John Sweeney, Director, Healthcare Informed

JCI Accreditation –
International Standards of
Excellence for Primary Care

John Sweeney, Director HCI

© Joint Commission International
Partner, Ireland

1910

Ernest Codman

1. Each hospital should have a medical staff.
2. The members of the medical staff should be
chosen based on graduation from medical
school, competency, and character.
3. There should be regular staff meetings to
review cases.


Ernest Codman

4. Medical records should be written and filed
for all cases.

5. Each hospital should have a clinical
laboratory and radiology section.


Ernest Codman

 Waldorf Astoria New York
 89 of 692
 Burned

 Unable to demonstrate Quality of Care
 No framework for what that is ….

 50 years….

Today


Building Control Authority Environmental Protection Agency Radiological Protection Institute of Ireland
Health & Safety Authority of Ireland Food Safety Authority of Ireland (EHO's)Pharmaceutical Society of
Ireland Health Services Executive CORU - Health and Social Care Professionals HIQA - Infection
Control Mental Health Commission National Disability Authority Clinical Indemnity Scheme Irish Medical
Council An Bord Altranais Opticians Board Dental Council Irish Medicines Board Irish Blood Transfusion
Service Royal College of Physicians in Ireland Faculty of Occupational Medicine Faculty of Paediatrics
Faculty of Public Health Medicine Institute of Obstetricians & Gynaecologists Royal College of
Surgeons in Ireland Faculty of Dentistry Faculty of Radiologists Irish College of Anaesthetists Irish
College of General Practitioners in Ireland Irish College of Psychiatrists Irish College of
Ophthalmologists Irish Society of Chartered Physiotherapists National Treatment Private Health
Insurance Purchase Fund Joint Assessment Group (GI )HIQA Pre-Hospital Emergency Care Council
Fire Officers Excellence Ireland National Standards Authority of Ireland Joint Commission International

CHKS Accreditation Centre for the Development of Nursing Policy and Practice, University of Leeds
Irish National Accreditation Board Clinical Pathology Accreditation (UK) Academy of Medical Laboratory
Science National Council for the Professional Development of Nursing and Midwifery NERA - National
Employment Rights Authority

2006 – 75%
Gaps?


Accreditation – A Definition

 Voluntary Process
 Centers of Excellence
 Framework for Clinical Care +
 Demonstrable Evidence of Quality (VHI)
 Not for all – NH – 3 of 700+

9

JCI

The Joint Commission
• Leading accrediting body for health
Health Care Informed (HCI) care institutions in the US
• Founded in 1951
• Quality, Risk and Regulation
• >19,000 accredited institutions
• Ireland and Australia
• Team of 20 MD including R&D
• Compliance– HIQA, IMB, ISO, ACHS Transforming
• Founded in 2005 patient safety
and quality of
care

JCI

• JCI is the international arm of the Joint Commission
• Framework for Centers of Excellence
• Work with health care orgs, NGOs, and governments
• 400+ JCI accredited organizations – 85 Countries
• Ireland 1999
10

JC Accreditation

 Mayo Clinic - Cleveland Clinic – John Hopkins -
Mount Sinai Medical Center – Mass. Gen Hospital
 Ireland (22 +)
– Mater Private, Hermitage Clinic, Blackrock,
Bon Secours, Galway Clinic, St Vincent’s UH,
VHI Homecare, Ambulance Services, LTC….
 Primary Care – Spain, Brazil, UAE, Singapore


Primary Care Accreditation

Community Involvement and Integration
Management of the Processes of Care
Patient and Family Rights
Assessment of Patients
Care of Patients
Patient and Family Education

Management Structure and Leadership

12

Primary Care Accreditation

Management of Information
Facility Management and Safety
Staff Qualifications and Education
Surveillance, Prevention, and Control of Infection
Quality Improvement and Patient Safety
Adverse Event Identification, Analysis, and

Prevention

13

14


International Patient Safety Goals

1. Identify Patients Correctly
2. Improve Effective Communications
3. Improve the Safety of High-Alert, High Risk
Medications
4. Eliminate Wrong-side, Wrong-patient, Wrong-
procedure Surgery

5. Reduce the Risk of Health Care-acquired Infections
6. Reduce the Risk of Patient Harm Resulting from Falls

Measures for Improvement
 Clinical Measure: associated with the delivery of health
care; may be diagnosis or procedure specific
 Health Status Measure: addresses the functional well-
being of specific populations
 Patient Satisfaction Measure: focus on the delivery of
clinical care from the patient’s, family’s or caregiver’s
perspective
 Financial/Administrative Measures: addresses
organisational structure, utilization rates, operations or
financial management


Tracer Evaluation

An effective way to assess a healthcare
organization’s performance of care and the
services provided as viewed or
experienced by the patient.


JCI Network

 Communication - Newsletters
 Education and Support
 Network Meetings
 Leadership Seminar – Patient Safety
 Information Exchange
 Quality Initiatives

 Promotion

What does it Accomplish?
 Improves Patient Care – Peer Review
 Continuous – Centres of Excellence
 Increase efficiency/reduce costs
 Improve the management of business services
 Enhance staff recruitment and retention
 Public Confidence - Reputation

 Other Stakeholders - Reputation

Does it Work?

“A better way of structuring how we
provide care and run our business”
Nicky Jermyn, CEO St Vincent’s University
Hospital


Tomorrow ..


John Sweeney, Director, Healthcare Informed

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