JCIA Joint commission international accreditation -Outline .

1. JCIA Outline
Dr.Mahboob ali khan Phd
Renowned Healthcare Quality
Consultant

2. Objectives
Upon the completion of this presentation audience will be
able to:

Acknowledge the importance of team work to achieve

JCIA

Define the following terms: accreditation, standard.


List the JCI-Patient-Centered Standards



List the JCI-Health Care Organization Management
Standards

Slide 2

3. Definitions

JCI Accreditation: Determination by the Joint
Commission International (JCI) accrediting body
that an eligible health care organization complies
with applicable JCI standards.


Standard: A statement that defines the
performance expectations, structures, or
processes that must be in place for an
organization to provide safe and high-quality
care, treatment, and service.

Slide 3

4. Slide 4

5. Once upon a time there wasWerean(A)Arabianand(B) rowing team s
‫ب‬ ‫و‬ ‫أ‬
Slide 5

6. Slide 6 of 92

7. Arabian
(A)
team and(B)Japanteam agreed to do an
annual rowing race. Each team should contain 8 men.
)‫(ب‬ )‫(أ‬

8. Both teams worked really hard to get in the best shape.
The day the race started both teams were in similar
condition. ....Teamthe Japanese(B) won by 1 mile.
....
)‫(ب‬ ‫ال‬ ‫يرف‬ ‫ق‬
Slide 8

9. ‫النهاية‬FINISH
Slide 9

10. The mood in the Arabian(A) team was really close to the freeze
point. The top management decided to win the race next year. So
they established a team of analysts to observe the situation and
recommend an appropriate solution.
)‫(أ‬
....
Slide 10

11. Slide 11

12. After several detailed analysis the team found out that
(B)Japaneseteam had 7 rowers and only one captain.
7 )‫(ب‬
Slide 12

13. (B )
Team
Slide 13

14. Of course the Arabian(A) team had 7 captains but only one rower.
7 )‫(أ‬
Slide 14

15. (A ) Team
Slide 15

16. Slide 16

17. After several months the consultants came up with
the conclusion that there were too many captains and
too few rowers in the Arabian)A( team. A solution
was proposed based on this analysis: the structure of
the Arabian)A( team has to be changed!
)‫(أ‬
)‫(أ‬
Slide 17

18. As of today there will be only 4 captains in the team led by 2
managers, one top-manager and one rower. Besides that, they
suggested to improve the rower’s working environment and to give
him higher competencies.
4
Slide 18

19. (A ) Team
Slide 19

20. Next year theTeamJapanese)B( won by 2 miles.
2 )‫(ب‬
Slide 20

21. ‫النهاية‬FINISH
Slide 21

22. The Arab)(ian team immediatelly displaced the rower from
the team based on his unsatisfactory performance.
)‫(أ‬
Slide 22

23. But the bonus award was paid to the
management for the strong motivation the the
team showed during the preparation phase.
Slide 23

24. The consulting company prepared a new analysis,
which showed that the strategy was good, the
motivation was O.K. but the used tool has to be
improved.
Slide 24

25. Currently the Arabian)( team is designing a new
boat.
)‫(أ‬
Slide 25

26. ‫النهاية‬FINISH
Slide 26

27. Slide 27 of 22

28. JCI-Patient-Centered Standards

International Patient Safety Goals (IPSG)



Access to Care and Continuity of Care (ACC)



Patient and Family Rights (PFR)



Assessment of Patients (AOP)



Care of Patients (COP)



Anesthesia and Surgical Care (ASC)



Medication Management and Use (MMU)



Patient and Family Education (PFE)

Slide 28

29. 1. International Patient Safety Goals
(IPSG)

The International Patient Safety Goals (IPSG) promote
specific improvements in patient safety. The goals
highlight problematic areas in health care and describe
evidence- and expert-based consensus solutions to
problems related to patient safety. Recognizing that
sound system design is intrinsic to the delivery of safe,
high-quality health care, the goals generally focus on
system wide solutions, whenever possible.

