Joint Commission International
Why JCI?
The U.S., Canada, and Australia have the oldest accreditation systems
In Europe, Germany, France, Ireland and Spain have new accreditation systems
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
JCR WHO Collaborating Center
JCR WHO Collaborating Center
for
for
Patient Safety Solutions
Turkey
Turkey
1. Istanbul Memorial Hospital
Accredited: 29 March 2002 Re-accredited: 29 April 2005 2. Vehbi Koc Foundation American Hospital
Accredited: 15 December 2002 Re-accredited: 16 December 2005 3. Metropolitan Florence Nightingale Hospital
Accredited: 26 June 2003 4. Dnya Eye Hospital
Accredited: 17 April 2004
5. Medline Alarm Salk Hizmetleri A..
Accredited: 28 April 2005
6. CardioCheck Grntleme Merkezi
Accredited: 10 December 2005
7. Private Vehbi Koc Foundation Italian Oncology and Rehabilitation Hospital
Accredited: 16 December 2005
8. Acibadem Healthcare Group Accredited: 3 June 2006 9. Kent Hastanesi Accredited: 10 June 2006
10.Mesa Hastanesi Accredited: 1 July 2006 11.Bayindir Hospital Accredited: 15 July 2006
Singapore
Singapore
1. National University Hospital Accredited: 1 August 2004 2. Johns Hopkins Singapore International Medical Centre
Accredited: 4 August 2004
3. Changi General Hospital Accredited: 11 June 2005 4. Singapore General Hospital Accredited: 16 July 2005 5. Alexandra Hospital Accredited: 22 July 2005
6. Institute of Mental Health/Woodbridge Hospital
Accredited: 29 July 2005
7. Tan Tock Seng Hospital Accredited: 6 August 2005
8. National Heart Centre of Singapore Accredited: 27 October 2005 9. KK Women's and Children's Hospital Accredited: 9 December 2005 10. Gleneagles Hospital Accredited: 27 May 2006
India
India
1. Indraprastha Apollo Hospital Accredited: 18 June 2005
2. Wockhardt Hospital, Mumbai Accredited: 26 August 2005 3. Apollo Hospital, Chennai Accredited: 29 January 2006
4. Shroff Eye Hospital Accredited: 18 February 2006
5. Apollo Hospital, Hyderabad Accredited: 28 April 2006
Republics of China
Republics of China
• Clifford Hospital Accredited: 20 December 2003 • Beijing United Family Hospital and Clinics
Accredited: 1 September 2005 • Hong Kong Adventist Hospital
Accredited: 25 February 2006
• Tsuen Wan Adventist Hospital Accredited: 3 March 2006
DCSC for Acute Stroke: 29 April 2006
Taiwan
Taiwan
• Min-Sheng General Hospital Accredited: 15 July 2006 • Taipei Medical University-Wan Fang Medical Center
Qatar
Qatar
1. Hamad General Hospital Hamad Medical Corporation
Doha, Accredited: 15 September 2006 2. Al Khor Hospital Hamad Corporation
Doha, Accredited: 15 September 2006
3. Rumailah Hospital Hamad Medical Corporation
Philippines
Philippines
1. St. Luke's Medical Center
Thailand
Thailand
1. Bumrungrad International Hospital
Accredited: 2 February 2002 Re-accredited: 8 April 2005 Focus survey: 10 December 2006
Public Sector Quality
Public Sector Quality
Awards
Awards
Thailand Quality Awards
Thailand Quality Awards
SQA SQA Strategy Deployment HR Focus Process Management Customer & Market Focus Business/ Business/ Organization Organization Results Results UK UKQAQA
Total Quality Management M Malcolm alcolm B Baldrige aldrige N National ational Q Quality uality A Award ward MBNQA MBNQA J JQAQA EEQAQA Singapore Quality Award European Quality Assurance Japan Quality Award UK Quality Award
Leadership Information& Analysis
World class J JCIACIA Joint commission International Accreditation
HA 2006 JCIA 2008
Clinical Tracer of Quality
HA-Thailand PSGs
Tracer Methodology/DSC
HA
Standard
JCI Standard 3C-PDSA InnovationKM
KM
Mng
PI/CQI Safety Pt care processQA
HA and JCI
JCI Standard
JCI Standard
HA Standard
JCI Standard
QA
QA (Process)
PI
CQI
ToolTool/KM
HA StandardHA and JCI
JCI Standard
Unit
Daily JOB
responsibility
Training EducationTeam
P&PLeader
HA StandardHA and JCI
JCI Standard
JCI Standard
HA Standard
Patient Tracer
An Overview of care as a System Mesosystem Macrosystem Microsystem The Whole Work Units Clinics
