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  1. 1. Joint Commission International: An Overview Karen H. Timmons President and Chief Executive Officer Joint Commission International © Copyright, Joint Commission International Association of Companies Health Insurance Funds 13 March 2009 Prague, Czech Republic
  2. 2. Mission ofJoint Commission International– To improve the safety and quality of care in the international community through the provision of education, publications, © Copyright, Joint Commission International consultation, evaluation, and accreditation services 2
  3. 3. Ernest A. Codman: End Result Theory– “So I am called eccentric for saying in public that hospitals, if they want to be sure of improvement, – Must find out what their results are. – Must analyze their results, to find their strong and weak points. – Must compare their results with those of © Copyright, Joint Commission International other hospitals. – Must welcome publicity not only for their successes, but for their errors.”[1] 3
  4. 4. The American College of Surgeons described the need for standardization of hospitals through accreditation as the need to:– “Encourage those which are doing the best work, and to © Copyright, Joint Commission International stimulate those of inferior standard to do better.” 4
  5. 5. The Joint Commission– An independent, non-profit, non- governmental agency– Accredits over 15,000 health care organizations in the United States © Copyright, Joint Commission International 5
  6. 6. Why International Standards?The Joint Commission standards:– Are filled with U.S. and state laws and regulations– Include many “political” considerations such as requirements for an organized medical staff– Use American jargon such as “advanced directives”– Rely on National Fire Protection Association requirements for facility review–no international version of these requirements © Copyright, Joint Commission International– Have a U.S. cultural overlay for patient rights 6
  7. 7. Standards Subcommittee: How We Get Stakeholder Input– Brazil– Czech Republic– Germany– Italy– Poland– Portugal– P.R. of China © Copyright, Joint Commission International– Republic of South Africa– Saudi Arabia– U.S.A. 7
  8. 8. JCI Hospital Standards Translations–Brazilian Portuguese –German–Chinese –Greek/Cyprus–Arabic –Italian–Czech –Korean–Danish –Japanese © Copyright, Joint Commission International–European –Spanish Portuguese –Turkish 8
  9. 9. International Structure– International Board of Directors– International Accreditation Committee– International Standards Committee– Regional Advisory Councils– Four International Offices– International translations of many products © Copyright, Joint Commission International 9
  10. 10. Offices– Headquarters – Oak Brook, IL, USA– International – Europe – Ferney-Voltaire, France (edge of Geneva) – Milan, Italy (Project Office) – Middle East © Copyright, Joint Commission International – Dubai Health Care City – Asia Pacific – Singapore 10
  11. 11. Regional Advisory Councils– Asia-Pacific– Europe– Middle East – Provide advice and counsel to JCI management about standards and patient safety initiatives – Guidance on regional or cultural © Copyright, Joint Commission International adaptations 11
  12. 12. European Regional Advisory Council– BQS – Health Care Quality Indicator– Danish Institute for Patient Safety Project– Danish Institute for Quality and – HOPE (European Hospital Accreditation in Healthcare Federation) (IKAS) – International Hospital Federation– European Parliament – International Pharmaceutical– European Society for Quality in Federation (FIP) Healthcare (ESQH) – The Karolinska Institute– Fundación Acreditación – Ministry of Health, State of Israel Desarrollo Asistencial – Ministry of Health, Turkey © Copyright, Joint Commission International– Georgian Alliance for Patient – National Patient Safety Agency Safety – Socialstyrelsen– Haute Autorité de Santé (HAS) – Swedish Medical Injury Insurance – WHO 12
  13. 13. JCI Today– Global knowledge disseminator of quality improvement and patient safety– Non-profit affiliate of the Joint Commission– 236 accredited organizations in 35 countries– Commitment to partnering with NGOs, HCOs, etc. © Copyright, Joint Commission International– ISQua-accredited– WHO Collaborating Centre for Patient Safety Solutions 13
  14. 14. Programs International Accreditation 14© Copyright, Joint Commission International
  15. 15. Accredited Hospitals in Czech Republic• Central Military Hospital• Institute of Hematology and Blood Transfusion• Na Homolce Hospital © Copyright, Joint Commission International 15
  16. 16. Accreditation – A Definition• A government or non-government agency grants recognition to health care institutions which meet certain standards that require continuous improvement in structures, processes, © Copyright, Joint Commission International and outcomes• Usually a voluntary process 16
  17. 17. Accreditation: A World Trend– The U.S., Canada, and Australia have the oldest accreditation systems– In Europe, Germany, France, Ireland, and Spain have new accreditation systems– In Asia, China, Thailand, and Malaysia are developing national accreditation programs– The WHO, World Bank, and development banks recognize and endorse the accreditation model © Copyright, Joint Commission International– The International Society for Quality in Health Care (ISQua) accredits accrediting bodies 17
