dr. ashraf ismail presentation
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What Is New In
JCI 5th Edition Hospital Standards
PFE
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Ashraf Ismail, MD, MPH, CPHQManaging Director, Middle East RegionJoint Commission International
KFSHDammam, KSA- Dec. 2013
5th Edition Update Overview• Global healthcare has changed in many ways
over the last 3 years of the 4th Edition and will continue to change
• Standards ensure hospital care not only reflects up to date practice but also help hospitals prepare for a different future
• Change means that improving quality and patient safety will always be a work in progress with continuous advances but no end point
• Some of these changes in global healthcare stimulated revisions to the JCI standards
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What Is New In This 5th Edition • Many changes
• Continuous readiness & compliance of JCI accredited hospitals is emphasized by conducting unannounced as well as announced surveys by JCI.
• All of the significant changes are listed in a table at the beginning of each of patient-centered and organization management- centered chapters
• Nearly, all of the 4th edition text has been edited for clarity in the 5th edition
• The total number of standards has been reduced by more than 10% & MEs by more than 5%
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What Is New In This 5th Edition • New standards and established standards
deemed by the field as more difficult to meet are supported with evidence-based references
• References of various types are cited in the text of the standard's intent and are listed at the end of the applicable standard chapter
• A new Section, “ Accreditation Participation Requirements” (APR) has been added.
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What Is New In This 5th Edition • Standards requiring a written policy or
procedure are indicated by a icon after the standard text . In previous editions, each required policy or procedure was specified in its own ME. In this edition, all policies and procedures will be scored together at MOI.9 and MOI.9.1.
• Examples that better illustrate compliance are provided in most standards' intents
• JCI’s policies and procedures are summarized and moved from the front of the manual to their current location on page 253. Starting in late 2013, JCI policies will be published on JCI’s public website.
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What Is New In This 5th Edition • The Medical Professional Education
(MPE) and Human Subjects Research Programs (HRP) standards for Academic Medical Center Hospitals are now included in this manual.
• The “Management of Information” (MOI) chapter has been changed from “Management of Communication and Information” (MCI) in the 4th edition.
• Widespread wording changes for clarity, including frequently substituting the term program for plan or process
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MMU
PFE
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Accreditation Participation Requirements (APR)
APR Chapter New Chapter
It is about how compliance will be evaluated
APRs are not scored like standards during the on-site survey; hospitals are considered either compliant or not compliant with the APR
Most of APR requirements have been moved from many 4th edition documents
The consequence of non-compliance
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• APR.1 – timely submission of data and information
• APR.2 – accurate and complete information
• APR.3 – reporting changes in hospital profile
• APR.4- Hospital permits on site review of compliance or verification of concerns or regulatory sanctions (at ANY TIME)
• APR.5- Hospital allows JCI to request/review results and reports of external evaluations from publicly recognized bodies
• APR.6- Hospital allows observations by JCI Board members and JCI staff
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APR Chapter Standards
• APR.7- The selection and use of the Library of Measures is integrated into the hospital’s measurement priorities
• APR.8 – The hospital accurately represents its accreditation status and program
• APR.9 – Any hospital staff member can report concerns about safety or quality of care without retaliatory action
• APR.10 – translation and interpretation services are provided by licensed translation and interpretation professionals
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APR Chapter Standards
• APR.11 – The hospital notifies the public it serves about how to contact its hospital management and JCI to report concerns about patient safety and quality of care
• APR.12 - The hospital is required to provide patient care in an environment that poses no risk of an immediate threat to patient safety, public health or staff safety
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APR Chapter
Joint Commission International 5th
Edition Hospital Standards MMU
Patient Centered Standards
IPSG, ACC, PFR & AOP
PFE
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Major Changes in the IPSG, ACC, PFR, and AOP Chapters
Major Changes in the IPSG, ACC, PFR, and AOP Chapters
• Focus on highlights, not all changes
• Clearer and more comprehensive intent statements, with more examples
• New decision rule #5 for IPSG’s
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IPSGInternational Patient Safety
Goals
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Emphasizes the need for more focused compliance on 3 distinct communication-related areas
Highlights reporting of critical results of diagnostic tests as an important communication issue
Introduces a new requirement for effective handovers of patient care within the hospital-NEW STANDARD IPSG.2.2
IPSG Major Changes
