This document outlines the CBAHI standards and survey process. It discusses the structure of the new 3rd edition NHS standards, which are organized into 23 chapters. It introduces the concept of Essential Safety Requirements, which are critical standards that are more closely evaluated. The survey process has been updated to focus more on direct observation, interviews and tracers. Hospitals are given an accreditation decision of accredited, conditionally accredited, or denied based on their overall score and compliance with ESRs. Requirements for maintaining accreditation such as corrective action plans and self-assessments are also outlined.
JCI is the world’s leader in health care accreditation and the author and evaluator of the most rigorous international standards in quality and patient safety.
hospital_220_a
With its newly published 5th edition of JCI’s Accreditation Standards for Hospitals, JCI addresses the unique concerns of hospitals and academic medical centers, as well as the challenges of preserving quality care as patients move from inpatient to outpatient and other care providers.
Our unique tracer methodology provides the cornerstone of the JCI on-site survey, serving as a tool for surveyors and health care organizations to evaluate patients and systems in unprecedented depth. JCI separates itself from its competitors with innovations network accreditation, where similar organizations within a single system or larger entity can achieve accreditation efficiently through a single network application.
JCI is committed to keeping pace with the dynamics of global health care while remaining the standard bearer for its universally recognized Gold Seal of Approval®.
Rigorous process for developing international standards
Due to the expertise and scope of its international team, JCI is uniquely positioned to adapt leading global practices to the delivery of local care. Standards are developed and organized around important functions common to all health care organizations. In fact, the functional organization of standards is now the most widely used around the world and has been validated by scientific study, testing, and application.
Standards Advisory Panel
To maintain best practices, JCI turns to its Standards Advisory Panel, comprised of experienced physicians, nurses, administrators, and public-policy experts. The panel guides the development and revision process of the JCI accreditation standards. Panel members are from five major world regions: Latin America and the Caribbean, Asia and the Pacific Rim, the Middle East, Europe, and the United States. The panel’s recommendations are refined based on an international field review of the standards and input from experts and others with unique content knowledge.
JCI is the world’s leader in health care accreditation and the author and evaluator of the most rigorous international standards in quality and patient safety.
hospital_220_a
With its newly published 5th edition of JCI’s Accreditation Standards for Hospitals, JCI addresses the unique concerns of hospitals and academic medical centers, as well as the challenges of preserving quality care as patients move from inpatient to outpatient and other care providers.
Our unique tracer methodology provides the cornerstone of the JCI on-site survey, serving as a tool for surveyors and health care organizations to evaluate patients and systems in unprecedented depth. JCI separates itself from its competitors with innovations network accreditation, where similar organizations within a single system or larger entity can achieve accreditation efficiently through a single network application.
JCI is committed to keeping pace with the dynamics of global health care while remaining the standard bearer for its universally recognized Gold Seal of Approval®.
Rigorous process for developing international standards
Due to the expertise and scope of its international team, JCI is uniquely positioned to adapt leading global practices to the delivery of local care. Standards are developed and organized around important functions common to all health care organizations. In fact, the functional organization of standards is now the most widely used around the world and has been validated by scientific study, testing, and application.
Standards Advisory Panel
To maintain best practices, JCI turns to its Standards Advisory Panel, comprised of experienced physicians, nurses, administrators, and public-policy experts. The panel guides the development and revision process of the JCI accreditation standards. Panel members are from five major world regions: Latin America and the Caribbean, Asia and the Pacific Rim, the Middle East, Europe, and the United States. The panel’s recommendations are refined based on an international field review of the standards and input from experts and others with unique content knowledge.
Quality management in nursing professionSANJAY SIR
Quality improvement requires in any field to provide best services to the community in the health care system. it is uploaded to aware the the paramedics & nursing personnel to improve the quality care & helps educators to teach their students.
Credentialing refers to the process of collection and verification of the evidences of credentials of a doctor who is to be given the responsibility of
treating patients in the hospital. The process
ensures the authenticity of the details provided
by the healthcare practitioner or doctor.
An introductory overview of the basic concepts of Healthcare Quality, a starter for beginners.
Prepared in 2014 for the new staff of the Quality Management Department in King Saud University Medical City in Riyadh as a part of their capacity building plan.
