JCI Introduction ppt

1. JCIA Update
(April – May 2011)

2. KFSH&RC Mission
JCIA accreditation is designed to create that culture.
KFSH&RC provides the highest
level of specialized healthcare in
an integrated education and
research setting.
It is important to have a culture of :
Quality
Patient safety
Continuous Improvement

3.  2008 JCIA survey visit findings
 Standards Changes
 Medical Quality Directors Role
Objectives

4. 4
2008 JCIA Survey visit findings

5.  H&P form (Admission Notes) use.
 Procedural Sedation Assessment form
completion (Endoscopy).
 Pain documentation.
 D4 Chronic Patients Weekly Assessment.
2008 JCIA Survey visit findings
Documentation

6.  Authentication of telephone orders.
 PRN order for Restraint.
 Inconsistency in ASA score documented for
the same patient.
 Renewed orders completion (e.g. cont
fentanyl)
2008 JCIA Survey visit findings
Documentation

7.  Consultants co-signature on Residents
entries as hospital policy states
 Date documentation in the progress notes
 Significant Medical Record Documentation
issues: Timeliness, Eligibility, Completeness
2008 JCIA Survey visit findings
Documentation

8.  ASA Score of III accepted for procedural
sedation in Outpatient w/o explanation
 Inconsistency in the location of documenting
site marking (tooth) in dental clinic
 Patient discharged from post anesthesia unit
w/o physician order
2008 JCIA Survey visit findings
Practice & Documentation

9. Quality Management is currently
working with concerned departments
and staff to implement the required
policies & processes for the standards
changes
Standards Changes

10.  Heart Failure (HF)
 Stroke (STK)
 Children’s Asthma Care (CAC)
 Hospital-Based Inpatient Psychiatric Services (HBIPS)
 Perinatal Care (PC)
 Pneumonia (PN)
 Surgical Care Improvement Project (SCIP)
 Venous Thromboembolism (VTE)
 Acute Myocardial infarction (AMI)
 Nursing Sensitive care (NSC)
(International Library of
Measures)
At least 5 Clinical
Measures
should be chosen from
International
Library of Measures

11.  IPSG – stay the same but more emphasis on monitoring
1. Identify Patients Correctly
2. Improve Effective Communication
3. Improve the Safety of High-Alert Medications (IPP list)
4. Ensure Correct Site , Correct- Procedure , Correct –
Patient Surgery
5. Reduce the Risk of Health Care Associated Infections
6. Reduce the risk of patient harm resulting from falls
Standards Changes
(International Patient Safety Goals (IPSG))

12. (High Alert Medication Policy)

13. (High Alert Medication Policy)

14. Standards Changes
 Patient’s right to seek a second opinion without fear
 Consent is obtained in a language the patient can
understand
 Process to respond to patient’s request for additional
information on the practitioner
 The organization obtains informed consent from live
donors
Standards Changes
(Patient and Family Rights – PFR)

15. Standards Changes
 Patient’s right to seek a second opinion without fear
 Consent is obtained in a language the patient can
understand
 Process to respond to patient’s request for
additional information on the practitioner
 The organization obtains informed consent from
live donors
Standards Changes
(Patient and Family Rights – PFR)

16. Standards Changes
(Access to Care and Continuity of
Care – ACC)
 Patients with emergent, needs are given priority for
assessment and treatment.
 The clinical records of outpatients receiving continuing
care contain a summary of all significant diagnoses,
drug allergies…etc
 Follow-up process for patients who leave against
medical advice.
 Planning to meet the patients’ transportation needs.
 Medication reconciliation upon admission.
Standards Changes
(Access to Care and Continuity of
Care – ACC)

17. Standards Changes
(Care Of Patient –COP)
 The planned care is documented in the record in
the form of measurable progress (goals) & updated
based on assessment
 The care planned is reviewed and verified by the
responsible physician.

18. Standards Changes
(Aesthesia & Surgical Care – ASC)
 The post-surgical plan is documented by the
responsible surgeon or verified by the responsible
surgeon
 The plans of care are documented within 24 hours
of surgery.
 The anesthesiologist are identified in the patient’s
anesthesia record.

19. Standards Changes
(Staff Qualification and Education-SQE)
 Each medical staff member provides only those
services that have been permitted by the
organization.
 Have a uniform process (defined by organization
policy for ongoing professional practice evaluation &
(at least) annual review on quality & safety of
services

20. Standards Changes
(Staff Qualification and Education-SQE)
 Uses comparative data such as benchmarking to
literature-based medicine.
 Use conclusions of in-depth analysis of known
complications as applicable.
 Feedback to staff.

21. Reinforce the following to department members:
 Patient Safety.
 Safety reporting (SRS).
 Applying Infection Control Measures.
 Promote the Just culture.
Your role as a Quality Director

22. Documentation :
(Not documented, Not completely done !!)
 Identify documentation compliance issues in your
area (i.e. insufficient computers, training..etc ) and
work with Chairman for solutions.
 Review tracer reports & Quarterly documentation
reports. Discuss results with the concerned staff.
Your role as a Quality Director

23. Medical Staff files, Ensure that :
 Staff privileges are up to date
 Saudi Commission registration completed
 Life Support certification is completed
 Fire training completed
 Evaluations
Your role as a Quality Director
Reference: Joint Commission
International Accreditation Hospital
Survey Process Guide
Page 67

24. Departmental education on :
 New JCIA standards
 Hospital policies related to physicians.
Your role as a Quality Director

25.  Help directors to provide JCIA visit update in
departments’ meetings.
 Provide Educational material for directors.
 Prepare Readiness Tips.
Quality Management Educational Role

26. Thank You