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Clarify expectations for high-alert medications & concentrated electrolytes
Clarifies the purpose and content of the preoperative verification process & the approach for the time-outprocedure
IPSG Major Changes
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Clarifies the need to address fall risk assessment and reassessment in both inpatients & outpatients
Raises requirements for addressing falls to include locations and situations at high risk for falls
IPSG Major Changes
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ACCAccess to Care and Continuity of Care
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Adds a new requirement for hospitals to manage the flow of patients throughout the hospital NEW STANDARD ACC.2.2.1
Separates the AMA requirements according to two conditions:
• Leaving Against Medical Advice with notification: full D/C summary is required
• Leaving Against Medical Advice without notification
ACC Major Changes
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New standard to require mechanism to manage patient flow throughout the organization including:
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The available supply of
inpatient beds
Plans for temporaryBoarding
Staffing plans
Efficiency of other clinical
areas
Efficiency of the nonclinical
services
Access to support services
PFRPatient and Family Rights
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added a new requirement for informing patients and families of the tests & treatments that require a separate informed consent
Informed Consent must be in a manner/language that patient understands (NEW) & must have uniform recording requirement (NEW)
Informed Consent to be obtained before high risk procedures or treatments & before admission for inpatient care
PFR Major Changes
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Further emphasized the need to ensure patient & family rights regarding organ & tissue donation
Clarify requirements regarding organ & tissue procurement
PFR Major Changes
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AOPAssessment of Patients
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- Patient assessment and documentation must be more patient centric
- Patient and family participation in decisions more critical
- Patient record and out‐patient summaries are essentialcommunication tools
- Patient and family education at many points in care process
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AOP Major Changes
Establishes a NEW STANDARD to emphasize the need to reduce special risks for laboratory staff related to infection control & biohazards
Adds a NEW STANDARD to detail requirements for reference (contract) laboratories used by the hospital
Introduces a NEW STANDARD specific to blood bank and transfusion services
AOP Major Changes
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Joint Commission International 5th
Edition Hospital Standards MMU
Patient Centered Standards
COP, ASC, MMU & PFE
PFE
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Major Changes in the COP, ASC, MMU, and PFE Chapters
COPCare of Patients
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Emphasizing the need for uniform process for prescribing patient orders
Adds new requirement: the person requesting, and the reason for requesting, the procedure or treatment are documented in the patient’s record
Clearly identify expectations for the care of high-risk patients in the hospital
COP Major Changes
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Introduces new requirement for staff training to recognize & respond to changes in a patient’s condition NEW STANDARD
Adds new requirement to emphasize the need for resuscitation services to be available & consistent throughout the hospital NEW STANDARD COP.3.2
Adds ME to emphasize the need for timely distribution of food and honoring special requests
COP Major Changes
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Adds a requirement on communicationwith patients regarding potential pain from planned treatments, procedures, or examinations
Introduces several standards to emphasize the need for safety & quality of organ and tissue transplant services
NEW STANDARDS COP.8- COP.9.3
COP Major Changes
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ASCAnesthesia and Surgical Care
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ASC Major Changes
Adds a description of sedation & anesthesia
Emphasizes the importance of standardization, qualification of practitioners, and professional practice guidelines as they relate to procedural sedation
Adds a new requirement for discussing the risks, benefits, and alternatives of procedural sedation with the patient, family, and other decision makers
NEW STANDARD ASC.3.3
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ASC Major Changes Adds text to include documentation of the
anesthesia agent, dose, and anesthetic technique in the patient’s anesthesia record
Emphasizes the need for postoperativeanalgesia education
Adds clarification that monitoring needs to be consistent with professional practice guidelines
Clarifies that the patient’s assessment should also be used to guide the identification of significant findings during monitoring
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ASC Major Changes Better detail requirements of
surgery documentation in the patient’s record
Adds text to expand on what is included in postsurgical plan of care
Adds a new requirement regarding the special considerations needed in planning surgical care that involves the implanting of medical devices
NEW STANDARD ASC.7.4
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MMUMedication Management and Use
