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JOINT COMMISSION INTERNATIONAL ACCREDITATION(JCIA)
• Presented By:-MANOJ.P142803008
ACCREDITATION• Accreditation is a process in which an entity, separate & distinct from
the health care organization ,usually non governmental• assesses the healthcare organization to determine if it meets a set of
requirements (standards) designed to improve the safety and quality of care .
• Accreditation is usually voluntary.• It has gained world wide attention as an effective quality evaluation
and management tool.
BENEFITS OF ACCREDITATION• Improve public trust
• Provide a safe and efficient work environment
• Negotiate with sources of payment
• Listen to patients & their families ,respect their rights & involve them in the care process as partners
• Create a culture that is open to learning
• Establish collaborative leadership & continuous leadership
Introduction to JCI
• Joint Commission International (JCI) was founded in the late 1990s to survey hospitals outside of the United States. • JCI, which is also not-for- profit, currently accredits
facilities in Asia, Europe, the Middle East, and South America.• A count of JCI-accredited hospitals worldwide (as
listed on the JCI website till 2015) shows 820 hospitals in 47 & above countries. • 21 hospitals in India
JCIA Global Presence JCI team:
World headquarters in North America
Regional offices in Asia-Pacific, Europe, and the Middle East
More than 200 international consultants and accreditation surveyors
WHAT IS JCI?HOW IS IT GOOD FOR US ?
• JCI stands for JOINT COMMISSION INTERNATIONAL.
• It is US based , not for profit accreditation body , which sets & addresses standards for the healthcare providers level of performance in key functional areas , such as patient rights , patient treatment & infection control
• JCI’S mission is to improve the quality of healthcare in the international community by providing worldwide accreditation services
• JCIA is an initiative designed to respond to a growing around the world for standards – based evaluation in health care.
HOW WILL IT HELP US?• JCI standards would lead us to improved patient care, safety & path of
continuous quality improvement .
• This would strengthen patient , third party and insurer confidence and would provide us a competitive edge
• JCI accreditation is the gold standard for quality as it reflects the provision of the highest level of patient care & patient safety
• JCI ACCREDITATION. JCI accredits 8 types of healthcare programs:-• 1.hospitals• 2.academic medical center hospitals• 3.ambulatory care facilities • 4.clinical laboratories• 5.home care facilities • 6.long term care facilities • 7.medical transport organizations• 8.primary care centers
JCI 5TH Edition• Effective from 1st April 2014• Consists of four sections Section 1 consists of accreditation participation requirements APRSection 2 Patient centered standards • 1.IPSG• 2. ACC (Access to care and continuity of care)
JCI 5th Edition • 3. PFR (Patient and Family Rights)• 4. AOP (Assessment Of Patients)• 5. COP (Care Of Patients) ambulatory• 6. ASC (Anesthesia and Surgical Care)• 7. MMU (Medication Management and Use)• 8. PFE (Patient and Family Education)
JCI 5TH edition Section 3 consists of Health care organization management standards• 9. QPS (Quality improvement and Patient Safety)• 10. PCI (Prevention and Control of Infections) laboratory• 11. GLD (Governance, Leadership and Direction) for hospitals and
academic medical institutions
JCI 5th edition
• 12.FMS (Facility Management and Safety)• 13.Staff qualification and education SQE• 14.Management of Information MOISection 4 academic medical center hospitals
standards• 15.Medical profession education MPE• 16.Human subjects research Programs HRP
JCI 5th edition 5th edition of the Hospital Standards contains • 285 Standards• 1160 Measurable Elements
4thEdition of the Hospital Standards• Contains 320 standards• Over 1200 criteria measured during the survey/evaluation
process
REVISION OF STANDARDSThe standards will be revised and published at least every 3 years
JCI survey methodology
Thorough survey process becomes Operational:
Typical survey team consists of a physician, nurse, and administrator
Surveyors evaluate various units within an organization and meet to discuss their finding
Surveys conduct a complete system analysis on integration and coordination of care processes
ACCREDITATION SURVEYS• Interview with staff & patients & other verbal information• On-site observations of patient care process by surveyors• Policies, procedures, clinical practice guidelines, and other documents
provided by the organization
Jci accreditation process timeline
CONTINUOUS QUALITY IMPROVEMENT JOURNEY
6-9 MONTHS PRIOR TO TRIENNIAL DUE DATE
WITHIN 15 DAYS OF SURVEY
SURVEY DATES
2 MONTHS PRIOR TO SURVEY
4-6 MONTHS PRIOR TO SURVEY
6-9 MONTHS PRIOR TO SURVEY
12-24 MONTHS PRIOR TO SURVEY
JCI Accreditation survey occurs
Submit revised application & schedule triennial JCI accreditation re- survey
Receive Accreditation Decision & Official Accreditation findings report from JCI
JCI Survey team leader contacts your organization to determine survey agenda
Receive & complete JCI survey Contract & Travel Instructions Form
Submit application for survey to JCI, & schedule survey dates with JCI
Obtain JCI standards manual & begin preparing for JCI accreditation.
Scoring the Survey Results
• Each standard must have a scoring of at least 5• Each chapter must have a score of at least 8
• All standards must together average for at least 9• All measurable elements are averaged to obtain the score for the
standard
Scoring survey results• Each Measurable Element (ME) is scoredMet (10) Partially Met (5) Not Met (0)
• All Standards are averaged to obtain the score of the chapter• All Chapters are averaged to obtain the overall score
IPSGINTERNATIONAL PATIENT SAFETY GOALS GOAL 1• Identify patients correctlyGOAL 2• Improve effective communication GOAL 3 Improve the safety of high alert medicationsa. IV potassium chloride = or > 2meq concentrationb. Sodium chloride >0.9%c. Magnesium sulphate =or >50% concentration d. Potassium phosphate = or > 3mmol/ml concentration
GOAL 4• Ensure correct site , correct procedure & correct patient surgery GOAL 5 • Reduce the risk of healthcare associated infectionGOAL 6• Reduce the risk of patient harm resulting from falls
PIPELINE CARRYING COLOR CODES
As per BIS(Bureau of Indian Standards) :-• Oxygen –yellow line & white strips • Vacuum - blue & black strips • Air – blue & white & black strips • Nitrous oxide – yellow line with dark blue strips • Dry nitrogen – yellow with light green strips • ENTONX – blue & white strips • Carbon dioxide – yellow with ash strips • Calibration gas – white & red strips