  18. 18. Common Core of Health Care Accreditation Around the World Administered by a recognized body • Establishes and publishes standards • Conducts objective on-site evaluations • Publishes accreditation decision Professional involvement © Copyright, Joint Commission International • Consensus on standards of quality and safety • Professionals serve as the external evaluators Focus is on continuous improvement 18
  19. 19. What is Accreditation Intended to Accomplish?• Maximize quality/minimize safety risk • Improve patient care processes and outcomes • Enhance patient safety• Strengthen the confidence of patients, professionals, and payors about the organization• Improve the management of health services © Copyright, Joint Commission International• Enhance staff recruitment, retention, and satisfaction• Provide education on better/best practices 19
  20. 20. Increasing Requests for EnsuringQuality and Safety for Medical Travel• International Medical Travel Association issued position paper advocating that international health care organizations be held to high standards set by recognized accreditation authorities1• American Medical Association adopted guiding principles on medical tourism2 – Outline steps for care abroad for consideration by patients, employers, insurers, and third parties – Require patients to be made aware of their legal rights and have access to physician licensing and facility accreditation• Increasing exposure in international trade journals highlighting © Copyright, Joint Commission International the need to research quality when considering medical travel3• Deloitte study mentions JCI in particular in reference to patients’ increasing concerns about quality in international hospitals4 20
  21. 21. Accreditation– Assesses the capability of an organization to provide good results © Copyright, Joint Commission International 21
  22. 22. Joint Commission International AccreditationInternational Accreditation Philosophy– Maximum achievable standards– Patient-centered– Culturally adaptable– Process stimulates continuous improvement © Copyright, Joint Commission International 22
  23. 23. The Accreditor’s Tools Standards Evaluation Methodology Patient Safety Goals and Tools Data on Performance and Benchmarks Education © Copyright, Joint Commission International 23
  24. 24. Standards– A system framework– Address all the important managerial and clinical functions of a health care organization– Focus on patients in context of their family– A balance of structure, process, and outcomes standards © Copyright, Joint Commission International– Set optimal, achievable expectations– Set measurable expectations 24
  25. 25. Standards are Continually a “Work in Progress”– The heart of any accreditation program is the standards upon which all else is based – the evaluation methodology, decision process, evaluator training, and other operational elements– Thus, a standard must be “good”, not just on © Copyright, Joint Commission International the day the standard is written, but on a continuing basis 25
  26. 26. Evidence of Performance is Available– Standards have multiple dimensions and thus have multiple sources of evidence – Policy – document review – Knowledge – staff training logs, interviews with staff – Practice – clinical observation, patient interviews – Documentation of practice – open and closed © Copyright, Joint Commission International record review– A good standard permits a convergent validity scoring process – all surveyors evaluating all types of evidence and reaching one score 26
  27. 27. Joint Commission International Standards– Organized Around Important Functions – Patient-Centered Standards – Access to Care and Continuity of Care – Patient and Family Rights – Assessment of Patients – Care of Patients © Copyright, Joint Commission International – Anesthesia and Surgical Care – Medication Management and Use – Patient and Family Education 27
  28. 28. JCI Standards, continued– Organized Around Important Functions – Organization Management Standards – Quality Improvement and Patient Safety – Prevention and Control of Infections – Governance, Leadership, and Direction – Facility Management and Safety – Staff Qualifications and Education © Copyright, Joint Commission International – Management of Communication and Information 28
  29. 29. 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 © Copyright, Joint Commission International potential vulnerabilities as far as patient quality and safety 29
  30. 30. International Patient Safety Goals and Tools– Represent 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 © Copyright, Joint Commission International IPSG to foster an atmosphere of continuous improvement is even more important 30
  31. 31. JCI International Patient Safety Goals 1. Identify patients correctly 2. Improve effective communication 3. Improve the safety of high-alert medications 4. Ensure right-site, right-patient, right-procedure surgery 5. Reduce the risk of health care-associated © Copyright, Joint Commission International infections 6. Reduce the risk of patient harm from falls 31