Acknowledgments:
*Dr. Magdy Gamal Yousef, MBBCh, MS, CPHQ - for his contribution in the scientific content
**Ms. Maram Baksh, MS, CPHQ - for the design of the full HCQ capacity building plan in KSUMC
Risk Management has been a valuable and essential subject in projects and financial businesses but it is new to health care management. This presentation will help you understanding basics of Risk Managment.
Quality assurance is one of the important topic for our Nursing field this is important for M.Sc. Nursing Final Year students for the subject of management that will also help to all nurses either in the filed of clinical as well as education
Implementing CMS Hospital QAPI Guidelines for 2024Conference Panel
Explore the significance of Quality Assessment and Performance Improvement (QAPI) programs in Medicare-certified hospitals, focusing on the updated CMS standards and interpretive guidelines. Learn about essential requirements, assessment areas, and hospital leadership's role in ensuring compliance and enhancing patient safety.
Title: Understanding CMS Hospital QAPI Standards and Guidelines: Key Elements for Implementation and Compliance
Description: Explore the significance of Quality Assessment and Performance Improvement (QAPI) programs in Medicare-certified hospitals, focusing on the updated CMS standards and interpretive guidelines. Learn about essential requirements, areas of assessment, and the role of hospital leadership in ensuring compliance and enhancing patient safety.
Quality Assessment and Performance Improvement (QAPI) Conditions of Participation deficiencies rank among the top three cited issues for Medicare-certified hospitals, highlighting the critical need for robust QAPI programs. CMS emphasizes the pivotal role of well-designed and maintained QAPI initiatives in enhancing patient care quality, reducing medical errors, and fostering a safer healthcare environment.
Register,
https://conferencepanel.com/conference/cms-hospital-qapi-standards-2024
Quality management in nursing professionSANJAY SIR
Quality improvement requires in any field to provide best services to the community in the health care system. it is uploaded to aware the the paramedics & nursing personnel to improve the quality care & helps educators to teach their students.
Credentialing refers to the process of collection and verification of the evidences of credentials of a doctor who is to be given the responsibility of
treating patients in the hospital. The process
ensures the authenticity of the details provided
by the healthcare practitioner or doctor.
An introductory overview of the basic concepts of Healthcare Quality, a starter for beginners.
Prepared in 2014 for the new staff of the Quality Management Department in King Saud University Medical City in Riyadh as a part of their capacity building plan.
Acknowledgments:
*Dr. Magdy Gamal Yousef, MBBCh, MS, CPHQ - for his contribution in the scientific content
**Ms. Maram Baksh, MS, CPHQ - for the design of the full HCQ capacity building plan in KSUMC
Risk Management has been a valuable and essential subject in projects and financial businesses but it is new to health care management. This presentation will help you understanding basics of Risk Managment.
Quality assurance is one of the important topic for our Nursing field this is important for M.Sc. Nursing Final Year students for the subject of management that will also help to all nurses either in the filed of clinical as well as education
Implementing CMS Hospital QAPI Guidelines for 2024Conference Panel
Explore the significance of Quality Assessment and Performance Improvement (QAPI) programs in Medicare-certified hospitals, focusing on the updated CMS standards and interpretive guidelines. Learn about essential requirements, assessment areas, and hospital leadership's role in ensuring compliance and enhancing patient safety.
Title: Understanding CMS Hospital QAPI Standards and Guidelines: Key Elements for Implementation and Compliance
Description: Explore the significance of Quality Assessment and Performance Improvement (QAPI) programs in Medicare-certified hospitals, focusing on the updated CMS standards and interpretive guidelines. Learn about essential requirements, areas of assessment, and the role of hospital leadership in ensuring compliance and enhancing patient safety.
Quality Assessment and Performance Improvement (QAPI) Conditions of Participation deficiencies rank among the top three cited issues for Medicare-certified hospitals, highlighting the critical need for robust QAPI programs. CMS emphasizes the pivotal role of well-designed and maintained QAPI initiatives in enhancing patient care quality, reducing medical errors, and fostering a safer healthcare environment.
Register,
https://conferencepanel.com/conference/cms-hospital-qapi-standards-2024
Presentation by Carmel O'Brien, Chief Nurse and Quality Officer at East Leicestershire and Rutland Clinical Commissioning Group to the Patient and Public Engagement Group on 15th July 2015
Dissertation presentation: Study of the Process of Hospital Accreditation and Its Impact on Healthcare Facilities.
