2009 middle eastern international practicum on quality ... · 2009 middle eastern international...

2009 Middle Eastern International Practicum on Quality Improvement and Accreditation

Joint Commission InternationalAmman, JordanGrand Hyatt Amman13 - 17 December 2009

Joint Commission International (JCI) would like to graciously thank the Jordanian Private Hospital Association for their assistance in hosting the 2009 Amman International Practicum. JCI would also like to thank our tracer demonstration hosts, The Specialty Hospital and the King Hussein Cancer Center, for their generous contribution of time and resources.

1

Table of Contents Day 1: The JCI Process and Standards Agenda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Overview of JCI and Practicum Logistics . . . . . . . . . . . . . . . . . . . . . . . . . 9 JCI Process 1: Introduction to the JCI Standards . . . . . . . . . . . . . . . . . . .25 JCI Process 2: Introduction to the Evaluation Methodology . . . . . . . . . .36 Patient-Centered Standards Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Organizational Management Standards Review. . . . . . . . . . . . . . . . . . . .61 Access to Care and Continuity of Care Standards. . . . . . . . . . . . . . . . . . .81 JCI Process 3: After the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Day 2: The Survey Process Tracer Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 The Survey Simulation: What to expect. . . . . . . . . . . . . . . . . . . . . . . . . . .114 Case Study 1: Answering Tracer Questions . . . . . . . . . . . . . . . . . . . . . . . 123 Root Cause Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Day 3: The Survey and Continual Improvement Failure Modes and Effects Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148 Failure Modes and Effects Analysis Example Sheets . . . . . . . . . . . . . . .169 Day 4: The Survey and International Patient Safety Goals Last Survey Simulation Discussion and Reflective Learning . . . . . . . . . .177 Four Steps for Continual Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Day 5: Tools and Techniques Communication Between Hospital Staff, Patients, and Families . . . . . . 191 International Patient Safety Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .205 How to Get Started with JCI Accreditation. . . . . . . . . . . . . . . . . . . . . . . . 214 Appendix Tracer Activity Data Collection Tool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Speaker Biographies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

2

2009 Amman Practicum Agenda

Day 1: The JCI Process and Standards 13 DecemberStart End Speaker7:30 - 9:00

9:00 - 9:30Dr. Ashraf Ismail and Dr. Fawzi Al

Hammouri, MD, President, Jordanian Private Hospital Association

9:30 - 9:45 Mr. Matt Spurgeon

9:45 - 10:15 Dr. Ashraf Ismail

10:15 - 10:30

10:30 - 11:00 Ms. Sherry Kaufield


12:15 - 13:15


14:30 - 14:45



SessionRegistration

Welcome

Introduction of Joint Commission International and Practicum Overview

The JCI Process 1: Introduction to JCI Standards

Break

The JCI Process 2: Introduction to Evaluation Methodologies

Patient-Centered Standards Review

Lunch

Organizational Management Standards Review

Break

Standards in Detail: Access to Care and Continuity of Care (ACC)

The JCI Process 3: After the Survey

3


Day 2: The Survey Process 14 December

Start End Speaker



10:30 - 10:45

10:45 - 11:45 The Speciality Hospital Leadership and Consultants, Moderator: Dr. Ashraf Ismail

11:45 - 13:15

13:15 - 14:15 AM Goup: Case Study 1 Ms. Sherry Kaufield and Mr. Matt Spurgeon

14:15 - 15:15 Root Cause Analysis Ms. Sherry Kaufield and Mr. Matt Spurgeon

AM Group Adjourns at 3:15 PM

Day 3: The Survey and Continual Improvement 15 December

Start End Speaker

9:00 - 10:20 PM Group: Survey Simulation Discussion and Reflective Learning Ms. Sherry Kaufield and Mr. Matt Spurgeon

10:20 - 10:40 Break

10:40 - 12:00 PM Group: Advanced Quality Strategies: FMEA Ms. Sherry Kaufield and Mr. Matt Spurgeon

12:00 - 13:30

13:30 - 14:50 AM Group: Survey Simulation Discussion and Reflective Learning Ms. Sherry Kaufield and Mr. Matt Spurgeon

14:50 - 15:10 Break

15:10 - 16:30 AM Group: Advanced Quality Strategies: FMEA Ms. Sherry Kaufield and Mr. Matt Spurgeon

AM Group: Introductory Tracer Simulation

Session

15:15 - 16:30

PM Group: Final Tracer Simulation

JCI Evaluation Methods: Tracer

Session

The Survey Simulation

Break

Mock Opening Conference

Lunch and Travel

PM Group: Introductory Tracer Simulation

Lunch and travel

4


16 December

Start End Speaker

9:00 - 9:45 PM Group: Survey Simulation Discussion and Reflective Learning Ms. Sherry Kaufield and Mr. Matt Spurgeon

9:45 - 10:00 Break

10:00 - 11:00 Root Cause Analysis Ms. Sherry Kaufield and Mr. Matt Spurgeon

11:00 - 12:00 PM Group: Case Study 1 Ms. Sherry Kaufield and Mr. Matt Spurgeon

12:00 - 13:15


14:00 - 14:15

14:15 - 15:30 Moderated by Ms. Sherry Kaufield

15:30 16:00 Dr. Ashraf Ismail

PM Group adjourns at 4:00 PM Ms. Sherry Kaufield and Mr. Matt Spurgeon

Day 5: Tools and Techniques 17 December

Start End Speaker

9:00 - 10:00 All Faculty

10:00 - 10:30



12:00 - 13:00

13:00 - 13:45 Moderated by Dr. Ashraf Ismail


14:30 - 15:00 All Faculty

Break

Challenging Standards

AM Group: Final Tracer Simulation

Session

Day 4: The Survey and International Patient Safety Goals

16:00 16:45-

Lunch

Getting Started: Advice for those seeking their first Accreditation

Closing Remarks and Presentation of Certificates

Session

Small Group Discussions

Check-Out Break

Communication Between Hosptial Staff, Patients, and Families

Lessons Learned From Local Accredited Organizations: The Specialty Hospital

AM Group: Survey Simulation Discussion and Reflective Learning

Lunch and Travel

The Cost of Accreditation

Lessons Learned From Local Accredited Organizations: King Hussein Cancer Center

International Patient Safety Goals

5

Learning Objectives 2009 Middle Eastern International Practicum on Quality Improvement and Accreditation Amman, Jordan 13 – 17 December Course Objectives Participants who complete this program will be able to:

1. Use the 3rd Edition of Hospital Standards to identify and understand accreditation requirements

2. Explain the most challenging and difficult standards 3. Implement needed measures to comply with JCI Accreditation Standards for

Hospitals 4. Explain the activities that take place during a survey 5. Implement the processes necessary to reduce the risks for errors and improve safety

Specific Session Objectives Understanding the Tracer Methodology Survey Process Participants who complete this learning section will be able to:

1. Explain the major attributes of the tracer methodology process 2. Begin to use elements of the tracer methodology to improve the delivery of

healthcare in their organization 3. Use the tracer methodology to assess relationships and communications among

disciplines and across important functions Root Cause Analysis Participants who complete this learning section will be able to:

1. Explain the major attributes of the root cause analysis method 2. Use RCA to understand how and why adverse events occur in their organization 3. Use RCA data to minimize the repetition of similar adverse events

Getting Started: The Road to Accreditation Participants who complete this learning section will be able to:

1. Explain how the accreditation process functions 2. Explain the timeline for accreditation 3. Develop a plan for meeting the requirements of accreditation

6

International Patient Safety Goals Participants who complete this learning section will be able to:

1. Explain how the International Patient Safety Goals (IPSGs) function within the context of the International Standards for Hospitals, 3rd Edition

2. Explain the changes that the IPSGs bring to the accreditation process 3. Explain the current set of IPSGs

7

Day 1: The JCI Process

8

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Joint Commission InternationalWelcome to

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Overview of JCI and Practicum LogisticsMatthew SpurgeonAssociate Director, International ServiceJoint Commission International

Introduction to JCI and Accreditation

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Welcome

– We are pleased to welcome you to the first Amman Practicum

9


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

– To improve the safety and quality of care in the international community

– Thank you for joining us in our shared mission to positively impact the lives of patients around the world.

Mission of Joint Commission International


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

What is JCI?

– Joint Commission International (JCI) is the international arm of The Joint Commission (USA).

– Both organizations are independent, non-profit, non-governmental agencies


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

JCI’s International Structure

– International Board of Directors (of JCR)– International Accreditation Committee– International Standards Committee– Regional Advisory Councils – Four International Offices

10


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Mission Work at Three Levels

– Individual organizations– accreditation, consultation, and education

– Country level efforts– assist Ministries of Health and

Governmental Agencies to strengthen the role of quality oversight

– International level– build consensus; share quality and safety

information


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Joint Commission Family of Organizations

Accreditation Consulting


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal



11


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal




©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal



•Accreditation survey

•Education for accredited organizations

•Development of new standards

•Assist organizations in meeting their patient safety and accreditation goals

•Consulting service

•Custom Education

•Accreditation and Quality Improvement education for all organizations.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

– Usually 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.

Accreditation – A Definition

– Usually a voluntary process– Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions

– Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standards

dVoid

VoidVoid

VoidVoid

VoidVo

SHANGRI-LA HOSPITALEl Dorado, Republic of Freedonia

ampleSample Sample Sample Sample Sample

dVoid

VoidVoid

VoidVoid

VoidVo



12

JCI Accredited Organizations

Currently, JCI has accredited over 273 of the world’s best healthcare organizations

Bermuda

Brazil

Mexico

Barbados

Chile

Costa Rica

Pakistan

India

Thailand

Singapore

Philippines

China

Hong Kong

Taiwan

S. Korea

Bangladesh

Indonesia

Malaysia

Turkey

Egypt

Ethiopia

Saudi Arabia

QatarUAE

JordanLebanon

Spain

Ireland

Demark

Germany

Cz. R.

Aus

Italy

Swz.


Currently, JCI has accredited over 273 of the world’s best healthcare organizations

Bermuda

Brazil

Mexico

Barbados

Chile

Costa Rica

Pakistan

India

Thailand

Singapore

Philippines

China

Hong Kong

Taiwan

S. Korea

Bangladesh

Indonesia

Malaysia

Turkey

Egypt

Ethiopia

Saudi Arabia

QatarUAE

JordanLebanon

Spain

Ireland

Demark

Germany

Cz. R.

Aus

Italy

Swz.

JCI HeadquartersChicago, USA

JCI European OfficeFerney-Voltaire, France

JCI Middle East OfficeDubai, UAE

JCI Asia-Pacific OfficeSingapore


JCI’s work is supported by our headquarters and three regional offices

13

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

JCI Accreditation and Quality Improvement AssistanceConsulting, Education, Publications, Tools


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Assistance from JCI

– JCI recognizes that the accreditation and quality improvement process can be difficult and confusing.

– JCI has assembled a global group of experts and resources to help organizations achieve our common goal: Increased patient safety and continuous quality improvement


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Assistance from JCI

– JCI’s assistance is separated into three categories:– Consulting Assistance– Education Programs– Publications

14


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Joint Commission Firewall



©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Firewall

– No sharing of organization-specific information

– Neither side may share their “client” list.– Ensures the integrity of our accreditation

decisions and consultation advice.



©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

JCI Consulting Assistance

– JCI Consultants are available to provide expert education and advice.

– JCI Consultants provide a wide scope of services, designed to meet the needs of our partner organizations.

15


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

18-24 Months

Typical Preparation Process

Organizational

Assessment

Ongoing

Technical

Assistance

Off-site Document

Review

Mock Survey

JCIA Survey

Ongoing

Technical

Assistance

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Practicum Logistics

Matthew SpurgeonAssociate Director, International ServiceJoint Commission International


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Learning Objectives

1. Use the 3rd Edition of Hospital Standards to identify and understand accreditation requirements

2. Explain the most challenging and difficult standards3. Implement needed measures to comply with JCI

Accreditation Standards for Hospitals4. Explain the activities that take place during a survey5. Implement the processes necessary to reduce the

risks for errors and improve safety

After completing this course, participants will be able to:

16


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Day 1: The JCI Process

– Overview of the entire accreditation process

– Overview of the JCI’smethodology

– Comprehensive review of individual standards replaced by overviews of challenging standards and case studies.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Day 2: The Survey Process

– In depth exploration of how JCI surveys organizations– Tracer methodology– The survey– Mock leadership interview

– Our first “split session” is scheduled for Tuesday afternoon

– AM group will break early


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

How Are Participants Divided?

Practicum Participants (100 ppl)

Green Morning Group (50)

Team 1 (8)Team 2 (8)

Team 3 (9) Team 4 (8)Team 5 (8)

Team 6 (9)

Blue Afternoon Group (50)

Team 7 (8)Team 8 (8)

Team 9 (9)

A Section (25) B Section (25) C Section (25) D Section (25)

Team 10 (8)Team 11 (8)

Team 12 (9)

17


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Your Name Badge

– Please note your group and team assignments

– Unfortunately, we cannot change your group assignment

– Please write your preferred name in the box

Elvis


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Tracer Demonstration Assignments

A

B

D

C

B

A

C

D

AM PMTuesday

AM PMWednesday

AM PMThursday

Tracer Team 1

Tracer Team 2


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Day 3: The Survey and Continual Improvement– Both groups will

participate in a tracer today

– When not tracing patients, groups will:– Discussion and

reflective learning– Five steps for

continual improvement

18


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Day 4: The Survey and International Patient Safety Goals– The Morning group

finishes their second tracer

– Mock closing conference

– International Patient Safety Goals

– Afternoon group breaks early


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Day 5: Tools and Techniques

– Discuss how organizations prepare for the accreditation process

– Advanced Quality Strategies

– Closing remarks


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Help us…

– Please complete an evaluation form– If we have spelled your name incorrectly

on your name badge, please see us before the end of the day on Tuesday

19


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Thank You

– Questions?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Next Presentation

20

Notes

21

Notes

22

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Introduction to the JCI Standards

Client name/ Presentation Name/ 12pt - 2

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2

The Transparent JCI Process

International Standards

On-siteEvaluation of

Standards

Accreditation Decision

Rules

Accreditation Certificate

dVoid

VoidVoid

VoidVoid

VoidVo



dVoid

VoidVoid

VoidVoid

VoidVo




©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

3

Joint Commission International Standards

– Set optimum, achievable expectations

– Focus on the patient– Designed to be

interpreted/surveyed within the local culture and legal framework

– Stimulates continuous improvement

25


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

4

Sources of Input for Standards

– Scientific literature– Research findings– Survey compliance data– Input from field experts and key

stakeholders– Regional Advisory Councils– JCI staff and surveyors


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

5

Review and Approval Process

– Consensus of the Standards Subcommittee (12 members)

– Review by individual experts or expert panels – Focus groups on select areas– Internet review by as many international

users as possible– Final approval by Accreditation Committee

and the Board of JCI


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

6

Standards Subcommittee– Subcommittee members from:

– Singapore (2) - Chair– Czech Republic– United States (3)– Brazil– Saudi Arabia– Denmark– P. R. China– South Africa– A JCI Surveyor

26


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

7

What is a standard?