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• Emphasizes the need for proper storage of medications inside and outside of the pharmacy
• Introduces concept that hospitals should define standards of practice for a safe and clean dispensing environment
• Required elements for prescriptions are separated from the processes for problematic or special types of prescriptions
• New requirements for auditing by hospital to determine the accuracy and completeness of prescriptions
MMU Major Changes
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Recognizes two reviews of the prescriptions
• Review 1 - Review of appropriateness
• Review 2 - Review of medication against order
Identifies that properly trained staff other than pharmacists may perform the medication review for appropriateness & specifies that the requirement applies when the pharmacy is open or closed
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MMU Major Changes
PFEPatient and Family Education
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PFE Major Changes• Chapter now contains standards relating
to general education principle
• Specific education has been moved to chapters where education applies
Compliance with PFE Chapter
Uniform documentation and staff knowledge
Patient and Staff interview and Medical records review
• Compliance issues: Staff and patient lack of knowledge No evidence of documentation or
training •
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Joint Commission International 5th
Edition Hospital Standards MMU
Organization Management
Standards
QPS, PCI, & GLD
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Major Changes in the QPS, PCI, and GLD Chapters
QPSQuality Improvement and
Patient Safety
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QPS.1 - Qualified leader of quality program NEW STANDARD
• Selection of the right individual to lead program
• Selection of the right staff for program functions
• Coordination of quality across the organization
• Implementation of a staff training program
• Regular communication to hospital staff about quality issues
QPS Major Changes
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QPS Major Changes
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QPS.2 – Support and coordination of quality within the hospitalNEW STANDARD
• Quality program supports the selection of measures
• The program has a supportive function for department/service and hospital wide measure priorities
• Program integrates event reporting systems, safety culture measures and others to facilitate an integrated approach
• Tracks progress
QPS.5 – Impact AnalysisNEW STANDARD
• At least one impact analysis of cost efficiency per year of an improvement project
• Evaluate and re-evaluate the use of resources for the current and improved process
• Coordination with other departments: HR, IT, Finance
• Report to leadership
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QPS Major Changes
QPS.7 – Managing Sentinel Events
• Sentinel event definition has been expanded to include:
• Death of a full term infant • Transmission of a chronic or
fatal disease – blood, blood products, or transplant
• Rape, assault, homicide –while on site at hospital
• Reporting requirement change-completion time of Root Cause Analysis within 45 days from date of the event
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QPS Major Changes
PCIPrevention and Control
of Infections
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PCI Major Changes
Emphasize the need for hospitals to track infection risks and trends in an effort to reduce risks within the hospital
• Use a risk-based approach to identify epidemiologically important infection prevention strategies and focus on infection prevention.
• Consider clinical practice guidelines, and antibiotic stewardship
• Annual assessment of the program
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PCI Major Changes
Clarifies further requirements for safe handling and disposal of sharps and needles
Increases the emphasis on reducing the risk of infections associated with the operations of food services
Addresses reporting to and taking action on reports from public health agencies
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PCI Major Changes
Clarifies further that the infection prevention and control program is staffed according to hospital size, level of risk, and the program’s complexity & scope
Emphasizes that program strategies should cross all levels of the hospital
Emphasizes the importance of mechanical and engineering controls in minimizing infection risk
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PCI Major Changes
concentrate on programs integration of infection prevention and control program with the hospital quality program
A new emphasis on the measure selection and measurement based on the hospital wide and department/service specific priorities
Requires reporting the data and recommendations to the leadership on a quarterly basis
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A new requirement on the environmental cleaning of contaminated isolation rooms NEW
Focuses in the management of sudden influx of patients with contagious diseases and airborne infection when negative rooms are not available NEW
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PCI Major Changes
GLDGovernance, Leadership and
Direction
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Governance, Leadership and Direction (GLD) Overview
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Leadership role in communication
• Clear and consistent communication is a responsibility of leadership
• Process, effectiveness and content
• Measure of “effectiveness” of communication
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GLD Major Changes
Leadership reports to staff and governance
• Develop and implement a quality program and select leadership for the program