Presented By: Yasser Alsharif, Muwafag Kamash, Nasrat Esmat, Amer Tayeb
Supervised By: Dr. Mohammad Kamal Hussain
NABHSTANDARDS-VKS_AKA.ppt Components of Standards Development Multiple Inform...DelphyVarghese
Components of Standards Development
Multiple Information Sources
Scientific literature
JCI Standards
UK Healthcare Quality Standards
Thailand Standards
AHA Draft Standards
JCI Survey compliance data
Research Findings
Individual input from field experts and key stakeholders
ISO 9001-2000
A presentation on mastering key management concepts across projects, products, programs, and portfolios. Whether you're an aspiring manager or looking to enhance your skills, this session will provide you with the knowledge and tools to succeed in various management roles. Learn about the distinct lifecycles, methodologies, and essential skillsets needed to thrive in today's dynamic business environment.
Comparing Stability and Sustainability in Agile SystemsRob Healy
Copy of the presentation given at XP2024 based on a research paper.
In this paper we explain wat overwork is and the physical and mental health risks associated with it.
We then explore how overwork relates to system stability and inventory.
Finally there is a call to action for Team Leads / Scrum Masters / Managers to measure and monitor excess work for individual teams.
Public Speaking Tips to Help You Be A Strong Leader.pdfPinta Partners
In the realm of effective leadership, a multitude of skills come into play, but one stands out as both crucial and challenging: public speaking.
Public speaking transcends mere eloquence; it serves as the medium through which leaders articulate their vision, inspire action, and foster engagement. For leaders, refining public speaking skills is essential, elevating their ability to influence, persuade, and lead with resolute conviction. Here are some key tips to consider: https://joellandau.com/the-public-speaking-tips-to-help-you-be-a-stronger-leader/
Employment PracticesRegulation and Multinational CorporationsRoopaTemkar
Employment PracticesRegulation and Multinational Corporations
Strategic decision making within MNCs constrained or determined by the implementation of laws and codes of practice and by pressure from political actors. Managers in MNCs have to make choices that are shaped by gvmt. intervention and the local economy.
Enriching engagement with ethical review processesstrikingabalance
New ethics review processes at the University of Bath. Presented at the 8th World Conference on Research Integrity by Filipa Vance, Head of Research Governance and Compliance at the University of Bath. June 2024, Athens
Senior Project and Engineering Leader Jim Smith.pdfJim Smith
I am a Project and Engineering Leader with extensive experience as a Business Operations Leader, Technical Project Manager, Engineering Manager and Operations Experience for Domestic and International companies such as Electrolux, Carrier, and Deutz. I have developed new products using Stage Gate development/MS Project/JIRA, for the pro-duction of Medical Equipment, Large Commercial Refrigeration Systems, Appliances, HVAC, and Diesel engines.
My experience includes:
Managed customized engineered refrigeration system projects with high voltage power panels from quote to ship, coordinating actions between electrical engineering, mechanical design and application engineering, purchasing, production, test, quality assurance and field installation. Managed projects $25k to $1M per project; 4-8 per month. (Hussmann refrigeration)
Successfully developed the $15-20M yearly corporate capital strategy for manufacturing, with the Executive Team and key stakeholders. Created project scope and specifications, business case, ROI, managed project plans with key personnel for nine consumer product manufacturing and distribution sites; to support the company’s strategic sales plan.
Over 15 years of experience managing and developing cost improvement projects with key Stakeholders, site Manufacturing Engineers, Mechanical Engineers, Maintenance, and facility support personnel to optimize pro-duction operations, safety, EHS, and new product development. (BioLab, Deutz, Caire)
Experience working as a Technical Manager developing new products with chemical engineers and packaging engineers to enhance and reduce the cost of retail products. I have led the activities of multiple engineering groups with diverse backgrounds.
Great experience managing the product development of products which utilize complex electrical controls, high voltage power panels, product testing, and commissioning.
Created project scope, business case, ROI for multiple capital projects to support electrotechnical assembly and CPG goods. Identified project cost, risk, success criteria, and performed equipment qualifications. (Carrier, Electrolux, Biolab, Price, Hussmann)
Created detailed projects plans using MS Project, Gant charts in excel, and updated new product development in Jira for stakeholders and project team members including critical path.