A statement of the safety A statement of the safety and and

quality expectedquality expected


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

8

Types of Expectationsin Standards

– Inputs (Structures): Resource

– Processes: Activities

– Outcomes: Results


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

9

InputsInputsPersonnelPersonnelEquipmentEquipmentSuppliesSupplies

ProcessesProcessesAdmissionAdmissionTest ProceduresTest ProceduresPatient EducationPatient EducationTreatmentTreatment

OutcomesOutcomesImproved health Improved health

statusstatusEfficient Efficient

servicesservicesPatient Patient

satisfactionsatisfaction

At the System Level

27


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

10

InputsInputsPhysicianPhysicianMidwifeMidwifeClampsClampsDrapesDrapesGlovesGloves

ProcessesProcessesCut the umbilical cordCut the umbilical cordAssess the newbornAssess the newbornDeliver the placentaDeliver the placenta

OutcomesOutcomesA healthy baby A healthy baby

is bornis bornMother has no Mother has no

complicationscomplications

System Example -Delivery


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

11

Comparisons with other standards regimens

– International standards include all topics found in Joint Commission (USA) standards

– International standards contain all the quality control and quality leadership ISO 9000 criteria

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


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

12

Translation of StandardsThe JCI hospital standards have been

translated into:– Chinese– Spanish– German– Danish– Italian

–Portuguese–Turkish–Czech–Brazilian Portuguese–Arabic

28


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

13

Hospital Standards-3rd

Edition ChaptersPatient-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


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

14


Edition ChaptersHealth Care Organization and

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 Communication and

Information


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

15

Standards Components

29


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

16

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


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

17

Hospital Standards and Requirements

– Over 300 standards– Over 1000 criteria measured during the

survey/evaluation process– Required compliance with the

International Patient Safety Goals– International Core Measures are

voluntary


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

18

Scoring of Lists in Intent Statements

– Note that there are two ways the lists in the Intent Statements are scored.– The list may be all scored as part of one

measurable element.– The list may be scored with each a

separate measurable element– The difference is the type of evidence of

compliance or the critical nature of each item on the list

30


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

19Next Presentation

31

Notes

32

Notes

33

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Introduction to the JCI StandardsEvaluation Methodology

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2




Standards


Rules


dVoid

VoidVoid

VoidVoid

VoidVo



dVoid

VoidVoid

VoidVoid

VoidVo



©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

3

The JCI Evaluation Process

– Covers all portions of an organization and all systems of care and management

– Is focused on what happens to patients – patient tracers used

– Is proactive – evaluates the likely quality and safety of patient care in the future

36

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

4

What is the Tracer Methodology?

An evaluation method that is an effective way to assess a healthcare organization’s performance of care and the services provided as viewed or experienced by the patient.

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

5

Tracer Methodology

Tracers provide the methodology to assess an organization’s systems and

processes by; – Following the treatment path an individual

patient has taken in the hospital, or– Following a process in the hospital from a

beginning to an endpoint.– It is about areas for improvement

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

6

Tracer Selection Criteria Top diagnoses and procedures. (surgical, medical, intensive care)A patient on dialysis. A psychiatric patient. A pediatric patient. A patient receiving lab/imaging services. A patient receiving rehabilitation services.Patients due for discharge that day or the next day System tracers.

37

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

7

Opening Conference– Introductions

– Staff– Hospital leadership

– Review agenda– Discussion of key survey activities

– Patient and System Tracers– Process for requesting staff files for review– Daily briefings

– Surveyor Scoring Process– Orientation of surveyors by hospital (30 min)

– The hospital and its scope of services– QI model used by hospital & a process that had been

improved

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

8

Patient Tracer: Systems Analysis

– Set of components that work together toward common goal

– Evaluation of how - and how well - the organization’s systems function

– Addresses interrelationships of elements– Translates standards compliance issues into

potential vulnerabilities as far as patient quality and safety

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

9

System Tracers– Medication Management

– Traces:– medication management processes– processes in use of medications of a patient

– Infection Control– Traces:

– infection control process– hospital practice in prevention of health-care

associated infections– use of a particular antibiotic

38

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

10

Tracer of Use of Data– Evaluates effectiveness of data

gathering and analysis in improving processes– Validate implementation of QI plan– Review analysis and use of measurement

data– Determine improvements in quality of care

and patient safety

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

11

Tracer of Use of Data– The Processes

– Data collection– Data analysis– Use of information to improve processes – Sustainment of improvements

– Data use in proactive risk reduction

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

12

Facility Tour

–Addresses issues related to– Physical facility– Security– Medical and other equipment– Hazardous waste– Fire safety– Utility systems– Patient and visitor safety– Infection control

39

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

13

Staff Qualifications and Education Interviews

–Reviews processes for– Recruitment;– Orientation;– Education;– Evaluation of staff

–Review of staff files– Surveyors will request

specific files after tracers on 1st day of survey

Separate interviews for medical staff and nursing & other health care staff

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

14

Assessment of Complaints– Any complaint about the hospital received by JCI

before the survey will be assessed by the survey team

– The team will be provided with specific complaint information

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

15

Assessment of Complaints– Surveyors address issues identified in the

complaint during the survey – During scheduled activities or in special

sessions, as appropriate – Team leader will share pertinent information

with the CEO at an appropriate time and report assessment findings

– Findings included in the survey report to JCI

40

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

16

Feedback Sessions:Daily Briefings

– Conducted each morning except first day

– Provides senior leaders with pertinent observations from previous day’s activities

– Allows organization to clarify issues or provide additional needed documents for consideration

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

17

Feedback Sessions:Exit Conference

– Surveyors confer with organization’s CEO and other leaders at end of survey

– Provides strictly preliminary information about findings

– Written preliminary report

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

18Next Presentation

41

Notes

42

Notes

43

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

StandardsReview


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2


Edition ChaptersPatient-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

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Access to Care andContinuity of Care (ACC)

46


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

4

Intent– Care should be seamless from when a

patient enters the org to discharge.– Care should be seamless to both the care

provider and the patient. – The patient’s health needs should match

the services available.– Services provided should be coordinated.– Discharge should be planned and

followed-up


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

5

ACC-Five Areas of Focus

1. Admission to the Organization2. Continuity of Care3. Discharge, Referral, and Follow-up4. Transfer of Patients5. Transportation


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

7

Questions– Is there a type of patient that you

would not admit to your organization?

– Is there a standard that would support or prohibit this policy?

47

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Patient and Family Rights (PFR)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

13

Intent– Patients are unique and should be

treated as individuals. – Their rights should be respected.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

14

PFR – Four Areas of Focus

1. Identify, Protect and Promote Patient Rights

2. Informed Consent3. Research4. Organ Donation

48


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

15

Questions– Is there a right that is missing from

the PFR chapter?– Why is it important?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

20

Assessment of Patients (AOP)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

21

Intent– Effective patient assessment process

results in decisions about the patient's immediate and continuing treatment needs.

– Patient assessment consists of:– Collecting patient information– Analyzing this information– Developing a plan of care

49


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

22

Questions

– What is your personal role in patient assessment/reassessment in your organization?

– List the specific tasks you perform– Open the manual, and find at least three

standards that explain what you might be accountable for doing or documenting.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

23

AOP – Three Areas of Focus1. Collecting and Analyzing Patient

Data and Information2. Laboratory Services3. Radiology and Diagnostic Imaging

Services

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Care of Patients (COP)

50


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

28

Intent– Patient care is a health care organization’s

main purpose. To provide the best possible care, organizations must:– Plan and deliver care– Monitor the patients to understand the results

of care– Modify care when necessary– Complete the care– Plan follow-up


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

29

Questions– If you take care of patients…stand up.– What do you do to take care of patients?– I need two people that both treat patients in the

same organization.– How do you know that you are giving the same care to

the same type of patient?– Find standard that relates to refusing or

discontinuing treatment– Has anyone disagreed with a patient that refused

treatment? What did you do? What do the standards say? Is there another chapter that might apply?

– For those of you not standing, what do you do?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

30

COP-Four Areas of Focus1. Care Delivery for All Patients2. Care of High – Risk Patients and

Provision of High – Risk Services3. Food and Nutrition Therapy4. Pain Management and End-of Life

Care

51


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

31

Care of Patients– Treatments– Feeding– Meeting their needs– Any interaction with patients

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Anesthesia and Surgical Care (ASC)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

37

Intent– Anesthesia, sedation, and surgical

interventions are common and complex.– They require:

– Complete and comprehensive assessment– Integrated care planning– Continued patient monitoring– Criteria-determined transfer for continuing

care– Rehabilitation– Eventual transfer and discharge

52


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

38

Questions– How many of you use anesthesia in

your organization?– How many do so in different places

in the org?– What are the biggest risk factors in

delivering anesthesia?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

40

ASC-Four Areas of Focus

1. Organization and Management2. Sedation Care3. Anesthesia Care4. Surgical Care


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

42

SedationModerate Sedation:•Patients respond purposefully to verbal commands•No interventions are needed to maintain a patent airway•Cardiovascular function is usually maintained

Deep Sedation:•Patients cannot be easily aroused but respond purposefully after repeated or painful stimulation•Airway may be impaired•Cardiovascular function is usually maintained

53

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Medication Management and Use (MMU)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

47

Intent– Medication Management encompasses the

system and processes an organization uses to provide pharmacotherapies to its patients.

– This usually includes:– Coordinated staff efforts– Effective process design– Procurement and storage– Transcribing– Dispensing– Monitoring


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

48

The Medication Management Processes

Selection andProcurement

Storage

DispensingAdministrationMonitoring

Ordering andTranscribing

Preparing and

54


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

49

The Medication Use ProcessOrder

Review

Administer

Monitor

Verify

Prepare Dispense

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Patient and Family Education (PFE)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

54

Intent– Patient education helps patients and

their families make informed care decisions.

– The best processes:– Use a multidisciplinary approach– Suits an individual’s learning

preferences, values, and language skills– Provide education at an appropriate

time

55


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

55

PFE – Four Areas of Focus

1. Education to Support Patient Decisions2. Education Tailored to Each Patient3. Collaborative Delivery of Education4. Education to Support Care at Home


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

56

Questions– Stand up if you educate patients in your

organization– Nurses: What are most important things

that physicians can teach their patients?– Physicians: What are most important

things that nurses can teach their patients?

– Others?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

61

Final Discussion– Are there any chapters that you think

do not apply to your job or role?

– Find the standard that deals with…

56

Notes

57

Notes

58

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

StandardsReview


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2


Edition ChaptersHealth Care Organization and

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 Communication and

Information

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Quality Improvement and Patient Safety (QPS)

61


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

4

Intent– Integral to overall improvement in quality is the

ongoing reduction of risk to patients and staff– Risks may be found in clinical processes and the

physical environment– The approach includes:

– Leading and planning the quality improvement and patient safety process

– Designing effective clinical and managerial processes– Monitoring how well processes work– Analyzing this data– Implementing and sustaining improvements


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

5

QPS - Five Areas of Focus1. Leadership and Planning2. Design of New and Modified

Processes3. Data Collection for Quality

Monitoring4. Analysis of Data5. Process Improvement


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

6

Leadership and PlanningKey concepts:– Those at the highest levels of the

organization are very involved in all aspects of planning and monitoring the quality and patient safety program

– Leader prioritize activities– Leaders provide the resources needed

62


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

7

Design of New and Modified Processes

Key concepts:– Information on how safe, quality

processes should work comes from many sources

– Clinical practice guidelines and clinical paths are to be used


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

8

Data Collection for Quality Monitoring

Key concepts:– Leaders set priorities and select

measures– Contracted services are monitored

as well


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

9

Required Clinical Measures IClinical monitoring includes the following

selected by the leaders:– Aspects of patient assessment – Aspects of laboratory services – Aspects of radiology services – Aspects of surgical procedures – Aspects of antibiotic and other medication use

Continued on next slide

63


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

10

Required Clinical Measures II– 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


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

11

Required Managerial MeasuresManagerial monitoring includes aspects of the

following selected by the leaders:– procurement of routinely required supplies and

medications essential to meet patient needs – reporting of activities as required by law and regulation – risk management – utilization management – patient and family expectations and satisfaction – staff expectations and satisfaction – patient demographics and clinical diagnoses – financial management – prevention and control of events that jeopardize the safety

of patients, families, and staff, including the IPSGs


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

12

Analysis of DataKey concepts:– You will need individuals with experience

in data display and analysis– Comparison with self, others and best

practices is essential– Root cause analysis of sentinel events– Analysis of all adverse events– Monitoring near misses

64


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

13

Process ImprovementKey concepts:– Consider priority areas– Ensure that improvement actually

occurred and was maintained– Use proactive risk reduction

strategies to identify needed improvements

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Prevention and Control of Infections (PCI)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

15

Intent– Infection prevention and control programs

seek to reduce the risk of acquiring and transmitting infection.

– Effective programs have:– Identified leaders– Well-trained staff– Methods to identify and proactively address

infection risks– Appropraite policies and procedures– Staff education– Coordination throughout the organization

65


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

16

PCI - Six Areas of Focus1. Program Leadership and

Coordination2. Focus of the Program3. Isolation Procedures4. Barrier Techniques and Hand

Hygiene5. Integration of Program with Quality

Improvement and Patient Safety6. Education of Staff About the Program


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

17

Program Leadership and Coordination

Key questions:– Who will lead the program and what are

their qualifications?– Who and what mechanism will we use to

coordinate activities?– What is the science on which to base the

program?– What resources will the program need to

be effective?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

18

Focus of the ProgramKey questions:– What is the scope of the program in terms

of places and people?– On what types of medical devices, and

clinical procedures, will we focus?– What are the essential elements of our

sterilization program?– How do we need to handle infectious

waste, sharps and needles?– What are the risks during construction?

66


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

19

Isolation ProceduresKey questions:– What types of precautions and

procedures are needed to manage infectious patients?

– How about immunosuppressed patients?

– What do we do with many patients with a contagious disease?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

20

Barrier Techniques and Hand Hygiene

Key questions:– What supplies and equipment do we

need and where should they be located?

– How can we stimulate and monitor use?

– What guidelines for hand hygiene will we use? – See IPSG


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

21

Integration of Program with Quality Improvement and

Patient SafetyKey questions:– What do we monitor?– How does this fit with other quality

monitoring going on?– How do we know if our program is weak or

strong?– What and when do we communicate

infection control information to all staff?

67


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

22

Education of Staff About the Program

Key questions:– Who will provide the education?– What must all staff know about infections?– How do we educate and involve the

patient and their family in infection control?

– How should we communicate infection trends and other information to all staff?

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Governance, Leadership, and Direction (GLD)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

24

Intent– Excellent care requires effective

leadership– Leadership should:

– Identify the organization’s mission and ensure the resources needed to meet it.