• Quarterly report to governance
• Six month review of sentinel events
• Progress communicated to staff
• Review minutes: governance, senior leadership, and quality departments
• “Sustainability of Improvements”
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GLD Major Changes
Leadership sets hospital wide improvements
• Focus on measurement for system improvement
• Focus on research and education when present
• Focus on full compliance with IPSGs
• Evaluate the impact of Improvement
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GLD Major Changes
GLD Major Changes
NEW STANDARD to emphasize the need to protect patients and staff from contaminated, fake, and diverted drugs, medical technology, and supplies
NEW STANDARD for hospital leadership to create, implement, support, monitor, and take action to improve a culture of safety
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GLD Major Changes
NEW STANDARDS applicable to hospitals that conduct human subjects research but do not meet the eligibility criteria for Academic Medical Center Hospital accreditation
- NEW STANDARD to emphasize the need for department/ service quality improvement activities to be used in the ongoing professional practice reviews of physicians and the annual performance evaluations of nursing and other health professionals staff
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Joint Commission International 5th
Edition Hospital Standards MMU
Organization Management
Standards
FMS, SQE, & MOI
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Major Changes in the FMS, SQE, and MOI Chapters
FMSFacility Management and Safety
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Emphasize the distinctions for managing all aspects of the hazardous materials and waste program;
References the WHO list of hazardous materials and waste categories
Program for control and disposal
Explanation of content of MSDS (Material Safety Data Sheets)
Immediate availability of the MSDS to manage spills
FMS Major Changes
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Medical technology’s term introduced (formerly medical equipment)
Includes all fixed and portable medical equipment used for diagnosis, treatment, monitoring and direct care of individuals
New requirement for testing of alternative water and electricity sources quarterly (NEW)
New requirement for determination of on-site fuel storage needs related to emergency power (NEW)
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FMS Major Changes
FMS.9 – Utility SystemsNEW STANDARD
• Expanded to all utilities• A program for effective and efficient
operation • Inventory of utilities system
defined• Written inspection, maintenance
activities, inspecting and testing intervals defined
• Criteria from manufacturers maintenance and testing requirements
• Labeling of utility system controlsintroduced
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SQE
Staff Qualifications and Education
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• Total rewrite of some standards to add clarity with terminology explained
• New Measurable Elements and wording changes, consolidation of other Measurable Elements
• Flow of standards now is more like naturalprocess
• Identifies the need for more rigorous vaccinations program for staff (NEW)
• Acknowledges that violence in the workplace has become an increasingly common problem in health care organizations (NEW)
SQE Major Changes
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New, more complete explanationsfor key terms:
credentials medical staff verification appointment reappointment
Revise the requirement for primary source verification for initial surveys (new time frame)
Clarifies requirements for determining medical staff membership
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SQE Major Changes
Clarify requirements regarding the privilege delineation process for medical staff members
Provides definition of key terms & expectations to clarify requirements for monitoring and evaluation of medical staff
Emphasize the need to document and take action on findings that affect the appointment or privileges of medical staff members (new)
Separates out and clarifies requirements for reappointment and renewal of clinical privileges of medical staff members based on ongoing monitoring and evaluation
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SQE Major Changes
MOIManagement of Information
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• New language in the standards, intent and MEs
• Need to assess, test, evaluate health information technology (HIT) systems before and after implementation
• Evaluate HIT systems for usability, effectiveness and patient safety
• Stakeholders participate in selection, implementation and evaluation of HIT system
MOI Major Changes
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• Written guidelines on documents, policies, procedures, and plans managed to a consistent manner
• Standardized formats of similar documents
• Evidence found when documents reviewed
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MOI Major Changes
MOI.9.1 – Consistency across the organization in policy managementNEW STANDARD
• Ensuring proper implementation of policies, procedures, plans that guide clinical and nonclinical practices
• When this symbol is found a document is expected
• All are scored together at this standard – one score for the hospital - not at each location
• Tracking, training, knowledge and implementation are expected
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P
MOI Major Changes
5th Edition JCi hospital standards Manual
ChallEnging
aChiEvablE
FoCusEd on thE saFEty and quality oF patiEnt CarE
bEst WishEs
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