  32. 32. JCI’s Measurement Strategy– Accreditation is continuous– Accreditation status publicly disclosed– Complements existing standards requirements– International comparisons– Meets needs of multiple stakeholders– Develop and identify measures that address clinical and managerial dimensions © Copyright, Joint Commission International– Need for and rigor of data validation– Measurement system supported by IT platform– JCI currently has 20 performance measurement requirements 32
  33. 33. 33© Copyright, Joint Commission International
  34. 34. International Cardiac Surgery Benchmarking (ICSB) Project• Pilot program addressing international clinical cardiac indicators• Enables hospitals to evaluate the current status of their coronary artery bypass graft (CABG) and valve- related surgery risk-adjusted mortality rates• Encourages hospitals to implement and measure rates of improvement using the New York State © Copyright, Joint Commission International Department of Health (NYSDOH) Cardiac Surgery Reporting System (CSRS) as a model 34
  35. 35. ICSB Project Objectives• Participating hospitals will get information to help them improve quality of care and assess a patient’s risk factors before cardiac surgery• Multi-site and multi-country use of the ICSB assessment and reporting tool to guide organized quality improvement and benchmarking efforts• Long-term goal–to improve the outcomes of cardiac © Copyright, Joint Commission International surgical procedures in participating organizations 35
  36. 36. Speak Up™– Help Prevent Errors in Your Care– Help Avoid Mistakes in Your Surgery– Information for Living Organ Donors– Five Things You Can Do to Prevent Infection– Help Avoid Mistakes With Your Medicines– What You Should Know About Research Studies– Planning Your Follow-up Care– Help Prevent Medical Test Mistakes © Copyright, Joint Commission International– Know Your Rights– Understanding Your Doctors and Other Caregivers– What You Should Know About Pain Management 36
  37. 37. Sentinel Event Database– Sentinel Event database collects data from accredited organizations on errors that have occurred– Information in database led to the publication of Sentinel Event Alert, published by The Joint Commission– Sentinel Event Alerts highlight significant risk areas in care © Copyright, Joint Commission International– Offer suggestions and recommendations for mitigating risk– Latest Alert focuses on information technology 37
  38. 38. Sentinel Event Experience to Date Of 5632 sentinel events reviewed by the Joint Commission, January 1995 through December 2008: 741 Events of wrong site surgery 698 Inpatient suicides 631 Operative/post op complications 492 Events relating to medication errors 442 Deaths related to delay in treatment 341 Patient falls 218 Assault/rape/homicide 212 Retained foreign objects 189 Deaths of patients in restraints 175 Perinatal death/injury © Copyright, Joint Commission International 132 Transfusion-related events 113 Infection-related events 86 85 Deaths following elopement Anesthesia-related events = 5632 RCAs 85 Fires 992 “Other” 38 Client name/ Presentation Name/ 12pt - 38
  39. 39. Accreditation Represents a Risk Reduction Strategy– That an organization is doing the right things and doing them well;– Thereby significantly reducing the risk of harm in the delivery of care; and © Copyright, Joint Commission International– Optimizing the likelihood of good outcomes. 39
  40. 40. Accreditation The Value and Impact of 40© Copyright, Joint Commission International
  41. 41. Impact of Accreditation– What is the evidence that – Accreditation improves quality and safety of care? – High quality lowers cost of health care? – The cost of implementing accreditation standards is worth the achievable © Copyright, Joint Commission International benefit? 41
  42. 42. Impact of Accreditation (cont’d)– The process of Joint Commission International accreditation has set many of the fundamental principles that guide health care organizations today– Many of these principles are routine in health care today but were revolutionary in their time © Copyright, Joint Commission International 42
  43. 43. Impact of Accreditation: Some ExamplesMedical Records • First required in 1917, many considered the medical record unnecessary • Today the medical record is inarguably the central point of information gathering for treatment decisions, research, patient © Copyright, Joint Commission International monitoring, outcomes measurement, and even billing 43
  44. 44. Impact of Accreditation: Some ExamplesInfection Control Programs – In the mid-1950s, patients, especially surgery patients and newborns, acquired infections in epidemic proportions – In the 1950s, hospitals were required to appoint infection control committees to direct activities aimed at curbing epidemics of infections © Copyright, Joint Commission International – Infection control programs were created that reduced the spread of devastating infectious agents 44