29

30. International Patient Safety Goals
(IPSG)

Goal 1: Identify Patients Correctly



Goal 2: Improve Effective Communication



Goal 3: Improve the Safety of High-Alert Medications



Goal 4: Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery


Goal 5: Reduce the Risk of Health Care–
Associated infections


Goal 6: Reduce the Risk of Patient Harm
Resulting from Falls


31. Armed Forces Hospital, Southern Region
Policies
Policy Policy Title
No.
ACC.1 Improving Patient Identification
AOP.1 Verbal and Telephone Orders
AOP.2 Reporting of Critical Results
ACC.2 Hand Off Communication
MMU.1 Improving Safety of High-Alert Medications
ASC.1 Surgical Invasive Procedure Site Verification, Marking and Time out
PCI.1 Improving Hand Hygiene to Prevent Health Care-Associated
Infections
AOP.3 Adult Falls Assessment and Prevention Plan
AOP.4 Pediatric Falls Assessment and Prevention Plan
Slide 31

32. 2. Access to Care and Continuity
of Care (ACC)

These standards address which patient
needs can be met by the hospital, the
efficient flow of services to patients, and
the appropriate transfer or discharge of
patients to their home or to another
care setting.

32

33. Access to Care and Continuity of
Care (ACC)

Screening for Admission to the Hospital



Admission to the Hospital



Continuity of Care



Discharge, Referral, and Follow-Up



Transfer of Patients



Transportation

Slide 33

34. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
ACC.3 Access to Armed Forces Hospital, Southern Region Services and
Out Patient Registration
ACC.4 Standard Screening and Diagnostic Tests
ACC.5 Responsibility of Patient Care and Managing Patients when there is
a Delay for Diagnostics and Treatment Services
ACC.6 Reduction of Barriers to Access and Delivery of Services
ACC.7 Elective Admission of Patients
ACC.8 Emergency Admission of Patients
ACC.9 Intensive Care Unit Admission, Discharge and Transfer Criteria
ACC.10 Pediatric Intensive Care Unit Admission, Discharge and Transfer
Criteria
ACC.11 Coronary Care Unit Admission, Discharge and Transfer Criteria
Slide 34

35. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
ACC.12 Neonatal Intensive Care Unit Admission, Discharge and Transfer
Criteria
ACC.13 Renal Transplant Unit Admission, Discharge and Transfer Criteria
ACC.14 Continuity and Coordination of Patient Care Services
ACC.15 Outpatient Medical Care Profile
ACC.16 Patient Referral, Discharge Planning and Discharge Process
ACC.17 Discharge Summary
ACC.18 Patient Transfer within the Hospital
ACC.19 Patient Transfer to another Healthcare Facility
Slide 35

36. 3. Patient and Family Rights (PFR)

These standards address issues such as
promoting consideration of patients’ values,
recognizing the hospital’s responsibilities
under law, and informing patients of their
responsibilities in the care process. Standards
regarding patient rights with respect to
informed consent, resolution of complaints,
and confidentiality are also included.

36

37. 
General Consent



Informed Consent



Organ Donation

Slide 37

38. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
PFR.1 Patient’s and Family Rights and Responsibilities
PFR.2 Improving Patient and Families Participation in Care Process
PFR.3 Informed Consent
PFR.4 Patient Right of Refusal or Discontinuing of Treatment
PFR.5 Do Not Resuscitate DNR
PFR.6 Patient and Family Complaint
PFR.7 Organ and Tissue Procurement
PFR.8 Safe Keeping of Patient Belongings
PFR.9 Identification and Reporting of Adult or Child Abuse and Neglect
PFR.10 General Consent
Slide 38

39. 4. Assessment of Patients (AOP)

These standards addresses patient assessment at all
points of care within the hospital. Assessment
includes collecting information and data on the
patient’s physical and psychosocial history, analyzing
the data and information to identify the patient’s health
care needs, and developing a plan of care to meet
those identified needs. It also includes standards that
address laboratory services and diagnostic imaging
and radiology services.