– Coordinate and integrate activities– Understand how staff members work together,

along with their respective responsibilities– Overcome barriers and disputes between

departments

68


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

25

GLD - Four Areas of Focus1. Governance of the Organization2. Leadership of the Organization3. Direction of Departments and

Services4. Organizational Ethics


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

26

Governance of the Organization

Terminology:– Governance-the highest accountable group– Leadership-the senior mangers– Direction-the department or unit directorsKey decisions regarding governance:– The assignment of accountabilities to the

governance structure– The written documents that support this structure

and accountabilities


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

27

Leadership of the Organization

Key decisions regarding leadership:– Identification of the leadership structure– Assignment of responsibilities– Planning with community leaders– Determination of services and supplies

and equipment to deliver the services– Management of contracts– Establish uniform HR programs

69


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

28

Direction of Departments and Services

Key decisions regarding directors:– Their responsibilities for managing

the departments and units of the organization

– The process for recommending space, equipment and staff

– The process for monitoring quality and staff performance


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

29

Organizational EthicsKey decisions regarding organizational

ethics:– The framework and ethical and legal

norms for operation– The content of the guiding documents– The application of the framework and

guiding documents to ethical dilemmas in patient care

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Facility Management (FMS)

70


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

31

Intent– In order to provide a safe and

functional facility for all, the physical facility, medical equipment, and people must be effectively managed.

– Management must strive to:– Reduce and control risks and hazards– Prevent accidents and injuries– Maintain safe conditions


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

32

FMS - Eight Areas of Focus

1. Leadership and Planning2. Safety and Security3. Hazardous Materials4. Emergency Management5. Fire Safety6. Medical Equipment7. Utility Systems8. Staff Education


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

33

Considerations for All Areas– Relevant laws and regulations– Separate plans or one overall plan– Knowledge of the type and location of

risks for each area– Plans to reduce or mitigate risks– Integration of facility quality and safety

information with all other such information– Ensuring that the right staff have correct

information to ensure safety of staff and patients

71

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Staff Qualifications and Education (SQE)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

35

Intent– Leaders collaborate to identify the numbers and

types of staff needed to fulfill the organization’s mission

– Recruiting, evaluating, and appointing staff are best accomplished through a coordinated and uniform process

– Documentation is a critical part of this process:– Applicant skills– Knowledge– Education– Previous work experience– Credential review (for clinical staff)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

36

SQE - Five Areas of Focus1. Planning2. Orientation and Education3. Medical Staff 4. Nursing Staff 5. Other Professional Staff

72


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

37

PlanningKey considerations:– How to determine and define the desired

number and skill level for all staff– What will job descriptions look like and

contain– Defining the processes for recruitment,

etc.– Setting up staff files– Final judgment that staff capabilities are

consistent with patient need


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

38

Orientation and EducationKey considerations:– Process to orient everyone to the

organization, his/her department and actual job responsibilities

– Provision on ongoing staff education– The management of student education in

the organization– Special education such as resuscitative

techniques


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

39

Medical StaffKey considerations:– Setting up a process to gather and verify

(from the primary source) all the credentials of the physician

– Setting up the decision process to decide staff membership and what services they will provide

– Using a process for ongoing clinical practice evaluation

73


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

40

Nursing Staff Key considerations:– Setting up a process to gather and verify

(from the primary source) all the credentials of the nurse

– Setting up the decision process to decide competencies and job description or assignment

– Choosing a procedure to evaluate participation in the quality program


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

41

Other Professional StaffKey considerations:– Setting up a process to gather and verify

(from the primary source) all the credentials of the individual

– Setting up the decision process to decide competencies and job description or assignment

– Choosing a procedure to evaluate participation in the quality program

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Management of Communication and

Information (MCI)

74


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

43

Intent– Failures in communication is one of the

most common root causes of patient safety incidents.

– Over time, organizations should increase their ability to:– Identify information needs– Design an information management system– Define and capture data and information– Analyze data and transform it into information

that can be reported– Integrating and using information


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

44

MCI – Six Areas of Focus1. Communication with the Community2. Communication with Patients and

Families3. Communication Between Providers

Within and Outside the Organization4. Leadership and Planning5. Patient Clinical Record6. Aggregate Data and Information


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

45

Major Considerations for All Focus Areas

– Open communications are key with clear content in an understandable format to enhance patient safety

– Special considerations for the communication of patient information such as confidentiality and security

– Patient records with a consistent format and content

– Understanding the importance of data and the use of data for quality and safety

75


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

46Next Presentation

76

Notes

77

Notes

78

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Access to Care andContinuity of Care (ACC)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2

ACC-Five Areas of Focus

1. Admission to the Organization2. Continuity of Care3. Discharge, Referral, and Follow-up4. Transfer of Patients5. Transportation


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

3

ACC.1 “ADMISSION” of In-Patients & “REGISTRATION” of Out-Patients

– Screening at point of first contact– Determine if care can be provided– Diagnostic test are available for

decision making-standardized by policy

– Patients are informed if any wait or delay and reasons (waiting list)

81


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

4

ACC.1.1 Process of Admission or Registration

– Policies & Procedures (PP) standardize admission and registration

– PP Admitting Emergency patients– PP Holding patients for observation– PP Managing patients when bed space not

available


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

5

ACC.1.1.1 Emergency Patients– Criteria are developed and used to prioritize patients with

immediate needs (“triage”)– Criteria are physiologic-based whenever possible– Staff use criteria to prioritize patients based on urgency of

needs


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

6

ACC.1.1.2 Needs are Prioritizedfor In-patients

– Screening Assessment focuses on deciding which service to meet the patient first

– Preventative– Palliative– Curative– Rehabilitative

–Appropriate selection of services of treatment unit

82


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

7

ACC.1.2 Information Provided– Patient and Family receive information

during the admission process on:– Proposed care– Expected out comes of care– Expected costs– Sufficient information to make

knowledgeable decisions


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

8

ACC.1.3 Reduction of Barriers– Leaders and staff understand most

common barriers for patients– Physical– Language– Cultural– Other

– A process is identified and implemented – to overcome or limit identified barriers– to limit impact of barriers on delivery of

services


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

9

ACC.1.4 Criteria for Admission or Transfer to Intensive Care

– Admission/transfer criteria established for Intensive and Specialized Units

– Criteria are physiologic-based– Appropriate individuals are involved in developing

and implementing the criteria– Patients meet the criteria (documented)– Patients are discharged/transferred when they no

longer meet criteria

83


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

10

ACC.2 Continuity of Patient Care – Leaders design and support continuity (coordination

& resources)– Criteria or policies determine transfers within the

organization– Processes support continuity and coordination of

care and are implemented between/among: (reference to bullet points in intent statement)– Emergency and Inpatient care– Surgical and Non-surgical care– The Organization and other care settings– Ambulatory Care Programs

– Continuity and coordination is evident to the patient –(coordinator).


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

11

ACC.2.1 Individual Responsible

– There is an individual responsible for patient’s care who is– a physician or other person– qualified to assume responsibility for

care– identified to the hospital staff


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

12

ACC.3 Referral and Discharge Policy

– Policy for the appropriate referral or discharge of patients– Based on patient’s needs for continuing

care– The patient’s readiness for discharge– Discharge planning begins early and

includes the family as appropriate– Policy guides patients “on pass” for a defined period

of time

84


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

13

ACC.3.1 Cooperation with Community Practitioners

– Discharge planning for both supportiveand continuing medical services

– Community providers, organizations and individuals are identified

– Appropriate referrals are made (in the patient’s home community whenever possible)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

14

ACC.3.2 Discharge Summary– Prepared at discharge, documented in the

patient’s record and contains:– Reason for admission– Significant physical and other findings– Significant diagnoses and co-morbidities– Diagnostic and therapeutic procedures– Significant medication and treatments– Condition at discharge– Discharge medications and all medications to be

taken at home– Follow up instructions

Continued on next page…..


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

15

ACC.3.2 Discharge Summary

– Unless contrary to policy, laws, or culture, patients are given a copy

– A copy is provided to the practitioner responsible for patient’s continuing or follow-up care

85


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

16

ACC.3.3 Follow-up Instructions– Patients and/or family receive follow-

up instructions that:– are provided in an understandable form

and manner– include any return for follow-up care– include when to obtain urgent care– are appropriate to the patient’s

condition


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

17

ACC.4 Transfer Policy– Guiding policy for transferring patients to

include:– Appropriateness of transfer using criteria– Based on need for continuing care– Transfer of responsibility to another provider

or setting– Criteria define when transfer is appropriate– Who is responsible during transfer– Situations where transfer is not possible


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

18

ACC.4.1 Referring and Receiving Organizations

– Referring organization determines whether receiving organization can meet patient’s needs

– Arrangements (formal or informal) are in place when patients are frequently transferred

ACC.4.2 Written Summary– Clinical summary is transferred with patient & includes:– Patient status– Procedures and other interventions provided– Patient’s continuing care needs

86


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

19

ACC.4.3 Monitoring Patients during Transfer

– All patients are monitored during direct transfer

– Qualifications of the staff member doing the monitoring are appropriate for patient’s condition


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

20

ACC.4.4 Documentation of Transfer

– Documentation includes:– Name of organization and individual

agreeing to receive patient– Reason for transfer– Any special conditions related to

transfer– Any change of patient’s condition or

status during transfer– Any other notes require by the

transferring organization


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

21

ACC.5 Transportation Needs– Transportation is appropriate to the

patient’s need – Transportation needs are considered

when:– Referring– Transferring– Discharging

87


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

22

ACC.6 – ACC.6.1Medical Transport

– Standards are relevant only if the medical transport services are owned and operated by the hospital

ACC.6 Meeting Legal Requirements

– Service meets relevant laws & regulations– Current license maintained when required


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

23

ACC.6.1 Safety and Quality– Qualified individual directs the service– Medical oversight during transfer for:

– Patient Assessment– Medical Services

– Quality and safety are monitored – Qualified individuals triage patients– Regular inspection of vehicles– Included in infection control program

– Exposures to biologic and chemical agents– Patient’s rights are respected during transport


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

24Next Presentation

88

Notes

89

Notes

90

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

After the Survey:The Decision

Joint Commission InternationalHospital Accreditation Program

Accreditation Decision RulesEffective Date 1 January 2009

I ACCREDITATION DECISIONSINTRODUCTIONThe Accreditation Committee considers all information from the initial or

triennial full survey and any required follow-up Focused Survey in making its decision regarding accreditation. The outcome is thatthe organization meets the criteria for accreditation or does not meet the criteria and is denied accreditation. The criteria for these two potential outcomes are as follows:

A. ACCREDITEDThis decision results when an organization meets all the following

conditions.1. The organization demonstrates acceptable compliance with each

standard. Acceptable compliance is:A score of at least “5” on each standard.

2. The organization demonstrates acceptable compliance with the standards in each chapter. The International Patient Safety Goals are considered a Chapter. Acceptable compliance is:

An aggregate score of at least “8” for each chapter of standards.

3.The organization demonstrates overall acceptable compliance. Acceptable compliance is:

An aggregate score of at least “9” on all standards.4. The total number of measurable elements found to be “Not Met” or “Partially Met” is not above the mean (three or more standard deviations) for organizations surveyed under the hospital accreditation standards within the previous 24 months.5. The organization submits an acceptable Strategic Improvement Plan (SIP).

B. ACCREDITATION DENIEDThis decision results when an organization meets one or more of the

following conditions at the end of any required Focus Survey subsequent to an initial or triennial full survey, or during the period of accreditation as a result of a Focus Survey for the evaluation of one or more policy related conditions that may place the organization At Risk for Denial of Accreditation.*


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal




Standards


Rules


dVoid

VoidVoid

VoidVoid

VoidVo



dVoid

VoidVoid

VoidVoid

VoidVo




©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Scoring the Survey Results

– Each Measurable Element (ME) is scored– Met (10)– Partially Met (5)– Not Met (0)

– All Measurable Elements are averaged to obtain the score for the standard

– All Standards are averaged to obtain the score of the chapter

– All Chapters are averaged to obtain the overall score

93


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Accreditation Decision Rules

– Each Standard must have a score of at least 55

– Each Chapter must have a score of at least 88

– All standards together must average at least 99


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Surveyor Report

– Surveyors complete their findings and leave a final copy with the surveyed organization

– If the organization disagrees with a finding and feels that proof of inaccuracy exists, appeal may be filed with JCIA, together with documentation that proves that the surveyors were in error


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

JCIA Communication

– Ten (10) days after receipt of the surveyors’ report, JCIA notifies the organization whether a focused repeat survey or other follow up condition will be required– In which case the decision regarding accreditation will be

postponed.– If a focused resurvey or other follow up condition is

not required, the organization will be notified that Strategic Improvement Plans (SIPs) must be submitted for each Measurable Element that received a score of “Not Met” or Zero (0).

94


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Strategic Improvement Plans

– Due date of the SIPs is 45 days after notification.

– JCI will evaluate the SIPs for adequacy.– If the decision is that they are all adequate, AND

the Standards Scores and Averages meet the Decision Rules, the finding will be that there has been “Acceptable Compliance” with the standards (for exception see “Rule No. 4” or “Outlier Rule”)

– If the decision is that they are not all adequate, JCIA declare the organization “At Risk of Denial of Accreditation” (see later) .


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Focused Resurvey for Inadequate Compliance with Standards

– Focused visit will occur at 60 days from Initial or Triennial Survey

– There will be one or (rarely) two surveyors

– Focused survey will be restricted to areas or standards that have been identified


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Accreditation Decisions

– ACCREDITED– Acceptable compliance with all Standards – If there are follow-up conditions, they are

all met

95


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Accreditation DecisionsACCREDITATION DENIED1. One or more standard is scored less than a “5”.2. The aggregate score of one or more chapter of

standards is less than a “8”.3. The aggregate score for all standards is less than

“9”.For 1., 2., and 3. see item 5. for additional condition of

Denial.4. The total number of measurable elements found to

be “Not Met” or “Partially Met” is above the mean (three or more standard deviations) for organizations surveyed under the hospital accreditation standards within the previous 24 months (statistics updated every Quarter).


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Accreditation Decisions

ACCREDITATION DENIED5. A required Focused Survey subsequent to an initial

or triennial full survey has not resulted in acceptable compliance with applicable standards. .

6. One or more of the conditions that place the organization At Risk for Denial of Accreditation have not been resolved at the time of the Focused Survey to evaluate the condition.

7. The organization voluntarily withdraws from the accreditation process.

8. The organization does not permit the performance of any survey by Joint Commission International


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Rule No. 4 (“Outlier Rule”)

The total number of measurable elements found to be “Not Met” or “Partially Met” is not above the mean (three or more standard deviations)for organizations surveyed under the hospital accreditation standards within the previous 24 months.