The System
of
Care
Lean Cons umption Use r Fr iendly and Ori ente d Te am ne ssEveryone Is Involved and Optimizes the Processes in the System
Change Occurs at All Levels
IMPACT Theory
Leadership
and System
Transformation
Improvement
on the front
lines
Joint Commission International Joint Commission International-
-Accreditation
Accreditation
Philosophy
Philosophy
Process stimulates continuous improvement
Maximum achievable standards
Maximum achievable standards
Patient
Patient
-
-
centered
centered
Culturally adaptable
Culturally adaptable
External, objective evaluation : 1,032 ME
Uses consensus standards : fields review
Involves the health professions : microsystem Proactive not reactive eg. OpenMRR, process
Organization wide : tracer methodology
Focus on systems not individuals : P&P, Training
Stimulates quality culture in the organization :
discipline
Periodic re-evaluation against standards : PI
Components of Standards
Development
Multiple Information Sources
Scientific literature
Survey compliance data Research Findings
Individual input from field experts and key stakeholders
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
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
JAMA,
111 (4) July 23, 1938, Page 327
What do you mean: „Don’t expect miracles“? Why shouldn’t I expect miracles?
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
Teamwork
Benefits for Patients
Access to a quality focused organization Rights are respected and protected
Understandable education and communication Satisfaction is evaluated
Involvement in care decisions and care process Focus on patient safety
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
University Hospital
< 1,000 Beds
1. Clínica Universitaria de Navarra Navarra, Spain Accredited: 29 May 2004
2. National University Hospital, Singapore Accredited: 1 August 2004Æ 928 Beds
3. Aga Khan University Hospital Karachi, Pakistan Accredited: 8 July 2006
4. Taipei Medical University-Wan Fang Medical Center, Taiwan Accredited: 22 July 2006Æ 800 Beds
Nurse
Smart &
Professionalism
EngagementDoctor
Buy inLeader
Human as well as technical factors and processes The science and technology of improvement The sociology and
organisation of improvement
Scorecards, metrics, measurement systems and technology, clinical
pathways, EBM Organisation,
culture, language & cognition, identity, leadership, structure,
strategy, citizenship etc
Dec 2006 Jan 2007 23-26 Jan 2007 Nov 2006
Review status
F/U Progression Focus on Core Standard Compliance meet to Mock Surveys Recommendations
Conclusion
Conclusion
Action Plan Timeframe
Action Plan Timeframe
Mid-Point Strategies/Dec 15,06 Continuous Performance review Continuous Performance review
Education Team Staff
Education Team Staff
Detailed Project Plan / Policies and Procedures redesign
Preparation along with Survey Process Guide
Preparation along with Survey Process Guide
IQA
15 27-30
สรุปผล
สรุปผล
IQA
IQA
ตาม
ตาม
JCI
71% 29%
Partially met Not met
ผล
155 110 165 319 49 73 0 76 66 3 87 62 54 37 38 26 6 0 9 3 0 5 0 50 100 150 200 250 300 350
Partially met Not met
ACC PFR AOP COP PFE QPS GLD FMS SQE MOI PCI
ผล
JCI No. Fully Met Partially
Met Not Met
Chapter 11 3 7 None
Standards 368 360 8 None
ME 1,032 1,011 21 None
Core 95 86 9 None
Non Core 273 259 12 None
Average =98.99% Core =9.5 Non-core=9.7
Healthcare Consultants - Gooch & Associates provides JCAHO ...
Please visit our International Section. A client in Turkey achieved
an unofficial score of 99.5%99.5%compliance on their initial JCI accreditation survey,...
ดังนั้น
ดังนั้น
Support different
situations
Quality Management
(
Excellent) Center
Quality Management
INPUT
PROCESS
OUTPUT
• Manpower • Material • Infrastructure • Mgt. system • MIS Quality Mgt. System • Hospital Accreditation • JCI Accreditation• Referral & Network Development • Hospital outcome • Quality Indicators • Quality Audit • Satisfaction
