JCIA 5th edition key elements
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JCIA 5th edition what new is expected.Effective from 1st April 2014.

JCIA 5th edition what new is expected.Effective from 1st April 2014.

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  • 1. Joint Commission International KeyJoint Commission International Key ElementsElements By Mahboob Ali Khan MHA CPHQBy Mahboob Ali Khan MHA CPHQ
  • 2. Joint commission internationalJoint commission international (JCI)(JCI)
  • 3. Who JCI isWho JCI is  Joint Commission InternationalJoint Commission International (JCI) was(JCI) was founded in the late 1990s to surveyfounded in the late 1990s to survey hospitals outside of the United States. JCI,hospitals outside of the United States. JCI, which is also not-for- profit, currentlywhich is also not-for- profit, currently accredits facilities in Asia, Europe, theaccredits facilities in Asia, Europe, the Middle East, and South America. A countMiddle East, and South America. A count of JCI-accredited hospitals worldwide (asof JCI-accredited hospitals worldwide (as listed on the JCI website in June 2012)listed on the JCI website in June 2012) shows 375 hospitals in 47 countries.shows 375 hospitals in 47 countries.
  • 4. JCIA Global PresenceJCIA Global Presence Our JCI team:Our JCI team:  World headquarters in North AmericaWorld headquarters in North America  Regional offices in Asia-Pacific, Europe, andRegional offices in Asia-Pacific, Europe, and the Middle Eastthe Middle East  A full service headquarters staffA full service headquarters staff  More than 200 international consultants andMore than 200 international consultants and accreditation surveyorsaccreditation surveyors
  • 5. Services of JCIServices of JCI  Advance certificationAdvance certification  HospitalsHospitals  Ambulatory healthcareAmbulatory healthcare  Behavioral healthcareBehavioral healthcare  Critical Access HospitalCritical Access Hospital  Disease Specific CareDisease Specific Care
  • 6. Services Of JCI (contd…)Services Of JCI (contd…)  Home careHome care  Health Care Staffing ServiceHealth Care Staffing Service  Laboratory ServicesLaboratory Services  Long term careLong term care  Nursing care centerNursing care center  Office based SurgeryOffice based Surgery
  • 7. JCI 5JCI 5THTH EditionEdition  Will be effective from 1Will be effective from 1stst April 2014April 2014  Will consists of four sectionsWill consists of four sections  Section one consists of accreditationSection one consists of accreditation participation requirements APRparticipation requirements APR  Section two Patient centered standardsSection two Patient centered standards  1.IPSG1.IPSG  2. ACC (Access to care and continuity of2. ACC (Access to care and continuity of care)care)
  • 8. JCI 5JCI 5thth EditionEdition  3. PFR (Patient and Family Rights)3. PFR (Patient and Family Rights)  4. AOP (Assessment Of Patients)4. AOP (Assessment Of Patients)  5. COP (Care Of Patients) ambulatory5. COP (Care Of Patients) ambulatory  6. ASC (Anesthesia and Surgical Care)6. ASC (Anesthesia and Surgical Care)  7. MMU (Medication Management and7. MMU (Medication Management and Use)Use)  8. PFE (Patient and Family Education)8. PFE (Patient and Family Education)
  • 9. JCI 5JCI 5THTH editionedition  Section three consists of Health careSection three consists of Health care organization management standardsorganization management standards  9. QPS (Quality improvement and Patient9. QPS (Quality improvement and Patient Safety)Safety)  10. PCI (Prevention and Control of10. PCI (Prevention and Control of Infections) laboratoryInfections) laboratory  11. GLD (Governance, Leadership and11. GLD (Governance, Leadership and Direction) for hospitals and academicDirection) for hospitals and academic medical institutionsmedical institutions
  • 10. JCI 5JCI 5thth editionedition  12.FMS (Facility Management and Safety)12.FMS (Facility Management and Safety)  13.Staff qualification and education SQE13.Staff qualification and education SQE  14.Management of Information MOI14.Management of Information MOI  Section four academic medical centerSection four academic medical center hospitals standardshospitals standards  15.Medical profession education MPE15.Medical profession education MPE  16.Human subjects research Programs16.Human subjects research Programs HRPHRP
  • 11. JCI 5th editionJCI 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
  • 12. JCI survey methodologyJCI survey methodology  Thorough survey process becomes Operational:Thorough survey process becomes Operational:  Typical survey team consists of a physician, nurse, andTypical survey team consists of a physician, nurse, and administratoradministrator  Surveyors evaluate various units within an organizationSurveyors evaluate various units within an organization and meet to discuss their findingand meet to discuss their finding  Surveys conduct a complete system analysis onSurveys conduct a complete system analysis on integration and coordination of care processesintegration and coordination of care processes
  • 13. 10-14 Months JCI survey methodologyJCI survey methodology Organizational Assessment Ongoing Technical Assistance Off-site Document Review Mock Survey Hospital Accreditation Survey Ongoing Technical Assistance
  • 14. JCI Tracer MethodologyJCI Tracer Methodology  Patient tracerPatient tracer Allows a surveyor 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
  • 15. Tracer Patient SelectionTracer Patient Selection  JCI Surveyors typically select a patient from a list of current admissions, after consultation with the hospital staff.  op diagnoses and procedures (surgical, medical, obstetrical, intensive care)  A patient on dialysis (if applicable)A patient on dialysis (if applicable)  A psychiatric patient (if applicable)  A pediatric patient (if applicable)  A patient receiving lab/imaging services  A patient receiving rehabilitation services  Patients due for discharge that day or the next day
  • 16. Scoring the Survey Results  Each standard must have a scoring of atEach standard must have a scoring of at least 5least 5  Each chapter must have a score of atEach chapter must have a score of at least 8least 8  All standards must together average for atAll standards must together average for at least 9least 9  All measurable elements are averaged to obtain the score for the standard
  • 17. Scoring survey resultsScoring survey results  Each Measurable Element (ME) is scored  Met (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
  • 18. Thank YouThank You