96


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2008

1214

2008

1104

2008

1006

2008

0914

2008

0707

2008

0602

2008

0512

2008

0421

2008

0312

2008

0121

60

50

40

30

20

10

0

N = 87

Sam

ple

Coun

t

_C=27.54

UCL=43.28

LCL=11.80

1

11

1

1

1

11

11

1

1

2008 Surveys (Initial and Triennial)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Reporting Requirements

– For all accredited organizations– Interim self-assessment report on status of standards

compliance at 18 months– Response to annual query about updated contact addresses

– For accredited organizations that meet the following:– Change of ownership or top management– Establishment of new service covered by JCI standards– Discontinuation of existing service– Increased volume (>25%) or contraction (>25%) of service

(e.g. number of beds, OPD clinics, etc.) – New location or significant change in current location of at

least 25% of services– Development of more intensive services– Merger with or acquisition of organization that provides

services for which JCI has standards


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Types of Focused Surveys

– Follow-up: performed after a full initial or triennial survey to evaluate selected standards noted at the time of the survey. – Conducted at 90 days following the original survey

– For Cause: performed whenever – JCI is persuaded that there is a risk to patients and staff or– JCI receives a quality incident report that requires on-site

evaluation or– organization has been placed “At Risk of Denial of

Accreditation.”– Focused Surveys evaluate a preset group of

standards

97


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Conditions that Place an Organization “At Risk for Denial of Accreditation”

1. An immediate threat to patient/public health or staff safety exists within the organization.

2. An individual who does not possess a license, registration, or certification is providing or has provided health care services in the organization that would, under applicable law or regulation, require such a license, registration, or certification and which placed the organization’s patients at risk for a serious adverse outcome.

3. Joint Commission International is reasonably persuaded that the organization submitted falsified documents or misrepresented information in seeking to achieve or retain accreditation, as required by the Information Accuracy and Truthfulness Policy.

4. A number of not compliant standards (Not Met or Partially Met) at the time of survey is above the mean (three or more standard deviations) for organizations in the same program surveyed during the previous 24 months.

5. The organization does not possess a license, certificate, and/or permit, as, or when, required by applicable law and regulation, to provide the health care services for which the organization is seeking accreditation.

6. The organization has not met the accreditation policy for “Reporting Requirements between Surveys”.

7. The organization fails to submit an acceptable Strategic Improvement Plan (SIP) within 45 days of the organization’s survey.

98

Day 2: The Survey Process

99

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Tracer Methodology


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2

What is a Tracer?– JCI’s key assessment method

– “Traces” a real patient’s journey through the hospital, using their record as a guide

– Along the path, JCI observes and assess compliance with the standards

– Allows us to understand hospital’s performance from patient’s perspective


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

3

Why Conduct Tracers?– Complex organizations (like those found in

healthcare) are made up of a series of systems and subsystems.

– Tracers are an effective way to study complex systems.

– If we can identify the imperfections or flaws within a system, we can understand how to correct errors that may cause patient harm.

100


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

4

Outcomes of Tracers• Integrated and cross sectional review of those

areas most critical to quality and safety of the patient

• Patient focused analysis of standard compliance

• Organizational specific information that can be used to design and target improvements


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

5

Types of TracersTwo types of Tracers

1. Patient Tracer: Follow the treatment path of an individual patient within the hospital

2. System Tracer: Follow a process in the hospital from beginning to end.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

6

Patient Tracer

An individual patient tracer:– Follows the experiences of a

patient throughout the healthcare system.

– Illustrates the relationship between a patient’s care and the JCI standards

101


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

7

System Tracers– A system tracer follows a complex process

throughout the healthcare system. – Traces the path of a complex process

Examples:– Medication Management System– Infection Control Management System– Data Management System


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

8

Medication Management System Tracer

• Selection of medications• Procurement of

medications• Storage of medications• Medication ordering

Policy & Procedure• Verifying prescriptions

• Allergy reconciliation• IT support for verification

• Controlled substance storage, monitoring and use

•High-risk therapy• IV mixing, TPN prep,

chemo agents prep• Concentrated

electrolytes• Look alike, sound alike

drugs• Preparation• Dispensing

•Pharmacy role in discharge planning and patient/family education


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

9

Medication Management System Tracer

Includes:Group discussion• Explore the process ; identify concerns• Discuss medication occurrences or errors• Review International Pt. Safety Goals (INPSG 1,

2, 3, 5, and 6)Focused Medication Tracer• Explore the path of a selected high risk medication

based on the group discussion or previous information identified through patient tracers

102


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

10

Medication Management Functions

• Selection• Procurement• Storage• Prescribing and Ordering• Preparation• Dispensing• Administration• Monitoring

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Tracing


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

14

Determine Your Purpose

• What is the purpose of your tracer?• Assess overall JCI standards compliance• Assess organizational policy compliance• Learn more about a specific process

• Your purpose will determine where you go and what you do

103


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

15

Pre-Work• At first, do not plan to do tracers within

your own department• Know and interpret the standards

correctly• Understand the intent of the standard• Consider pre-determining types of

questions (i.e. a focused topic area) until you are proficient at free-flowing


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

16

Effective Tracing Tips

• Don’t review the medical record by yourself—review with a staff member, so that you can ask for the “patient’s story.”

• Don’t conduct “peer” review.• Don’t indicate staff did something

“wrong”• Don’t assess best practices, focus on

what the standards require


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

17

Effective Tracing Tips• Follow the path of the patient or process • Assess standards based on the patient’s

experience of care• Observe patient care, procedures, and

processes• Use the patient record to identify “system”

issues based on the patient’s journey.

104


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

18

Effective Tracing Tips• Seize the moment, but don’t interrupt

patient care• Stay time aware and topic focused• Remain flexible• Maintain patient confidentiality• Set the proper tone


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

19

Set the Overall Tone• Put the staff at ease• Explain purpose of tracer• Dress professionally• Use a serious but approachable style• Educate and evaluate• Pretend you do not know the staff members

you are interviewing• Thank staff for participating

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Interviewing Strategy

105


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

21

Questions to Keep in Mind While Tracing Any Process

Think about asking questions that will help you know the following:

1. Is this step standardized? If not, why?2. Does the step occur consistently?3. Does it need improvement?4. Is it an unnecessary or impractical step?5. Is something absent that should be present?6. What are the risk points?7. How are the risk points mitigated?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

22

Questioning Strategies• Use active listening.• Drill down until issues are fully developed• Don’t pursue one standard; focus on

several standards related to a process.• Avoid hypothetical situations—pose

questions around the patient being traced.

• Base questions and findings on the standards.

• Question staff, not management• Question patients when feasible


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

23

Interviewing Patients• Ask questions based on your review of the

patient’s medical record (diet, education).• Talk to patients/families about relevant

issues/experiences; use caution not to alarm the patient.

• Observe environment of care in the patient’s room.

• Don’t “quiz” patient but engage in conversation.

106


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

24

How are Questions Asked?• Use “I” statements

• “I see that the patient was given Aspirin”• Not, “You gave the patient Aspirin.”

• Avoid a confrontational tone; the goal is to gather information, not “catch” someone

• Use opening question followed by “drill-downs.”• The same question, asked slightly different, may

deepen understanding of compliance


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

25

Leading QuestionsLeading Questions: The question

suggests the correct answer

• “Do you always wash your hands before interacting with a patient?”

• “I assume you would put this type of patient in a negative-pressure room.

• You keep this door locked, right?

Whenever possible, surveyors avoid this type of question.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

26

Leading vs. Neutral QuestionsLeading questions suggest the correct answerNeutral questions do not suggest the correct answer

Leading“Do you always wash your hands before interacting with a patient?”

Neutral“What kind of hand-washing protocols have you adopted? How effective have hand-washing protocols been?”

Leading“I assume you would put this type of patient in a negative-pressure room. How would you treat this patient?”

Neutral“There are many different ways to treat this type of patient. How would you handle this case?”

107


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

27

Closed QuestionsClosed Questions: Only allow a choice of

two options, typically “yes” or “no.”

• Have you been trained to operate this equipment?• Did you follow your organization’s policy when

admitting this patient?• Do you educate patients on their treatment?

• The respondent supplies a very limited amount of information to the questioner.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

28

Closed Vs. Open QuestionsClosed questions have very few responses (yes/no)Open questions require a full, elaborative response

Closed“Have you been trained to operate this equipment?”

Open

How do you know the correct way to operate this equipment?

Closed

Did you follow your organization’s policy when admitting this patient?

OpenHow did you admit this patient? What is your organization’s admission policy?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

29

After the Question• Make sure the question was understood.• Restate answers for clarification.• Pause after an answer to encourage more

information.• Give positive feedback for well-thought out

answers.• Ask for more information if you need it in

order to understand the answer.

108


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

30

Validate When you notice a policy violation or an

inconsistency in clinical practice, you should:• Drill down

Ask probing questions to more fully understand the problem

• ValidateLook for examples of the problem in other

settings or with other practitioners. Is this an isolated incident, or a trend?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

38

After the Tracer: Share your Findings

• Share with leadership• Share all findings to lay groundwork for new

improvements; communicate incremental responses to changes

• Share with staff• Share successes and challenges • The clearest and most accurate picture creates

respect for the tracer process• Issues should be shared in a non-punitive,

positive, and educational manner


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

39

Questions?

109

Notes

110

Notes

111

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Survey Simulation:What to expect


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2

The Purpose of the Survey Simulation

– You will observe the consultant/surveyor gathering information about how the organization complies with JCI standards.

– The purpose is to demonstrate the Tracer methodology and Tracer process, so that you might be able to better prepare for your upcoming survey.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

3

Inside the Host Hospital– Our host hospitals have been very

generous to allow us to visit their facility.

– Please respect their staff and patients by following the following guidelines:

114


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

4

1. Appropriate Questioning– Only the JCI faculty member that

serves as the “surveyor” should ask questions of the staff, patients, or administration.

– Any questions you have should be directed to your faculty member.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

5

1. Appropriate Questioning– Please also remember that the

objective of this session is to help you understand the survey process, not to survey this particular organization.

– It takes a full survey to have sufficient information to draw any conclusions about the organization.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

6

2. Requests– During the course of the simulation, you

may be shown a great many different forms, policies, and other resources that may be useful to you.

– Please do not ask the hospital staff for these resources directly.

– You may ask your JCI faculty member to acquire these documents. If possible and appropriate, they will attempt to secure these documents for you.

115


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

7

3. Stay with the Group– In order to move through the

simulation as efficiently as possible, please stay with your group and group leader at all times.

– We have already arranged to “survey” certain specific areas. Straying into other areas tests the goodwill of our hosts.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

8

4. Minimize Impact– No cell phones

– Please turn your phones off, or set them on silent.

– Please also refrain from taking calls during the session.

– No photos/videos– Please feel free to take notes, but

photos and videos are not permitted.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

9

Discussion Questions– When do we have enough data to

draw conclusions?

– What kind of conclusions can be drawn from this process?

116


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

10

What you should hear

– The neutral tone in which the questions are asked

– The way the same question, asked slightly differently, moves deeper into understanding compliance


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

15

What you should hear, see, and discover

– We will discuss your observations when we return.

– During your first tracer demonstration session, observe as much as you can about:– The survey simulator’s method– Those being interviewed by the survey

simulator


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

19

See if you discover…1. How the consultant discovered

information that resulted in a modification to the tracer and a change in direction?

2. Inconsistencies in the responses to similar questions that would lead you to suspect that all staff were not trained in the same way or the same content.

117


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

20

See if you discover3. Any portion of the building where you

could not identify a safe exit in the event of an emergency

4. Characteristics of a patient record that made it easy to trace a patient’s journey

5. The primary ways the hospital’s staff demonstrated compliance – data, verbal explanation, policies, procedures, etc.

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

QUESTIONS?

118

Notes

119

Notes

120

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Case Study 1

Answering Tracer Questions

2

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Case Study Overview

– For this exercise, we will be taking you on a “virtual” tracer.

– For your first case study, we want you to think carefully about what are the best answers you can give to a surveyor’s questions.

3

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Tracer Patient Selection–City Centre Medical Center–Surveyor traces a 68-year-old female patient:

– Mrs. Kale – admitted one week ago via the Emergency

Department (ED). – Admitted with:

– slurred speech– poor gait – completely dependent on help for all her needs.

– CT scan of the brain showed a right brain Ischemic Stroke.

123

4

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Medical Record Information

– History and Physical – she was treated for:

– hypertension, – Hyperlipidemia– diabetes mellitus.

– She was on diet control for the management of her diabetes.

– No bed available at the medical unit– Placed in a holding area for observations. – Her 70-year-old husband was with her and provided

relevant information.

7

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

ContinuedThe surveyor noted from the nursing chart that Mrs. Kale was assessed to be at risk for the following:

o Fallo Bed soreso Aspirationo Deep vein thrombosis

Mrs. Kale's husband has also shared with her nurse yesterday that they have no means to pay for the hospital bill.

8

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Surveyor visits Emergency Department

Step 1: Surveyor Speaks with the ED Staff

–After reviewing the medical record, surveyor visits ED–Discussions cover triage criteria, admission criteria, patient and family communication.

124

9

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

A. What processes were followed for admitting Mrs. Kale to the medical unit? B. What was the reason why she had to be in the ED for 6 hours? C. How did you communicate the reasons for her delayed admission?

(ACC.1.1 ME 5-6; MCI.2 ME 1; MCI.4 ME 4)

Surveyor visits Emergency Department

Step 1: Surveyors Speaks with the ED Staff

ExerciseExercise•Select one question.

•What is the worst answer you can give?

16

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Medical Unit

Step 2: Surveyor Speaks with Nurse and Physician

–Discussions cover assessment, reassessment, emergency care issues, IPSG.

17

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

B. Who has access to patient’s medical record? C. What is your organization policy on health information ?(MCI.7 ME 1; MCI.10 ME 4)

A. What communication took place between the ED and the unit before Mrs. Kale arrived? (IPSG Goal 2 ME 1-4, MCI 8, ME 1-7)

Medical Unit

Step 2: Surveyor Speaks with Nurse and Physician

D. What process do you have in place to address Mrs. Kale's risk for fall? (IPSG Goal 6 ME 1-3)

ExerciseExercise•Select one question.

•What are the elements of a good answer?

125

18

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Bad Answers

– “Bad” answers:– Give too much information– Highlight a deficiency that was not

otherwise apparent– Ramble– Untruthful or misleading

19

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Medical Unit

Step 3: Surveyor Speaks with the Physician

–Discussions cover assessment and reassessment, clinical practice guidelines and pathways

20

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

C. I noticed that there was no entry in the patient’s medical record by a physician on the weekend that Mrs. Kale was admitted. What is the hospital policy for assessment and reassessment of patients? (AOP.2 ME 4)

A. I noticed Mrs. Kale is on a stroke pathway. How is this pathway established? B. Who was involved in this decision?(QPS.2.1 ME 1-3)

Medical Unit

Step 3: Surveyor Speaks with the Physician

ExerciseExercise•Which question is the hardest to answer?

•What is an ideal answer to this question?