  45. 45. Impact of Accreditation: Some ExamplesFire Safety – Non-smoking standards for hospitals were developed due to the adverse effects of passive non-smokers and significant fire hazardsAdvance Directives – Protects patients from a life or death they would not have wished – Requires organizations to establish Do-Not-Resuscitate (DNR) standards and request an advance directive from each patient so © Copyright, Joint Commission International the individual’s wishes can be documented in the patient chart – In the 1980s only 20% of hospitals addressed this issue; since the implementation of the standard, nearly 100% of accredited organizations are in compliance with the standard 45
  46. 46. Accreditation: The Value Equation– JCI has conducted descriptive research with a sample of accredited hospitals to determine the value of accreditation– Accredited hospitals report significant improvements in: – Leadership – Medical records management – Infection control © Copyright, Joint Commission International – Reduction in medication errors – Staff training and professional credentialing – Improved quality monitoring 46
  47. 47. Recent Studies Support the Value of Joint Commission Accreditation– Longo study showed that accreditation is a significant factor in whether facilities engaged in actions widely recognized to improve patient safety; advocates accreditation as a means for improving health care5– Health Affairs report indicated that Joint Commission accreditation requirements influenced hospitals’ efforts toward implementing patient safety initiatives6 © Copyright, Joint Commission International– Study in Hospital Topics found accreditation to be effective in driving efforts to reduce errors7 47
  48. 48. WHO World Alliance for Patient Safety © Copyright, Joint Commission Internationalto address the problem of patient safety worldwide 48
  49. 49. World Alliance for Patient Safety: Ten Action AreasGlobal Patient Safety Challenges : Solutions to improve1. Clean Care is Safer Care patient safety2. Safe Surgery Saves Lives High 5s Patients for Patient Safety Catalyse Technology for Patient Safety Research for Patient Safety countries’ action to achieve Knowledge Management © Copyright, Joint Commission International International safety of care Special projects: Classification for - Education Patient Safety (ICPS) - Radiotherapy - Rewarding excellenceReporting & Learning - When things go wrong - Vincristine sulphate
  50. 50. Solutions for Patient Safety 50© Copyright, Joint Commission International
  51. 51. Clean Care is Safer Care 51© Copyright, Joint Commission Resources
  52. 52. Patients for Patient Safety• A patient engagement initiative• Focus on individuals (“champions”), not organizations• Links to other World Alliance strands• Creation of regional groups © Copyright, Joint Commission Resources 52
  53. 53. Taxonomy for Patient Safety 53© Copyright, Joint Commission Resources
  54. 54. International Patient Safety Events Taxonomy• Cornerstone of patient safety communications © Copyright, Joint Commission Resources 54
  55. 55. Reporting and Learning y s afet a tient . int/p © Copyright, Joint Commission Resources .who n www la ble oAvai 55
  56. 56. Research for Patient Safety Harvard PracticeCanadian Adverse Medical Study Event Study 2004 1984 Danish Adverse Event Study 2001 Adverse events in French AdverseUtah Colorado British Hospitals Event Study 1999-2001 2004 Study 1992 © Copyright, Joint Commission Resources The Commonwealth Fund Survey 2005 Australian Quality in Healthcare Study 1992 Adverse Events in New Zealand 56 Study 2002
  57. 57. Technology for Patient Safety– “To identify and clarify the role and objectives of technology in improving patient safety both in the developed and developing world, and future directions (research, education, implementation) for the alliance regarding technology for © Copyright, Joint Commission Resources patient safety.” 57
  58. 58. High 5s Project Objective– To achieve significant, sustained, and measurable reduction in the occurrence of patient safety problems over 5 years in at least 7 countries and build an international, collaborative learning community that fosters the sharing of knowledge and experience in implementing innovative standardized operating protocols and © Copyright, Joint Commission Resources evaluating their impact. 58
  59. 59. High 5s Standardized Operating Protocols– Managing Concentrated Injectable Medicines (U.K.)– Assuring Medication Accuracy at Transitions in Care (Canada)– Performance of Correct Procedure at Correct Body Sites (U.S.)– Improved Hand Hygiene to Prevent Health Care- Associated Infections (New Zealand) (deferred) © Copyright, Joint Commission Resources– Communication During Patient Care Handovers (Australia) (deferred) 59
  60. 60. WHO Collaborating Centre for Patient Safety Solutions– Identify Current Regional Safety Problems and Solutions Available– Understand Regional Barriers to Solutions– Assess Risk of Solutions– Adapt Solutions to Local/Regional Needs © Copyright, Joint Commission International– Develop/Disseminate Solutions 60
  61. 61. DefinitionA Patient Safety Solution is anysystem design or intervention that hasdemonstrated the ability to prevent ormitigate patient harm stemming fromthe processes of health care. © Copyright, Joint Commission International 61
  62. 62. Topic Selection Process– Sentinel Event Topic Areas– Expert Panels– National Agencies and Governments– Professional societies and organizations– Patient and family advocacy organizations– Field reviews © Copyright, Joint Commission International– Open solicitations 62