39

40. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
AOP.5 Outpatients Assessment and Reassessment
AOP.6 Inpatients Assessment and Reassessment
AOP.7 Triage Process and Emergency Patients Assessment
AOP.8 Pre Anesthesia/ Sedation Assessment and Reassessment
AOP.9 Skin Care Assessment
AOP.10 Nutritional Screening, Initial Assessment and Reassessment
PFR.11 Patient Social Assessment and Reassessment
PFR.12 Initial Physiotherapy Assessment and Reassessment of Patients
PFR.13 Obstetric Patients Assessment and Management in Emergency
Room
AOP.14 Assessment and Reassessment of Dialysis Patients
Slide 40

41. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
AOP.15 Respiratory Therapy Assessment and Reassessment of Patients
AOP.16 Assessment and Care of Patients at End of Life
AOP.17
AOP.18
AOP.19 Managing the Clinical Laboratory Services
AOP.20 Laboratory Quality Control Program
PFR.21 Laboratory Safety Program
PFR.22
PFR.23 Ordering Laboratory Tests
AOP.24 Laboratory Turnaround Times
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42. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
AOP.25 Guideline for Evaluating the Laboratory Reagents
AOP.26 Collection and Identification of Specimens
AOP.27 Laboratory Specimens Handling: Receiving, Tracking, Storage,
Recording and Disposal
AOP.28 Laboratory Proficiency Testing
AOP.29 Managing the Radiology and Diagnostic Imaging Services
AOP.30 Radiology Quality Control Program
PFR.31 Radiation Safety Program
PFR.32 Laboratory and Radiology Equipment and Medical Technology
Management Program
PFR.33 Reassessment of Non-Acute Inpatients
Slide 42

43. 5. Care of Patients (COP)

These standards discusses activities basic to patient
care, including processes for planning and coordinating
care, monitoring results, modifying care, and conducting
follow-ups. It also includes high-risk care services,
nutrition care, pain management, and end-of-life care.

43

44. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
COP.1 Law, Regulation and Uniform Patient Care
COP.2 Physician Orders
COP.3 Recognition and Management of Anaphylactic Reactions
COP.4 Code Blue Protocol
COP.5 High Risk Services and High Risk Patients
COP.6 Care of Comatose Patients
COP.7 Care of Patient on Ventilator
COP.8 Use of Patient Restraints
COP.9
COP.10 Care of Patients Receiving Dialysis
Slide 44

45. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
COP.11 Care of Patients Receiving Chemotherapy
COP.12 The Handling, Use, and Administration of Blood and Blood Products
COP.13 Pain Assessment and Management
COP.14 Kidney Transplant Program
COP.15 Rapid Response Team
COP.16 Breastfeeding
COP.17 Caesarian Section Guidelines
COP.18 Guideline for the Management of ST-Elevation Myocardial Infarction
COP.19 Guideline for the Management of Patients With Non–ST-Elevation
Acute Coronary Syndromes
COP.20 Clinical Practice Guidelines for the Management of Hypertension in
Adults
Slide 45

46. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
COP.21 Clinical Guidelines for Management of Community Acquired
Pneumonia in adult
COP.22 Clinical Guidelines for Management of Asthma in Children
Slide 46

47. 6. Anesthesia and Surgical Care
(ASC)
Slide 47

48. Anesthesia and Surgical Care (ASC)

These standards addresses sedation
and anesthesia use and surgical care.
Topics include procedures for preparing,
monitoring, and planning for aftercare
for patients who received sedation or
anesthesia and/or who had surgery.

48

49. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
ASC.2 Procedural Sedation Patient Care Guidelines
ASC.3 Anesthesia Patient Care Guidelines
ASC.4 Criteria for Recovery and Discharge from Sedation and Anesthesia
ASC.5 Special Consideration for Surgical Care Including Implanting of a
Medical Device
ASC.6 Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery
ASC.7 Risk of Surgical Fires
Slide 49

50. 7. Medication Management and Use
(MMU)
Slide 50

51. Medication Management and Use
(MMU)

These standards addresses systems
and processes for selecting, procuring,
storing, ordering/prescribing,
transcribing, distributing, preparing,
dispensing, administering, documenting,
and monitoring medication therapies.