126

29

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

C. How are staff educated in the management of infectious patients? D. How does the organization’s orientation program include infection control? E. Who attend this orientation? (PCI.8 ME 5; SQE.7 ME 1-3)

A. What hand hygiene guidelines do you follow?B. What hand hygiene products do you use? (IPSG Goal 5)

Medical Unit

Step 7: Surveyor talks to the staff and infection control practitioner

ExerciseExercise•In your organization, what is the best answer you can construct ?

•What would you change in your organization to have a better answer?

62

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

QUESTIONS?QUESTIONS?

127

Notes

128

Notes

129

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Root Cause Analysis (RCA)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2

What is a Root Cause– Root Cause: The underlying source

of an error, failure, or accident

– Most errors, failures, or accidents have multiple causes, but fewer (often one) root cause.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

3

What is a Root Cause Analysis?

– A Root Cause Analysis seeks to determine the root cause of an error, failure, or accident.

132


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

4

Why Conduct an RCA?– Some portion of our system just

broke/failed– E.g. Sentinel event

– We want to determine what broke in our system


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

5

What does Root Cause Analysis (RCA) do?

– Identify the causes that lead to variationfrom our performance expectation.

Types of Variation: Common Cause and Special Cause

Types of causes: Apparent and Underlying

Performance Expectation: What we want to happen (e.g. 0 Sentinel events)

In other words—what is causing us to miss our performance goals?

Multiple tools, including 5 Whys and Ishikawa


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

6

Performance Expectations– A standard that we want to meet

– Room service delivered within 30 minutes– Zero Sentinel Events– Lab work completed within 24 hours

– Good performance expectations are– Measurable– Specific– Within our control

– RCAs are most effective when they analyze a failure of a clear performance expectation

133


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

7

Types of Causes

–“Proximate Causes”–What factor(s) led directly to the “error”?–Usually, easy to see

–The causes that lead to our apparent cause–What factor(s):

– Allowed the “error” to happen

– Failed to prevent the “error”

– Started a chain of events that led to the “error”

–May be a Root Cause–Usually, harder to see

Apparent Causes Underlying Causes


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

8

Why?

Why?

Types of Causes in a Car Accident

–Driver did not hit the brakes fast enough to avoid hitting the car in front of them

–Driver reaction time slow because of lack of sleep the previous night–Driver did not get enough sleep because they were stuck in the ED until 3 AM, but still needed to report for their 7 AM shift–Driver needed to report at 7 AM because the hospital was short-staffed on this holiday weekend.–The hospital was short staffed because they do not have a staffing plan that assures adequate staff on holidays.

Apparent Causes Underlying Causes

Why?

Why?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

11

The Five Whys– We have just performed a simplified

version of the first RCA technique: the Five Whys.

134


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

12

How to Use the Five Whys– First, ask “Why did this error occur?”

– The driver didn’t hit the brakes fast enough.

– Then, ask “Why did that occur?”– They were tired

– Then, ask “Why did that occur?”– They were stuck in the ED until 3 AM

– Then, ask “Why did that occur?”


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

13

Why not the Six Whys?– Asking “Why” five times is generally

sufficient to identify a root cause.– If you have not discovered a

satisfying root cause after asking “why” five times, keep going until you do.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

14

Exercise: The Five Whys– Arrange yourself in groups of 4-7.– Select a single error, accident, or

failure.– For the purposes of this exercise,

you may use a fictional failure.– Perform the Five Whys as a group, to

discover the root cause.

135


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

15

What did you Learn?– What were your Root Causes?– If this were a real RCA, who would be

helpful to have on the team?– What kind of mindset is it important

that the team have in order to complete an effective RCA?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

16

RCA Team Makeup– Good RCA Teams often include the

following:– People involved (directly or indirectly) in the

failure– Team Leader

– Objective– Not part of the process– Experience conducing RCAs– Not always the most senior member of the

team– 5-8 members


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

17

Problems with the Five Whys

– Although it is a useful tool, the “Five Whys” does have faults.– Root cause depends on the group’s knowledge– Different groups = different root causes– It can be difficult to know when you have

discovered the real root cause– There may be several answers that answer a

single “why?” By selecting one, we choose simplicity over complexity, and may miss important causes that are not the main cause

It may be helpful to consider a tool that attempts to collect all of the potential causes of an error.

136


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

18

Tool 2: Ishikawa Diagram– If you are concerned about capturing

and assessing multiple root causes, consider using the Fishbone Tool.

– Like “5 Whys,” this tool requires a team to brainstorm causes.

– Also known as a “Fishbone Diagram”


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

19

The Ishikawa ToolStart with an explanation of the “problem”

The basic explanation of the problem.

I missed my

flight


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

20

The Ishikawa Tool– What are the categories of causes

that are leading to your problem?– Seek 3 to 6 categories– The “Four-M” categories are a good

place to start:–Materials–Machines–Manpower–Methods

137


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

21

The Ishikawa ToolDraw “bones” for each category of causes

MaterialsMachines

ManpowerMethods

I missed my flight


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

22

The Ishikawa ToolDrill down on each category

MaterialsMachines

ManpowerMethods

Materials Cause 1

I missed my flight


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

23

Materials

Materials Cause 1

The Ishikawa Tool

Materials Cause 2

Subcause

Subcause

Subcause

Sub-subcause

Sub-subcauseSub-subcause

Sub-divide each cause into sensible divisions

The further you subdivide, the more specificthe cause.

Sub-subcause

Sub-subcause

138


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

24

Materials

The Ishikawa ToolSub-divide each cause into sensible divisions

The further you subdivide, the more specificthe cause.

Ink smudged on my ticket

Passport doesn’t match ticket

Cheap penSweaty hands

Nervous about flight

Office too warm

Budget crisis

New pen supplier

New office

manager

wants to

lower costs

No A/C in

the summer

New office manager wants to lower costs

Bad

experience

Not enough

sleep


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

25

The Ishikawa Tool


MaterialsMachines

ManpowerMethods

Materials Cause 2

Subcause

Subcause

Subcause

Sub-subcause

Sub-subcause

Sub-subcause

Manpower Cause 1

Sub-subcause

Sub-subcause

Sub-subcause

Sub-subcause

Sub-subcause

Machines Cause 1

Subcause

Subcause

Sub-subcause

Sub-subcause

Sub-subcause

Methods Cause 1Sub-subcause

Sub-subcause

Sub-subcause

Machines Cause 2

Subcause

Subcause

Sub-subcause

Sub-subcause

Sub-subcause

Sub-subcause

Machines Cause 3


Sub-subcause

Sub-subcause

Sub-subcause

Subc

ause

Subc

ause Su

bcau

se

Materials Cause 1

Subc

ause

Subc

ause

Subc

ause

Manpower Cause 2

4th lev

el ca

use

4thlev

el ca

use

4thlev

el ca

use

4thlev

el ca

use

4thlev

el ca

use


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

27

How far down do we drill?– Keep separating causes into sensible

subdivisions. – You subdivided enough when the

“branches” are: – Specific– Measurable– Controllable

139


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

28

Exercise: Ishikawa Diagram– In small groups, create your own

Ishikawa diagram.


MaterialsMachines

ManpowerMethods

Materials Cause 2

Subcause

Subcause

Subcause

Sub-subcause

Sub-subcause

Sub-subcause

Manpower Cause 1

Sub-subcause

Sub-subcause

Sub-subcause

Sub-subcause

Sub-subcause

Machines Cause 1

Subcause

Subcause

Sub-subcause

Sub-subcause

Sub-subcause


Sub-subcause

Sub-subcause

Machines Cause 2

Subcause

Subcause

Sub-subcause

Sub-subcause

Sub-subcause

Sub-subcause

Machines Cause 3


Sub-subcause

Sub-subcause

Sub-subcause

Subc

ause

Subc

ause Su

bcau

se

Materials Cause 1

Subc

ause

Subc

ause

Subc

ause

Manpower Cause 2

4th le

vel c

ause

4th le

vel c

ause

4th le

vel c

ause

4th le

vel c

ause

4th le

vel c

ause


MaterialsMaterialsMachinesMachines

ManpowerManpowerMethodsMethods

Materials Cause 2

Subcause

Subcause

Subcause

Subcause

Subcause

Subcause

Sub-subcause

Sub-subcause

Sub-subcause

Manpower Cause 1






Machines Cause 1

Subcause

Subcause

Subcause

Subcause


Sub-subcause


Methods Cause 1Sub-subcauseSub-subcause



Machines Cause 2

Subcause

Subcause

Sub-subcause

Sub-subcause

Subcause

Subcause

Subcause

Subcause

Sub-subcause

Sub-subcause

Sub-subcause

Sub-subcause

Machines Cause 3

Methods Cause 2Sub-subcauseSub-subcause

Sub-subcause

Sub-subcause

Sub-subcause

Subc

ause

Subc

ause

Subc

ause

Subc

ause Su

bcau

se

Subc

ause

Materials Cause 1

Subc

ause

Subc

ause

Subc

ause

Subc

ause

Subc

ause

Subc

ause

Manpower Cause 2

4th le

vel c

ause

4th le

vel c

ause

4th le

vel c

ause

4th le

vel c

ause

4th le

vel c

ause

4th le

vel c

ause

4th le

vel c

ause

4th le

vel c

ause

4th le

vel c

ause

4th le

vel c

ause


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

29

What did you Learn?– What were your root causes?– What were the most important

differences between Ishikawa and “five-whys”?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

30

Problems with Ishikawa Diagrams

– The complexity of the tool can be difficult to know which is the “key”root cause

– Requires more time

140


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

31

Other RCA Tools– Five Whys and Ishikawa Diagrams

are two easy ways to conduct RCAson understandable processes

– For some problems, a statistically-based RCAs may be more useful


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

33

Why Did Our Root Cause Happen?

– Most Root Causes happen because we either:– Do not have a process– Have a bad process– Something causes variation within our

process


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

35

Variation from a process– Variation from an existing process is

one of the most difficult root causes to address.

– Two types of variation– Common Cause: The variation occurs

regularly as a result of the way the process operates

– Special Cause: The variation is rare, and is not a result of the process

141


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

36

Common Cause Variation–A result of the process.–The process allows this amount of variation.

20 2317

2419

25 2226

19 1722 19

28 25 26

0

10

20

30

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Wait Times for Room Service

–We would not expect that it is always delivered in 22 minutes.–Normal variation is often expected and allowed.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

37

Common Cause Variation– Room Service sources of common

cause variation include:– Imprecise burner temperatures– Staff availability– Slow elevators

– Sources of common cause variation work together to deliver our food a little bit earlier or a little bit later than average.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

38

When is Common Cause Variation a Problem?

– When it fails to meet our “customer’s” needs.

8092

6896

76100 88

10476 68

88 76

112 100 104

020406080

100120

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


Our promise/customer requirement

142


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

39

How do we Fix Common Cause Variation?

– Common Cause Variation suggests that your outcomes are a result of the process

– If the process does not meet customer needs, you must change the process


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

40

Special Cause Variation– Special Cause Variation happens

outside of the normal process.

– The process is functioning normally, until some event happens

20 23 17 24 19 25 22 26 19 17

327

19 28 25 260

100200300400

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15



©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

41

Special Cause Variation– Room Service sources of special

cause variation include:– A fire in the kitchen– Broken elevator– Crashing computer system

– A single sources of special cause variation causes us to miss our performance standard.

143


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

42

How do we fix Special Cause Variation?

– Sources of special cause variation must be identified and eliminated

– Eliminating a single special cause does not always mean that the error cannot reoccur.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

43

Common vs. Special Cause Variation

–Attributed to less than 15% of the cause of the problem–Improvement requires change by an individual or avoidance of an isolated event

–Cause of at least 85% of the problem–Systems based–Improvement usually requires intense analysis of the system and changes to the system

Special Cause Variation

Common Cause Variation


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

58

RCA Summary

144


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

59

What does Root Cause Analysis (RCA) do?

– Identify the causes that lead to variationfrom our performance expectation.

Types of Variation: Common Cause and Special Cause

Types of causes: Apparent and Underlying

Performance Expectation: What we want to happen (e.g. 0 Sentinel events)

This analysis helps us understand why we have missed our performance goals

Multiple tools, including 5 Whys and Ishikawa


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

60

RCA Tips

• Start with special causes in the clinical process and move to common causes in the organization process

• Repeatedly peel away the layers of the incident until no additional logical answers can be found

• Identify changes that could be made to systems and processes that would reduce the risk of such an event occurring in the future


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

61

RCA Tips

• Eliminate culture of blame• Continue to study the process and

compare it over time to assure ongoing change and improvement

145


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

62Next Presentation

146

Day 3: The Survey and Continual Improvement

147

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Advanced Quality Strategies

Failure Mode and Effects Analysis (FMEA)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2

Failure Modes and Effects Analysis (FMEA)

– FMEA is a tool which helps identify and prioritize potential failures in a process.

– FMEA does not fix failures

– Failure Mode: What one observes when a failure occurs.

– Effect: The consequences of a failure


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

3

A Failure?

148


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

4

A Failure in Pisa–Failure Mode:

–Effects:

•The tower was built on ground that could not support it.

•The tower leans to one side.

•Visitors must be careful when climbing the stairs.

•The building is unsafe.

•The building must be reinforced.

•More staff must be hired to accommodate additional visitors.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

5

Root Cause Analysis v. FMEA

Design

Root Cau

se

AnalysisFMEA

Building

Redes

ignFMEA

Impro

ve

FMEA is an early part of processimprovement

RCA examines why a specificfailure happened

FMEA can also be used to improve an existing system


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

6

JCI Hospital Std QPS.10

– An ongoing program of identifying and reducing unanticipated adverse events and safety risks to patients and staff is defined and implemented.– Identify high risk processes– Prioritize risks annually– Proactive risk reduction annually– Redesign process, based on activity

149


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

7

What will an FMEA give us?– A prioritized list of potential failures/risks

that include:

– What we will see when a failure occurs– How that failure impacts our “customers”– What is the likely cause of the failure

– Best for analysis of a system not an incident


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

8

What will we do with a completed FMEA?

