of individuals

A focus on systems examines

conditions where staff work and targets

strategy development to ensure that

there are fewer errors and risk is

reduced

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Accreditation as Part of a

Systems Focus

Errors need to be seen as consequences, not as causes

The best professionals can make the worst mistakes

Errors tend to have recurrent patterns

Organizations should review high reliability systems and anticipate the worst possibilities

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Accreditation as Part of a

Systems Focus

If systems are designed with the full

understanding that we do mistakes,

and nobody is perfect, errors should

occur less frequently.

Furthermore, increasing the

consistency of care provision will

decrease the frequency of errors.