51

52. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
MMU.2 Medication Organization and Management
MMU.3 Hospital Formulary and Medication Procurement
MMU.4 Storage of Medication and Nourishment
MMU.5 Emergency Medication and Crash Cart Management
MMU.6 Medication Recall
MMU.7 Medication Ordering, Appropriateness Review and Administration
MMU.8 Medication Samples
MMU.9 Patient's Own Medication Brought to the Hospital
MMU.10 Monitoring Medication Effect on patients and Adverse Drug Effects
MMU.11 Medication Errors and Near Misses Prevention and Reporting
MMU.12 Antibiotic Control
Slide 52

53. 8. Patient and Family Education (PFE)

These standards address the
effectiveness of education that is provided
to patients and families and the modalities
employed to successfully educate these
individuals. It also examines patients’
readiness to learn by considering their
language needs and learning preferences.

53

54. JCI-Health Care Organization
Management Standards

Quality Improvement and Patient Safety (QPS)



Prevention and Control of Infections (PCI)



Governance, Leadership, and Direction (GLD)



Facility Management and Safety (FMS)



Staff Qualifications and Education (SQE)



Management of Information (MOI)

Slide 54

55. Organization Functions

The chapters in the third section of
the manual examine the benefits of
the hospital’s management system for


patients, focusing on core processes
that support good management.
Examples of core processes include


leadership requirements, infection
prevention and control, and the
qualifications and education of staff.

55

56. 9. Quality Improvement and Patient
Safety (QPS)

The standards in this chapter identify the structure, leadership,
and activities to support the data collection,


analysis and improvement for the identified priorities—hospitalwide
and department- and service-specific.


This includes the collection and analysis of data on, and response
to, hospitalwide sentinel events, adverse


events, and near-miss events. The standards also describe the
central role of coordinating all the quality


improvement and patient safety initiatives in the hospital and
providing guidance and direction for staff


training and communication of quality and patient safety information.
The standards do not identify an


organizational structure, such as a department, as this is up to
each hospital to determine.

56

57. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
QPS.1 Guiding and Managing Effective Program of Continuous Quality
Improvement, Patient Safety and Risk Management
QPS.2 Internal Data Validation Process
QPS.3 Sentinel Event, Near Misses and Root Cause Analysis
QPS.4 Data Analysis
QPS.5 Failure Mode and Effect Analysis
Slide 57

58. 10. Prevention and Control of
Infections (PCI)

These standards address the methods a hospital uses
to design and implement a program to identify and


reduce the risk of patients and staff acquiring and
transmitting infections. Areas covered in this chapter


include the process for reporting infections and the
types of ongoing surveillance activities that are in
place.

58

59. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
PCI.2 Respiratory Hygiene and Cough Etiquette
PCI.3 Ventilator-Associated Pneumonia Prevention and Reduction
PCI.4 Catheter-Associated Urinary Tract Infections Prevention and
Reduction Program
PCI.5 Intravascular Catheter-Associated Infections Prevention and
Reduction Program
PCI.6 Surgical Site Infection Prevention and Reduction
PCI.7 Epidemiologically Significant Organisms Prevention and Reduction
PCI.8 MERS-Novel Coronavirus
PCI.9 Work Practice Controls
PCI.10 Employee Infectious Disease Prevention Program
Slide 59

60. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
PCI.11 Reuse of Disposables (Single-use) and Management of Expired
Supplies
PCI.12 Needles and Sharps Management
PCI.13 Infectious and General Waste Management
PCI.14 Management of Multi and Single-Dose Vials/Ampule Solutions
PCI.15 Care of Refrigerators and Freezers
PCI.16 Kitchen Sanitation and Food Preparation and Handling
PCI.17 Linen Management
PCI.18 Toy Selection, Cleaning and Storage Guidelines
PCI.19 Operation of the Mortuary
PCI.20 Cleaning and Decontaminating Spills of Blood or Other Body Fluids
Slide 60

61. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
PCI.21 Handling Contaminated Uniforms/Street Clothing
PCI.22 Transporting Laboratory Specimens
PCI.23 Blood and Body Fluid Exposure Evaluation and Follow-up
PCI.24 Prevention and Control of Infection Risk Assessment
PCI.25 Processing Endoscopes
PCI.26 Operating department Practice to Prevent Healthcare Associated
Infection in Patients
PCI.27 Personal Protective Equipments, Standard Precaution and Surface
Disinfection
PCI.28 Infectious Patients and Isolation Precautions
PCI.29 Immunocompromised Population
PCI.30 Prevention and Control of Infection Education Program
Slide 61