– Use the prioritized failures/risks to focus our improvement efforts on the most pressing problems

– Predict possible failures– Eliminate the possibility of intolerable

errors– Minimize the consequences of

unavoidable errors

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The FMEA Process

150


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

10

FMEA Process Steps

1. Select a process2. Assemble a team3. Diagram the process4. Brainstorm5. Complete the FMEA form6. Redesign the process/design controls7. Analyze and test the new process8. Implement & monitor redesigned

process


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

11

Step 1: Select a Process

– High-risk process

•Variable input•Complex•Non-standardized•Heavily dependent on human interaction•Hierarchical (not team) orientation

•Humans•Many processes•Many lack standards•High degree of human interaction•Very hierarchical

High Risk Process Healthcare


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

12

Step 2: Form a Team– 4 to 8 members– Experts on the process examined:

– If clinical at least one nurse and one doctor– Preferably individuals who command respect

– FMEA Expert (act as facilitator)– Hospital Leader with decision-making power– Team Leader (can be same as one of above)– At least one person unfamiliar with the

process to be examined

151


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

13

A Successful FMEA Needs

– Leadership support– Trained and qualified personnel– Honesty– Creativity


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

14

Step 3: Diagram the Process– Multiple ways to diagram any process

– Value Stream Mapping– Flow Charting

– Involve representation for everyone involved in the process

– Allocate plenty of time for this step

– Be as detailed and complete as possible

– Learn the flow chart process and symbols


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

15

Value Stream Map Example

Cola Factory

Cola unloaded at Conference Center

Carried to conference

room

Wait for program to

startCola carried to storage

room

Customer

Wait for Cola order

Cola refrigerated

Cola put on

ice

120 mins 30 mins

30 mins

17,280 mins

30 mins

120 mins 60 mins

Value Added

Non-Value

152


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

16

Cola Factory



room

Wait for program to


room

Customer

Wait for Cola order

Cola refrigerated

Cola put on

ice


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

17

Flow Charting

Physicianwrites order

Medicationorder

Order pulledfrom chart

Order transcribed

into medication administrationrecord (MAR)

Order transcribedinto Pharmacy

system

Copy oforder sent to

Pharmacy


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

18

Exercise 1: Flow Charting


Medicationorder


Order transcribed



system


Pharmacy


Medicationorder


Order transcribed



system


Pharmacy

–Ordering medication–Cleaning dishes–Making travel arrangement

–Minimum of 4 steps–Maximum of 8 steps–Pick something everyone in the group can understand

ExamplesInstructions

153


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

19

Value Stream Map Legend

Electronic Info Flow

PullSupply only when

consumed

PushSupply regardless if

consumed

External Customer/Supplier

Blood drawn by technician

Process StepWe are actually doing something

Hard Copy Info Flow

WaitSomething is

“sitting”

TransportingSomeone moved

something

ReworkSomething done

again

ShipmentSomething is

mailed/shipped externally

Cola Factory



room

Wait for program to


room

Customer

Wait for Cola order

Cola refrigerated

Cola put on

ice

Cola Factory

Cola Factory

Cola unloaded at Conference CenterCola unloaded at

Conference CenterCarried to

conference room


room

Wait for program to

start

Wait for program to


room

Cola carried to storage

room

CustomerCustomer

Wait for Cola order

Wait for Cola order

Cola refrigerated

Cola refrigerated

Cola put on

ice

Cola put on

ice

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Soda opened

and left out

Soda served

warm

No soda

served

Custom

er drin

ks

flat sod

a

Customer avo

ids

soda-remains

thirsty

Customer leaves

to find unopened

soda

Custom

er must

find ice

Customer avo

ids

soda-remains

thirsty

Customer leaves

to find unopened

soda

Custom

er must

drink w

ater

Customer

remains thirsty

Customer leaves

to find soda

Soda decarbonation

Soda decarbonation

Soda decarbonation

Refrigerator

broken

No ice available

Not enough time

to cool after

delivery

Distributor did

not deliver soda

Soda sent to

wrong room

Staff forgot to

deliver

Soda left out

too long

Distributor did

not deliver soda

Soda sent to

wrong room

Staff forgot to

deliver

Cannot drink

other options

FMEA Brainstorming


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

21

Step 4: FMEA Brainstorming– This FMEA looks for potential failure

points in the process we are implementing

– Essentially, FMEAs are very large brain-storming projects

154


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

24

Exercise 2: Brainstorm Failure Modes

– Brainstorm potential Failure Modes in your process– Failure Mode: What you

observe when a failure happens.

– Do not list causes, effects, or reasons at this point.

– Brainstorm at least 3 potential failure modes within your process.

– In a “real” FMEA, brainstorm until you run out of ideas.

– Leave plenty of room on your page!

Soda opened and left out

Soda served warm

No soda served


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

25

Exercise 3: Brainstorm Effects– Brainstorm the potential

effects for each failure mode– Effect: How the failure

impacts the customer.– Do not list causes or

reasons at this point.– Brainstorm at least 3

effects for each failure mode.




Soda served warm

No soda served

Customer drin

ks

flat soda

Customer avoids soda-remains thirstyCustomer leaves to find unopened soda

Customer must

find ice


Customer must

drink water

Customer remains thirsty

Customer leaves to find soda


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

26

Exercise 4: Brainstorm Causes– Brainstorm the likely

cause(s) for each effect– Cause: Whatever made

the effect or failure mode occur.

– Brainstorm at least 1 cause for each failure mode.




Soda served warm

No soda served

Customer drin

ks

flat soda


Customer must

find ice


Customer must

drink water



Soda decarbonation

Soda decarbonation

Soda decarbonation

Refrigerator broken

No ice available

Not enough time to cool after delivery

Distributor did not deliver sodaSoda sent to wrong room

Staff forgot to deliver

Soda left out too long



Cannot drink other options

155

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Complete the FMEA Form


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

28

Filling Out the FMEA


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

29

What Does the FMEA Form Help us Do?

– The FMEA form guides us through two questions:– 1. What are the important elements of a

potential failure?

– 2. Which potential failures should we start working on first?

156


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

30

Elements of a Potential Failure

– What will we observe when something fails?

– How will the failure impact our “customers”?

– What do we think might cause this failure?

3

1

2


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

32

What is your first Failure Mode?– Failure Mode: What you observe

when a failure occurs

1

Failure ModeWhat you observe when a failure occurs


1


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

33

What is the first effect of your first Failure Mode?

– Determine the effect on the customer

Failure Mode EffectWhat you observe when a failure occurs

How the failure impacts the ultimate “customer”

Customer drinks “flat” sodaSoda opened and left out

2

2

157


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

34

Severity– Determine the severity of the effect on the

customer– This is step 4, so skip it for now.

Mode Effecte when a failure How the failure impacts the

ultimate “customer”

Customer drinks “flat” sodaleft out

4

Severity

10 5 1

4


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

35

Mode Effecte when a failure How the failure impacts the

ultimate “customer”

orm X

g ordered

Customer drinks “flat” sodaleft out

ame ordered

Severity

10 5 1

Severity– Determine the severity of the effect on the

customer– This is step 4, so skip it for now.

4


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

36

Potential Cause– Determine the most likely cause of each

Failure Mode/Effect– List as many as apply

ffectimpacts the

mer”

s “flat” soda

Severity

10 5 1

Potential CauseThe most likely cause of the failure

Busy staff

Incorrect meeting times

Soda opened too early

Soda decarbonation

3

3Failure ModeWhat you observe when a failure occurs


158


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

37

Repeat Steps , , – Do you have all of the Potential Causes of

an Effect?– Now, go back and brainstorm another

Effect of the Failure Mode you are examining.

– What are the Potential Causes of that Effect?

– Exhaust all causes before moving on to a new effect. Exhaust all effects before moving on to a new failure mode.

31 2


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

38

Soda served warm Customer avoids soda, still thirsty

What’s the first failure mode?

Yes No

Yes

NoAre there more failure modes?

Yes

No

Cold soda left out too long

Customer leaves venue to find soda

Are there more likely effects of the failure mode?

Soda served warm

What’s the first effect of that failure mode?

What’s the next most likely cause of that effect?

Refrigerator broken

Are there more likely causes of the effect?

81 2 34 5 6 7


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

39

No soda served Customer leaves venue to find unopened soda Distributor did not deliver soda

Soda not ordered from distributor

Soda sent to the wrong room

Soda too warm to serve

Staff forgot to deliver soda

Soda opened and left out Customer drinks “flat” soda Soda decarbonation

Customer avoids soda-remains thirsty Soda decarbonation

Customer bumps table and spills open soda Soda decarbonation

Shaky table

Customer thinks open sodas belong to others Soda decarbonation

Customer leaves venue to find unopened soda Soda decarbonation

Soda served warm Customer avoids soda-remains thirsty Refrigerator broken

Not enough time to cool soda post delivery


No ice available

Customer leaves venue to find cold soda Refrigerator broken



No ice available

81 2 34 5 6 7

159


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

40









Shaky table






No ice available




No ice available

Some effects have the same set of causes

Different failure modesmay have the same

effects

Effects may have multiple or single

causes

81 2 34 5 6 7


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

41

Exercise: Brainstorming the FMEA

– Fill in , & only– In a real FMEA, brainstorm until you are

out of ideas.– Use the brainstorming you completed

earlier to fill in this form. – For this exercise, please limit yourself to

three causes, three effects, and two failure modes.

– Remember:– Many lines will remain blank– No idea is a bad idea

31 2


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

42




No ice available




No ice available

1 2 34 5


Soda served warm

No soda served

Customer drin

ks

flat soda


Customer must

find ice


Customer must

drink water



Soda decarbonation

Soda decarbonation

Soda decarbonation

Refrigerator broken

No ice available

Not enough time to cool after delivery



Soda left out too long



Cannot drink other options

160


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

43

What Does the FMEA Form Help us Do?

– An FMEA helps us answer two questions:– 1. What are the important elements of a potential failure?

– What will we observe when something fails?– How will the failure impact our “customers”?– What do we think might cause this failure?

– 2. Which potential failures should we start working on first?– Which failures are most severe?– Which failures occur most often– Which failures are hard to detect before they impact

our customers?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

44

Scoring the FMEA– In steps , & , you will assign a set

of numerical scores to your effects and causes.

4 65


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

45

Severity

– Determine the severity of the effect on the customer

– 10=Extreme (death)– 1=Customer doesn’t

care (not customer is happy)

4Severity

10 5 1

4

No soda served Customer leaves venue to find unopened soda

Soda opened and left out Customer drinks “flat” soda

Customer avoids soda-remains thirsty

Customer bumps table and spills open soda

Customer thinks open sodas belong to others

Customer leaves venue to find unopened soda

Soda served warm Customer avoids soda-remains thirsty

Customer leaves venue to find cold soda

1 2 4

No soda served Customer leaves venue to find unopened soda

Soda opened and left out Customer drinks “flat” soda





Soda served warm Customer avoids soda-remains thirsty


1 2 41 2 4


Customer drinks “flat” soda







2 4


Customer drinks “flat” soda







2 42 4

4

7

248

277

161


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

46

Occurrence

– How often does the cause occur?

– 10=Very often– 1= Very rare

5Occurrence

RareCommon

10 5 1

Distributor did not deliver soda

Soda decarbonation

Soda decarbonation

Soda decarbonation

Shaky table

Soda decarbonation

Soda decarbonation

Refrigerator broken



No ice available

Refrigerator broken



No ice available

3 5 6


Soda decarbonation

Soda decarbonation

Soda decarbonation

Shaky table

Soda decarbonation

Soda decarbonation

Refrigerator broken



No ice available

Refrigerator broken



No ice available

3 5 63 5 6

441

442

834

327

278


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

47Distributor did not deliver soda

Soda decarbonation

Soda decarbonation

Soda decarbonation

Shaky table

Soda decarbonation

Soda decarbonation

Refrigerator broken



No ice available

Refrigerator broken



No ice available

3 5 6


Soda decarbonation

Soda decarbonation

Soda decarbonation

Shaky table

Soda decarbonation

Soda decarbonation

Refrigerator broken



No ice available

Refrigerator broken



No ice available

3 5 63 5 6

441

442

834

327

278

6 Detectability

– How likely are we to detect problem before it effects the customer?

– 10=Unlikely– 1= Certain

Detectability

5 1

LikelyUnlikely

10

339

339

753

523

237


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

48

Scoring Hints– Big number = worse outcome– Precision is not important.

– Don’t waste time discussing if something should be scored a three or four.

– Keep the rest of the FMEA in mind as you score. – The first item may seem like a 10, but is it a 10

compared to the other items on the list?

162


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

49

Exercise: Scoring The FMEA

– Score the , & columns. – Remember:

– Score in relation to every item on your list.

– Precision is not important—there is very little difference between a score of 2, 3, or 4.

– Big number = worse outcome

4 65


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

50









Shaky table






No ice available




No ice available

5555777745884777777

1463146388838813724

98389838999399101279


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

51

Risk Priority Number– The Risk Priority Number determines

where our greatest danger lies– Severity X Occurrence X Detectability

5

7

Detectability

5 1

LikelyUnlikely

10

8

8

OccurrenceRareCommon

10 5 1

9

3

Severity

10 5 1

360

168

RPN

6

7

1

5

9

6

54

210

163


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

52

Risk Priority Number– The Risk Priority Number determines

where our greatest danger lies– Severity X Occurrence X Detectability

360

168

RPN

5

7

Detectability

5 1

LikelyUnlikely

10

8

8

OccurrenceRareCommon

10 5 1

9

3

Severity

10 5 1

6

7

1

5

9

6

54

210


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

53

Rank by RPN– Once you determine the RPN,

determine the rank.– Higher numbers mean greater risk.


Used felt pen on form X

Non-formulary drug ordered


Look alike drug name ordered 360

168

RPN

54

210


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

54

Rank by RPN– Use the RPN to determine where to

focus your limited resources– We are looking for failures that are most

severe, occur often, and are hard to detect.


Used felt pen on form X

Non-formulary drug ordered


Look alike drug name ordered 360

168

RPN

54

210

1

3

Rank

4

2

164


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

55

Exercise: RPNs and Rankings

– Use the scores you created to determine Risk Priority Numbers (RPNs).

– Use the RPNs to determine rank

RPN=Severity x Occurrence x Detectability


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

56









Shaky table






No ice available




No ice available

5555777745884777777

1463146388838813724

98389838999399101279

4516090120632241261682883605767228850470219898252

18914111771084311542161912126


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

57

Step 6: Redesign the process/design controls

– Brainstorm actions that could address the failure modes with the highest Risk Priority Number (RPN)– Eliminate risk if possible– Minimize/mitigate risk if it cannot be

eliminated– Look for opportunities to “failure proof”

165


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

58

Prioritized Potential Failure Modes

0

100

200

300

400

500

600

700

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

– All failure modes are important

– Some Failure Modes will be clear targets

Ris

k Pr

iorit

y N

umbe

r

Failure Modes


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

59

How can we Reduce Risk?– One way to reduce risk is to reduce

the Risk Priority Number– Can I make this failure less severe?– Can I make this failure occur less often?– Can I make this failure easier to detect?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

60

7. Analyze and Test the New Process

– One the new process has been developed, conduct another FMEA, examining the potential risks.

– For failure modes with high RPNs, look for additional ways to eliminate or mitigate risk

166


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

61

8. Implement and Monitor New Process

– Repeat several times, after elimination of each Failure Mode


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

62

Summary– Failure Mode Effects Analysis

(FMEA) is an effective proactive risk reduction technique

– Doing it right– requires a well functioning team– requires resources in time and talent– results in reducing patient harm and

improving patient outcomes


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

63

Filling out an FMEA: Words first

What is the first Failure Mode?

1What is the first effect of that Failure Mode?

2What is the most likely cause of the failure that produces this effect?