  63. 63. © Copyright, Joint Commission International Confusing drug names is one of the most common causes of medication errors and is a worldwide concern. With tens ofthousands of drugs currently on the market, the potential for error created by confusing brand or generic drug names and packaging is significant. The recommendations focus on usingprotocols to reduce risks and ensuring prescription legibility or the use of preprinted orders or electronic prescribing. 63
  64. 64. The widespread and continuing failures to correctly identify patients © Copyright, Joint Commission International often leads to medication, transfusion and testing errors; wrong person procedures; and the discharge of infants to the wrong families. The recommendations place emphasis on methods for verifying patientidentity, including patient involvement in this process; standardization of identification methods across hospitals in a health care system; and patient participation in this confirmation; and use of protocols for distinguishing the identity of patients with the same name. 64
  65. 65. Gaps in hand-over (or hand-off) communication between patient care © Copyright, Joint Commission International units, and between and among care teams, can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient. The recommendations for improving patient hand-overs include using protocols for communicating critical information; providing opportunities for practitioners to ask and resolvequestions during the hand-over; and involving patients and families in the hand-over process. 65
  66. 66. Considered totally preventable, cases of wrong procedure or wrong site surgery are largely the result of miscommunication and unavailable, or © Copyright, Joint Commission International incorrect, information. A major contributing factor to these types of errors is the lack of a standardized preoperative process. Therecommendations to prevent these types of errors rely on the conduct of a preoperative verification process; marking of the operative site by the practitioner who will do the procedure; and having the team involved in the procedure take a “time out” immediately before starting the procedure to confirm patient identity, procedure, and operative site. 66
  67. 67. © Copyright, Joint Commission International While all drugs, biologics, vaccines and contrast media have adefined risk profile, concentrated electrolyte solutions that are used for injection are especially dangerous. The recommendations address standardization of the dosing, units of measure and terminology; and prevention of mix-ups of specific concentrated electrolyte solutions. 67
  68. 68. © Copyright, Joint Commission International Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient transition points. The recommendations address creation of the mostcomplete and accurate list of all medications the patient is currently taking— also called the “home” medication list; comparison of the list against theadmission, transfer and/or discharge orders when writing medication orders; and communication of the list to the next provider of care whenever the patient is transferred or discharged. 68
  69. 69. The design of tubing, catheters, and syringes currently in use is © Copyright, Joint Commission Internationalsuch that it is possible to inadvertently cause patient harm through connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route. The recommendations address the need for meticulous attention todetail when administering medications and feedings (i.e., the rightroute of administration), and when connecting devices to patients (i.e., using the right connection/tubing). 69
  70. 70. One of the biggest global concerns is the spread of Human © Copyright, Joint Commission International Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles.The recommendations address the need for prohibitions on the reuseof needles at health care facilities; periodic training of practitioners and other health care workers regarding infection control principles; education of patients and families regarding transmission of blood borne pathogens; and safe needle disposal practices. 70
  71. 71. One of the biggest global concerns is the spread of Human © Copyright, Joint Commission International Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles.The recommendations address the need for prohibitions on the reuseof needles at health care facilities; periodic training of practitioners and other health care workers regarding infection control principles; education of patients and families regarding transmission of blood borne pathogens; and safe needle disposal practices. 71
  72. 72. Next Set of Solutions Preventing Central Line Infections Communicating Critical Test Results Recognizing and Responding to Deteriorating Patients Preventing Pressure Ulcers Preventing Harm from Patient Falls © Copyright, Joint Commission International 72
  73. 73. Next Set of Solutions (cont’d)Prototype will target four audiences:– Government policy at ministry of health level– Health care organization at the CEO level– Clinician/provider levels– Patient and family level © Copyright, Joint Commission International 73
  74. 74. 74© Copyright, Joint Commission International