62. 11. Governance, Leadership, and
Direction (GLD)
Effective leadership depends on successfully performing the
following processes:

Planning and designing services—defining a clear mission, including
a vision of the future and the values that underlie day-to-day activities


Directing services—developing and maintaining policies, providing
an adequate number of staff, and determining their qualifications and
competence


Integrating and coordinating services—identifying and planning the
clinical services required and integrating and coordinating those services
within and between departments


Improving performance—leaders’ critical roles in initiating performance
and maintaining a hospital’s performance improvement activities


The GLD chapter has been greatly expanded in the fifth edition
standards, focusing even more importance on the role of leadership in a
hospital’s safe and effective operation.

62

63. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
GLD.1 Hospital Governance, Leadership and Organization Chart
GLD.2 Contracts and Agreements Monitoring
GLD.3
GLD.4 Ethical Management Framework
GLD.5 Plan of Services and Staffing Plan
GLD.6 Standardization of Clinical Care Processes
Slide 63

64. 12. Facility Management and Safety
(FMS)

These standards measure the hospital’s maintenance
of a safe, functional, and effective environment for
patients, staff members, and other individuals. Areas
addressed include emergency preparedness, security,
safety, life safety, medical equipment, utility systems,
hazardous materials, and waste management.

64

65. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
FMS.1 Safety Orientation Program
FMS.2 No Smoking Policy
FMS.3 Environment of Care Rounds
FMS.4 Laser Safety
FMS.5 Restriction the Cellular Phones use in Critical Areas
FMS.6 Use of Adaptors and Extension Cords
FMS.7 Interim Life Safety Measures (ILSM)
FMS.8 Lost and Found Items
FMS.9 Violent Patients or Personnel (Code Gray)
FMS.10 Newborn, Infant, And Child Security (Code Pink)
Slide 65

66. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
FMS.11 Communication with Military Police
FMS.12 Bomb Threat (Code White)
FMS.13 Hazardous Material Spill (Code Orange)
FMS.14 Handling of Compressed Gases
FMS.15 Medical Equipment Tagging, Repair, Removal from Service and
Recall
FMS.16 Hazardous Chemical and Radioactive Waste Management
Slide 66

67. 13. Staff Qualifications and
Education (SQE)

This chapter includes sections on human resources
planning; staff orientation, training, and education;
staff competence assessments; handling staff
requests; and credentialing and privileging of licensed
independent practitioners, nurses, and other
practitioners.

67

68. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
SQE.1 Job Description
SQE.2 Personnel Files
SQE.3 Hospital Staffing Strategy
SQE.4 Credentialing of Healthcare Providers and Appointment of Medical
Staff
SQE.5 Granting of Medical Staff Privileges
SQE.6 Professional Practice Evaluation and Annual Review of Healthcare
Providers
SQE.7 Staff Health and Safety and Workplace Violence
Slide 68

69. 14. Management of Information (MOI)
Formerly named Management of Communication and
Information (MCI), these standards have been focused
to address how well the hospital obtains, manages, and
uses information to provide, coordinate, and integrate
services. The principles of good information
management apply to all methods, whether paper-based
or electronic, and JCI standards are equally compatible
with either method:

Information Management



Management and Implementation of Documents



Patient Clinical Record

69

70. Armed Forces Hospital, Southern
Region Policies
Policy Policy Title
No.
MOI.1 Information Privacy, Confidentiality and Security
MOI.2 Medical Record Accessibility and Confidentiality of Patient’s
Information
MOI.3 Medical Record and Data Retention
MOI.4 Policies and Procedures Development and Maintenance
MOI.5 Hospital Programs Development and Maintenance
MOI.6 Approved Abbreviations
MOI.7 Documentation Guidelines
Slide 70

71. What is next ?

Every staff has a role in the
accreditation process regardless of
his/her position, it requires collaborative
efforts and team work!

Think were you want to belong?
Slide 71

72. (A )
(A ) Team
Team
Slide 72

73. (B )
Team
Slide 73

74. Questions? Comments?
Slide 74