3

What is the next most likely cause of the failure? Enter causes until you run out.

4

When you run out of causes for the effect your working on, move on to another effect.

5Enter causes for this effect until you run out.

6

When you run out of effects, move on to another Failure Mode.

7

167


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

64

Filling out an FMEA: Numbers last

8

Fill in all of the severity ratings 9

10

11

12

13

14

15

16

17

18

19

Then, fill in all of the occurrence ratings

Then, fill in all of the detectabilityratings


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

65

Tips for Filling out an FMEA– Words first (Failure Mode, Effect,

Cause)– Number second (Severity,

Occurrence, Detectability)– The numbers are relative values—they

only mean something ranked against each other


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

66Next Presentation

168

Failure Mode Effect Potential Cause RPN RankWhat you observed when a failure occurs How the failure impacts the

customerThe most likely causes of the failure--this line must always be filled in

How severe is the effect to the customer?Severity Occurrence Detectability

How likely are we to be able to detect the failure or cause?

Failure Mode Effects Analysis

How often does the cause or Failure Mode occur?

Worksheet

10 5 110 5 1

RareCommon

10 5 1

RareCommon

10 5 1 5 1

LikelyUnlikely

10 5 1

LikelyUnlikely LikelyUnlikely

10

31 2 64 5 87

169







Worksheet

10 5 110 5 1

RareCommon

10 5 1

RareCommon

10 5 1 5 1

LikelyUnlikely

10 5 1


10

31 2 64 5 87

170







Worksheet

10 5 110 5 1

RareCommon

10 5 1

RareCommon

10 5 1 5 1

LikelyUnlikely

10 5 1


10

31 2 64 5 87

171







Worksheet

10 5 110 5 1

RareCommon

10 5 1

RareCommon

10 5 1 5 1

LikelyUnlikely

10 5 1


10

31 2 64 5 87

172







Worksheet

10 5 110 5 1

RareCommon

10 5 1

RareCommon

10 5 1 5 1

LikelyUnlikely

10 5 1


10

31 2 64 5 87

173







Worksheet

10 5 110 5 1

RareCommon

10 5 1

RareCommon

10 5 1 5 1

LikelyUnlikely

10 5 1


10

31 2 64 5 87

174







Worksheet

10 5 110 5 1

RareCommon

10 5 1

RareCommon

10 5 1 5 1

LikelyUnlikely

10 5 1


10

31 2 64 5 87

175

Day 4: The Survey and International Patient Safety Goals

176

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Last Survey Simulation Discussion and Reflective

Learning


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Discussion Questions– What differences did you notice

between the approaches that your two surveyors used?

– What do these differences mean for how you will prepare for your survey?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Discussion Questions– What surprised you the most about

the tracer process?

177


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Discussion Questions– What are three most important things

that you have learned about the tracer process?


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Discussion Questions– What are the three most important

pieces of advice that you would give to a staff members who must conduct their first tracer?

178

Notes

179

Notes

180

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Four Steps for Continual Improvement

It’s not where you’ve been—it’s where you’re going.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2

The Mindset

Accreditation is a milestone on the continuous journey of improvement

The effort is for your patients, not the certificate

Three years fly by quickly, staying ready is easier than getting ready


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

3

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

Motivational Goals bring collective energy and ideas to priority topics

Credible Data guide individual decisions and overall strategic direction

183


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

4

The ChallengeSustaining improvement requires establishing an organizational culture of safe, quality care

Individual behaviors must change one person at a time.

Organizational cultures can change at a moments notice

Sentinel events or leadership changes can alter culture immediately.Frequently measure the direction and rate of progress


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

5

Four Steps To Success1.1. Keep things simple and clearKeep things simple and clear

2. Consider data your best friend2. Consider data your best friend

3. Presume change and manage it3. Presume change and manage it

4. Practice the process 4. Practice the process


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

6

Success Step #1: Keep Things Simple and Clear

Policies and Procedures:As few as practicalShortSimple languageReadily accessible for those who need themKept up-to-date

A strong quality culture in an organization is sustained by leadership not policiesIndividual behaviors are shaped best by mentors and role models not policies

184


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

7

Find simple and effective ways to communicate essential quality and safety information to all parties – governance, leaders, staff, patients

A brief communication about quality once a week is better than a big document once a month

Success Step #1: Keep Things Simple and Clear


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

8

Success Step #2: Consider Data Your Best Friend

Consider how key points can be made more effective with data - a graph is worth a thousand words

Motivate governance, management, professional staff and patients with data

Post infection rates all over the hospital

Post average length of stay for procedures on the door of the staff lounge


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

9


Do not try to interpret all the data--let the data owners do so

Let the orthopedic surgeons explain why the complication rate for hip replacements is drifting upward for the last 2 quarters

Data owners must also own the actions for improvement and claim success for sustained improvements

185


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

10


Continue to refine and mature your data systems

Create data collection tools that people want to use Create event reporting processes that everyone uses

Strengthen the data analysis process so that it becomes more rapid and comprehensive

Demonstrate data use and how it contributes to understanding all aspects of your organization


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

11

Success Step #3:Presume Change and Manage It

Catalogue the changes occurring in your organization:

Leadership changesClinical services New/renovated buildings, facilitiesNew staff (including contract workers)Changes in the patient populationClinical and management activities

Consider how they should be managed


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

12

Success Step #3:Presume Change and Manage It

Ensure that standards are met as changes occur

Training for staff as they are hired

Fire safety in new facilities and during renovations

Build quality into all contracts for services

186


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

13

Success Step #4:Practice the Process

Do patient and system tracerscomplete at least one a month to be ready for survey or resurvey

Continually evaluate patient records to ensure they tell the entire “story” of the patient

Do exercises that “break” high-risk processes to see if adverse events can sneak though


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

14

Success Step #4:Practice the Process

Practice the group interviews of leaders

Practice using interpreters to ensure the comfort level of staff

Check the track record for all documentation

4 months for an initial survey12 months for a triennial survey


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

15

Some Final Tips

The accreditation survey is also a learning process—there is something new to learn every time you go through it.As you prepare for an accreditation survey or maintain continued readiness for survey, your quality and patient safety capabilities should and will growKeep quality and safety as an integrated activity

187


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

16

Some Final Tips

Quality and safety everyone’s job.

The quality department/unit is primarily for coordination and facilitation of quality with leaders setting priorities and all staff participating in monitoring and improving quality and safety.

Avoid the “it’s the quality department’s job”syndrome.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

17

Some Final Tips

Continue to celebrate your successes as

you continue to improve.

Constant, incremental improvement can

have a profound impact on patient safety.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

18

Step 5?– For those that are preparing for

reaccreditation, what practices have helped you?

188


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

19

Questions-Discussion

www.jointcommissioninternational.org

Next Presentation

189

Day 5: Tools and Techniques

190


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Communication Between Hospital Staff and Patients and Families:

Skills to Improve Patient Safety and Build Trust and Confidence


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2

To improve the safety and quality of care in the international community

through the provision of education, publications, consultation, evaluation, and accreditation services

Mission of Joint Commission International


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

3

The Importance of Communication to Medical

Errors– Poor communication among health

care providers places patients at risk

– Poor communication with patients and families destroys trust and confidence in providers and the health care system

191


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

4

Sentinel Event Experience to Date Provides the Evidence

531 events of wrong site surgery

520 inpatient suicides488 operative/post op

complications385 events relating to

medication errors302 deaths related to delay in treatment224 patient falls153 deaths of patients in

restraints138 assault/rape/homicide

Of 4064 sentinel events reviewed by the Joint Commission, January 1995 through December 2006:

= 4064 RCAs

125 perinatal death/injury94 transfusion-related

events85 infection-related events72 deaths following

elopement66 fires67 anesthesia-related events51 retained foreign objects

763 “other”


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

5

Root Causes of Sentinel Events

0 10 20 30 40 50 60 70 80 90 100

Organization culture

Care planning

Continuum of care

LeadershipEnviron. safety / security

Procedural compliance

Competency/credentialing

Availability of infoStaffing

Patient assessment

Orientation/training

Communication

(All categories; 1995-2004)

Percent of 2966 events

Average number of root causes cited per

RCA = 3.1


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

6


0 10 20 30 40 50 60 70 80 90 100


Care planning

Continuum of care

Leadership

Environ. safety / security



Availability of info

Staffing

Patient assessment


Communication

(All categories; 2005)


Average number of root causes cited

per RCA = 3.8

192


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

7


0 10 20 30 40 50 60 70 80 90 100


Care planningContinuum of care

Leadership

Environ. safety / security



Availability of info

Staffing

Patient assessment


Communication(All categories; 2006)


Average number of root causes cited

per RCA = 5.3


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

8

Why Communication Breaks Down

– Organizations and health care providers do not have the two way “conversations” with patients to build a trusting relationship.– Example: patients are asked questions

by health care providers and not permitted to tell their story on an initial assessment. Average patient is interrupted by the provider within 20 seconds when explaining why they are seeking care.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

9


– Communication is not standardized– Professional jargon used by all groups

of health care providers– Abbreviations and short hand notes

seem to be a personal preference not an organization policy

– Information is a mixture of electronic, verbal and paper in most organizations thus no single source captures everything

193


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

10


– Health care is complex and delivered across a continuum of acute care and community settings– The hand off of information from shift to

shift and from setting to setting is poor and even critical information can fall between the cracks for example, medications the patient is or should be taking


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

11


– The “culture” within and between professional groups is often a barrier– Nurses hesitate to challenge physicians

even when they sense an error is about to be made

– Admitting errors is not viewed as an opportunity to learn rather, they are covered up to save face


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

12

The Human Side of Errors– “By focusing on the human

consequences of medical errors, they (advocacy groups) force care givers to confront our inadequacies in communicating with patients and families when things go wrong”

– Lucian L. Leape, M.D.– Adjunct Professor of Health Policy – Harvard School of Public Health

194


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

13

JCI Standards and Accreditation Support Good

Communication– Patients have access to a quality focused

organization– Patient and family rights are respected and

protected– Education and communication is understandable– Satisfaction is seriously evaluated– Involvement in care decisions and care process

is welcomed– Kept informed of care process and when

unexpected errors and complications occur


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

14

JCI Standards and Accreditation Support Good Communication

– Family valued in the care process and part of all communication

– End of life care and pain management respect personal preferences and maintain dignity

– There are clear processes to resolve care issues or address complaints


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

15

Disclosing Medical Errors– Approach patients’ and their families’

need for communication and information with an attitude of understanding and respect.

– Tell patients and their families what went wrong as soon as it is known.

– Sincerely apologize.– Tell patients and their families how

such errors will be prevented in the future.

195


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

16

Internal Processes Related to Medical Errors

– Identify the individuals or departments who should be notified of an incident.

– Specify how the incident should be reported.

– Define who is responsible for reporting.– Define the process for the events that

follow reporting the incident.– Report errors promptly to supervisors,

risk managers, and others.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

17

Apology and Litigation– University of Michigan Health System

– A new policy on handling medical malpractice claims was based on three principles:– a) When we hurt someone through

unreasonable medical care we ought to make it right

– b) We ask the staff to do hard work. When the care they provide is reasonable, we need to support them even when something goes awry.

– c) We need to learn something from medical errors and patients’ experiences.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

18

Apology and Litigation– Results of an open disclosure policy

– August 2001 – 262 claims and suits– May 2006 – 93 claims and suits

– Before the policy - $48,000 average claim

– Since policy - $21,000 average claim

196


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

19

Patients as Partners:Involving Patients and

Families


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

20

FACT– Patients as respected partners in

health care– Feel free to ask questions until they

understand the answers– Feel empowered to challenge a

physician or nurse about some aspect of treatment

– Feel support from the entire organization

– Are more likely to comply with treatment


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

21

FACT– Have better outcomes– Are less likely to bring legal action if

things go wrong– Often identify potential medical errors

that hospital staff are overlooking

197


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

22

Reality– In most organizations patients are

not serious partners– They are only seriously listened too when a

bad event occurs– Making patients into partners takes change

that most organizations are reluctant to make– Creating a new culture takes leadership that is

often missing– Changing philosophy, attitudes and behaviors

is not easy


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

23

Brochures can be ordered that have a blank panel to allow for information about the organization, its commitment to patient safety, and the organization logo.

Organizations can order campaign buttons that can be worn by staff.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

24

198


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

25

SpeakUP Initiatives

– Speak Up: Help Prevent Errors In Your Care

– Universal Protocol: Wrong Site Surgery

– Three Things You Can Do To Prevent Infection

– Tips To Prevent Medication Mistakes


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

26

Communication is Critical– Have a conversation with a patient not just talk at

them– Make sure they understand all portions of a

consent form– Involve the patient and their family in care

decisions to the extent they want to be involved– Make sure patient rights are known by patients

and staff– Say you are “sorry” if something unexpected and

adverse happens– Communicate in a language and style the patient

understands


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

27

Some Tips– Post signs urging patients and families to ask

questions

– Develop a fact sheet with advice and questions that make patient and family participation easier

– Create a patient and family advisory council

– Find ways to ensure that patients understand the education you provide to them and their families

199


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

28

Advice to a Parent– “Every child is different, every parent

is different, every illness or behavior is somewhat different from any other……….Remember that you know a lot about your child and I

don’t know anything”– Benjamin Spock, M.D.– Baby and Child Care


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

29

www.JointCommissionInternational.org

THANK YOU For more information

please visit our website:

200

Notes

201

Notes

202

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

International Patient Safety Goals (IPSG)


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Evolution of the International Patient Safety Goals

2005 Announcement of the JCI International Patient Safety Goals (IPSG)

2006 Pilot testing of the JCI IPSG– Results did not impact accreditation

decision

2007 Implementation of IPSG as requirements for International accreditation of hospitals

2008 IPSG as part of published 3rd Edition of JCI Standards for hospitals, effective January 2008


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Implementation of IPSG….

Represents proactive strategies to reduce risk of medical error and reflect good practices proposed by leading patient safety experts

Incorporating these new tools into our accreditation requirements is a significant step

Organizations taking responsibility for using the IPSG to foster an atmosphere of continuous improvement is even more important

205


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

2008 International Patient Safety Goals

IPSG 1 Identify Patients CorrectlyIPSG 2 Improve Effective CommunicationIPSG 3 Improve the Safety of High-Alert

MedicationsIPSG 4 Ensure Correct-Site, Correct-Procedure,

Correct-Patient SurgeryIPSG 5 Reduce the Risk of Health Care

Associated InfectionsIPSG 6 Reduce the Risk of Patient Harm

Resulting from Falls


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

IPSG.1Identify Patients Correctly

A collaborative process is used to develop policies and/or procedures that address the accuracy of patient identification

Use at least two (2) ways to identify a patient:

• giving medications• giving blood and blood products• taking blood samples• taking other samples for clinical testing• providing treatment or procedure

The patient’s Room Number cannot be used as an identifier


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

A collaborative process is used to develop policies and/or procedures that address the accuracy of verbal and telephone communications

IPSG 2: Improve Effective Communication

Person receiving the following:

• Verbal order• Telephone order• Reporting of critical test results

Must use a verification “read back” of complete order or test result

The order or test result is confirmed by the individual who gave the order or test result

206


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Critical Test Results

– Ensure that there is collaborative process to determine what they are– Clinical Laboratories

– Bedside testing– Imaging Studies– Electrocardiogram– Pulmonary Function Testing– other


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

A collaborative process is used to develop policies and/or procedures that address the location, labeling and storage of concentrated electrolytesConcentrated electrolytes are not present in patient care units unless clinically necessary and actions are taken to prevent inadvertent administration in those areas where permitted by policy

IPSG 3: Improve Safety of High Alert Medications

Remove concentrated electrolytes from patient care units, including, but not limited to, the following:

• Potassium Chloride• Potassium Phosphate• Sodium Chloride > 0.9%


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Clinical Necessity

– Has to be supported by evidence– Is the substance really needed very

quickly?– If it is used to dilute, is the diluted

solution not available?

207


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

IPSG 4: Ensure Correct-site, Correct-procedure, Correct-patient Surgery

Collaborative process used to develop PP

Mark the precise site in clearly understood way and involve patient in doing thisDevelop process or checklist to verify correct documents and functioning equipment

Use a Checklist including “Time-Out” just before surgical procedure


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Universal Protocol

CORRECTSURGERYSITE

DOCUMENTS

EQUIPMENT

BODY PARTPROCEDURE

PATIENT


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

UniversalProtocol

208


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

A collaborative process is used to develop PP that address reducing the risk of health care–associated infections

IPSG 5: Reduce the Risk of Health Care-Associated Infections

The hospital has adopted or adapted currently published and generally accepted hand hygiene guidelines (can be national or international)

The hospital implements an effective hand hygiene program

Need data to demonstrate effectiveness


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

IPSG 6: Reduce the Risk of Patient Harm resulting from Falls

Develop PP using collaborative process Assess and periodically Reassesseach patient’s risk for falling, including the potential risk associated with the patient’s medication regime, Take action to decrease or eliminate any identified risks.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

209

Notes

210

Notes

211

©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

How to Get Started with JCI Accreditation


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Accreditation Journey:The Basics

Evaluate the commitment of leadership (Board, CEO, and clinical leaders) to a never ending journey.Assess the purity of purpose: to be a safe, high quality organization. Set a clear understanding that the process will require significant leader time. Assigning accreditation only to the quality department will not work.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Accreditation Journey List all barriers and strengths to success and plan strategies for each.

Understand implications for financial and human resources. These may include facility enhancement, training, recruitment of new staff, and redesign of systems.

Set a realistic timeframe for preparation. Average preparation time?

214


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Accreditation Journey:JCI Resources

• JCI International Standards for Hospitals, 3nd

Edition• Hospital Survey Process Guide• Web-based training on introduction to the

international accreditation process• ISAS – International Self Assessment System• Newsletters and publications, both print and

electronic• JCI Practicum – Several locations worldwide• JCI Executive Briefings


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Accreditation Journey:Continual Education

Provide education for organizational leaders and managersand then progressively for all staff. Re-educate frequently.Include:

Introduction to accreditation philosophy and approachDiscussion of accreditation as a patient-focused quality improvement and risk reduction strategyReview of the standards and measurable elementsDiscussion of the survey process and what to expectProject planning and next steps


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Accreditation Journey:Baseline Assessment

Determine the organization’s current adherence to thestandards and each measurable element.

Use knowledgeable and credible evaluators (either internal or external consultants) who will critically and objectively assess each area.Score as Met, Partially Met, or Not Met and cite specific findings and recommendations. Include all areas of the organization in the assessment.Consider an assessment of organizational “culture”related to quality and patient safety.

215


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal


In addition to addressing standards adherence, analyze and collect available baseline quality data as required by the quality monitoring standards (QPS).

More data and data sources may be available than you first realize.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal


Begin to combine activities of risk-management, quality management, facility safety, etc. into one comprehensive data set.

Examples: medication errors, hospital-associated infection rates, antibiotic usage, falls, hazardous material spills, surgical complications, etc.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Accreditation Journey:Action Planning

Using the findings of the baseline assessment, develop a detailed project plan with assigned responsibilities, deliverables, and timeframes.

Example: Revise informed consent policy, develop a new informed consent statement, educate staff by 30 August. Responsibility: One PersonIf available, use a software program such as MS Project or Excel to confirm project plan in writing.Hold leaders and staff accountable to plan.

216


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Accreditation Journey:Action Planning Tips

Think structure-process-outcome in the implementation sequence, in other words develop polices first. Expectation required actions result

Implement those requirements that will take the longest to make fully functional such as the quality monitoring system for the QPS indicators.

Do not forget the “track record” requirement = 4 months a first survey.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Accreditation Journey:Team Approach

Assign oversight of each chapter of standards to a respected champion or leader who will select team members from throughout the hospital.Tip: Involve those who may be skeptical of the process. Look for good people skills, time management skills, and consensus building skills.Be prepared to change assignments as new champions emerge and some leaders drop out.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Accreditation Journey:Policies and Procedures

In addition to an overall project plan, it is often helpful to compile a list of all required policies and procedures that will need development or revision.

It may take more time than you think to write, have organizational review, and get final approval on policies.Be certain that your policy reflects your actual practice. This is how surveyors will evaluate your organization.Plan time for education of new policies. Test understanding and compliance.Create, refine and/or test your document management system. (Policy on Policies)

217


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Accreditation Journey:Mid-Point Strategies

Continue to monitor your progress in meeting the standards; do a mini-evaluation of each chapter at regular intervals.

It is not a setback to adjust your project plan if necessary. Changes in processes often take longer than expected.

Continue to involve as many staff as possible in the process. Make accreditation an organizational quality goal that you are striving to achieve together.

Keep staff motivated.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Successful Strategies:Physician Perspective

Physician commitment to the accreditation process iscritical to success.

Physicians must see accreditation standards as a framework by which organizational processes will be improved in order to support good medical care.Accreditation is not a peer review process as many physicians suspect.Accreditation supports the use of good clinical science and best practices.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Suggested Strategies– Educate, Educate, Educate– Develop/revise P/P and forms based upon the

standards and MEs– Involve all staff including leaders on a regular

basis– Conduct monthly patient tracers and system

tracers– Focus the tracer, educate on standards and develop

interviewer skills– Practice questions in different ways with various

ways for staff to show evidence of compliance– Practice tracers with staff – not management

218


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Suggested Strategies– Conduct open medical record reviews

– Have staff involved in medical record reviews – Use MR evidence while conducting the tracers– Use the internal audit data to show progress or

areas of focus

– Train staff in care processes, P/P, and documentation expectations

– Educate, re-educate, re-educate


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Successful Strategies Learn from what others have done well and adapt the experience to the needs of your organization.

Ask JCI for assistance and clarification with standards interpretation. Don’t waste time going down the wrong path.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Pitfalls To Avoid: Be AwareTop leaders give “lip service” to the process, but are unrealistic in what it will take to achieve accreditation 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 make the entire accreditation process feel punitive and inspecting rather than motivating.

219


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

Final Mock SurveyPlan for a final “mock survey” at least 6 months in advance of the target date of your actual accreditation survey.

Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation. They will look at the organization with more objectivity. If using internal evaluators, mix disciplines and locations.

Plan revisions and corrections based on the findings of the mock survey. Educate.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

The Accreditation SurveyRequest an application from JCI at least 6 months or longer in advance of target dates for survey.

Once your application is completed, a surveyor team will be assigned and dates confirmed.

A survey team leader will be in contact to coordinate an agenda and plans for the survey.

Support staff in doing the work they routinely do so the survey does not cause undue anxiety and fear.


©C

opyr

ight

, Joi

nt C

omm

issi

on In

tern

atio

nal

After the SurveyCelebrate your success!

If there are areas for improvement, you may need to submit documentation or a follow-up progress report to JCI.

Maintain the momentum from your preparation and survey. Establish a system and process for ongoing standards compliance and survey readiness.

Continue education.

220

Notes

222

Notes

223

Appendix

226

Tracer Activity Data Collection Tool

Clinical Service:______________________________ Patient ID Number:____________ Focus Areas: Date of Tracer:________________ 1. _________________________________________ 3.___________________________________ 2. _________________________________________ 4.___________________________________

Unit / Department

Individuals Providing

Care

Issues Standards Focus Areas

©JCR, Inc. 2003 227

Notes

232

Notes

233

Zakaria Zaki Alattal, MSN Consultant, Joint Commission International Zakaria Zaki Alattal has more than 15 years of experience in management and training health care providers in various areas. His expertise includes utilizing Joint Commission International (JCI) standards to build quality systems in hospitals and health care organizations. Through management of the unique challenges facing each organization, he is able to identify quality concepts and enhance the quality of health care services. Dr. Alattal serves as a professional trainer for health care providers and health administrators on quality and management competencies at the Wollongong University Dubai, as well as providing on-the-job training for health care staff in Saudi Arabia, Yemen, Jordan, Egypt and the United Arab Emirates. He consults for hospitals in the Middle East on subjects related to quality and patient safety, but is also knowledgeable of the United States health care standards. He also lectures on patient safety quality management, performance management, and health management. Dr. Alattal holds an honor’s master’s degree in quality management and a master’s degree in nursing. He received the Dubai Quality Group Award as the top graduate of Wollongong University in 2003. He is currently conducting his PhD research at the University of Salford – Manchester in the UK on factors affecting the implementation of the JCI standards in UAE hospitals. Dr. Alattal is a certified senior assessor for Dubai Quality and EFQM (European Quality Award) as well as an ISO certified assessor. He is also a Certified Professional in Healthcare Quality (CPHQ) and National Association for Healthcare Quality (NAHQ).

234

Ashraf Ismail, MD, MPH, CPHQ Managing Director, Middle East International Office

Joint Commission International

In March 2009, JCI appointed Dr. Ismail as the managing director of its Middle East office located in Dubai. Dr. Ismail is a physician with 20 years of international experience in hospital accreditation, healthcare quality management, performance improvement and development of human resources for health. His contributions in postgraduate quality education and training are well recognized. As an adjunct professor at George Mason University, School of Health and Human Services, he teaches a variety of quality courses for the certificate in quality and outcomes management. Dr. Ismail is a WHO consultant in accreditation and health care quality. In 2006, he was appointed as Strategic Planning Advisor to the Minister of Health in UAE to develop the new strategy of the health sector. As a quality consultant, he assists healthcare facilities through the accreditation process. His experience in these areas has extended from USA to the Middle East. For four years, he was as a quality consultant to Inova Health System, the largest health system in Northern Virginia. As a faculty at Johns Hopkins University and Director of JHPIEGO’s Asia/Near East/Europe Regional office. While he was employed with USAID in Cairo, Egypt, he implemented the first National Quality Improvement Program in the Family Planning Clinics in Egypt

235

Suhail Kady, MD, MPH, CPE, CPHQ Consultant, Joint Commission International Suhail Kady is a certified physician executive with over 15 years of experience in health care, including expertise in medical management, medical staff leadership, performance improvement, staff credentialing and education of staff in leadership and quality improvement areas. Dr. Kady’s broad background includes teaching in a residency program, serving as both an assistant medical director and a medical director domestically and internationally. His consulting expertise includes operational management of health care delivery systems, quality measurement and management, hospital/physician relations, patient and family education, patient safety, medication management systems and credentialing. Dr. Kady has provided educational programs and international consulting services to organizations in UAE, Saudi Arabia, Ireland, Qatar, Lebanon, Turkey, South Korea, Singapore, Belgium and Thailand. Some of Dr. Kady’s experience with health care and acute hospitals includes serving as an attending physician at Generations+ Northern Manhattan Health Network, in New York, an Assistant Professor of Clinical Medicine at New York Medical College, in Valhalla, New York and a Senior Consultant\ Medical Director at Al Rahba Hospital in Abu Dhabi, UAE. Dr. Kady’s professional affiliations include a Certified Physician Executive at the American College of Health Care Executives and a Diplomate of the American Board of Internal Medicine. He received his doctor of medicine degree from Jordan University, in Amman, Jordan, and Master in Public Health (MPH) from New York Medical College, where he also completed his internal medicine residency.

236

Sherry Kaufield, MA, FACHE, Executive Director, International Services

Ms. Kaufield joined Joint Commission Resources in 2004 with over 30 years of experience in health care. Sherry oversees JCI international consulting and education services in over 80 countries, collaborating regularly with JCI Regional Managing Directors in Singapore, Dubai, Milan, and Ferney-Voltaire, France.

Sherry has advised both domestic and international healthcare organizations in the areas of standards compliance, accreditation readiness and patient safety and quality improvement. She has traveled extensively and worked with multiple clients in Europe, the Middle East, Asia, and Latin America. Clients include individual organizations, healthcare systems, Ministries of Health, health authorities, third party payors and other government bodies. Sherry regularly serves as a faculty member at international practica and other educational events. She is a consulting editor and contributor for the publication, "Joint Commission International Accreditation: Getting Started" and many other publications.

As a former Chief Operating Officer and Corporate Compliance Officer of a 400 bed tertiary Medical Center and Level I trauma center, Sherry has expertise in operations, business development, public relations and marketing, and in the development and implementation of multi-hospital performance improvement and strategic planning initiatives. Her background also includes consultation to non-profit healthcare and other organizations in the areas of board leadership and development.

237

Lynda E. Mikalauskas, BScN, MBA Consultant, Joint Commission International Lynda Mikalauskas has over 25 years of experience in health care and over 15 years of experience in international management and speaks fluent French, Turkish and English. Ms. Mikalauskas brings demonstrated expertise in nursing and administrative leadership to her role as a consultant for Joint Commission International, Inc. She specializes in organizational improvement and management and motivation of professional teams. She has adapted to multiple cultural diversities having worked in Saudi Arabia, Turkey, Canada and other parts of Europe and has consulted throughout Europe, Asia, and the Middle East. Ms. Mikalauskas’ consulting expertise includes operational assessment; patient safety assessment; medication management; infection prevention and control; environment of care; executive leadership and governing bodies; performance improvement; and incorporating tracer methodology and the periodic performance review as management tools. Ms. Mikalauskas’ experience with acute care hospitals and health care includes Associate Director, Joint Commission International, at the Europe Office, in Ferney-Voltaire, France; and Patient Care Services Group Manager and Director of Nursing, at V.K.V. American Hospital, in Istanbul, Turkey. Ms. Mikalauskas is professionally affiliated with the American College of Health Care Executives, the American Association of Nurse Executives and the International Society of Quality. She received her MBA from the University of Colorado in Boulder, Colorado and her BScN in Nursing from the University of Montreal in Montreal, Canada.

238

Notes

239

Notes

240

2009 middle eastern international practicum on quality ... · 2009 middle eastern international...

Documents