Great knowledge of ISO9001, NFPA, OSHA regulations.
User level knowledge of MRP/SAP, MS Project, Powerpoint, Visio, Mastercontrol, JIRA, Power BI and Tableau.
I appreciate your consideration, and look forward to discussing this role with you, and how I can lead your company’s growth and profitability. I can be contacted via LinkedIn via phone or E Mail.
Jim Smith
678-993-7195
jimsmith30024@gmail.com
Specific ServPoints should be tailored for restaurants in all food service segments. Your ServPoints should be the centerpiece of brand delivery training (guest service) and align with your brand position and marketing initiatives, especially in high-labor-cost conditions.
408-784-7371
Foodservice Consulting + Design
The case study discusses the potential of drone delivery and the challenges that need to be addressed before it becomes widespread.
Key takeaways:
Drone delivery is in its early stages: Amazon's trial in the UK demonstrates the potential for faster deliveries, but it's still limited by regulations and technology.
Regulations are a major hurdle: Safety concerns around drone collisions with airplanes and people have led to restrictions on flight height and location.
Other challenges exist: Who will use drone delivery the most? Is it cost-effective compared to traditional delivery trucks?
Discussion questions:
Managerial challenges: Integrating drones requires planning for new infrastructure, training staff, and navigating regulations. There are also marketing and recruitment considerations specific to this technology.
External forces vary by country: Regulations, consumer acceptance, and infrastructure all differ between countries.
Demographics matter: Younger generations might be more receptive to drone delivery, while older populations might have concerns.
Stakeholders for Amazon: Customers, regulators, aviation authorities, and competitors are all stakeholders. Regulators likely hold the greatest influence as they determine the feasibility of drone delivery.
Integrity in leadership builds trust by ensuring consistency between words an...Ram V Chary
Integrity in leadership builds trust by ensuring consistency between words and actions, making leaders reliable and credible. It also ensures ethical decision-making, which fosters a positive organizational culture and promotes long-term success. #RamVChary
Org Design is a core skill to be mastered by management for any successful org change.
Org Topologies™ in its essence is a two-dimensional space with 16 distinctive boxes - atomic organizational archetypes. That space helps you to plot your current operating model by positioning individuals, departments, and teams on the map. This will give a profound understanding of the performance of your value-creating organizational ecosystem.
10. 1. Leadership
2. Human Resources
3. Medical Staff
4. Provision of Care
5. Nursing
6. Quality Management and Patient safety
7. Critical Care Services
8. Labor and Delivery
9. Emergency Care
10. Hemodialysis
11. Anesthesia
12. Patient and Family Rights
13. Operating Room
14. Radiology Services
15. Burn Care
16. Oncology and Radiotherapy
17. Specialized Care Services
18. Management of Information
19. Medical Records
20. Infection Prevention and Control
21. Medication Management
22. Laboratory
23. Facility Management and Safety
CBAHI –NHS 3rd Edition Chapters
11. • Standards related to HR in the former “LD” chapter have been
moved to a new separate chapter “HR”.
• “Medical Staff and Provision of Care” has been divided into
two chapters:
– Medical Staff: describes structure and organization of the
medical staff.
– Provision of Care: addresses the quality and safety of the
actual clinical care processes.
CBAHI –NHS 3rd Edition Major Changes
12. • Ambulatory Care” and the “Psychiatry” chapters have been
merged with the “Provision of Care” chapter to emphasize the
continuum of care.
CBAHI –NHS 3rd Edition Major Changes
13. • The CBAHI accreditation standards for hospitals
underwent an extensive review based on the past
experience.
• The changes in this new edition include:
– Chapters,
– Standards,
– Survey process,
– Essential Safety Requirements (ESRs),
– Scoring Guidelines,
– Accreditation Decision Rules, and
– Introduction of Tracers
CBAHI –NHS 3rd Edition Major Changes
14. Essential Safety Requirements (ESRs)
• Selected standards have been assigned as Essential Safety
Requirements. ESR
• ESRs are selected based on:
– Proximity of risk,
– Probability of harm,
– Severity of harm, and
– Number of patients at risk.
– Score will be the same as the other sub- standards
15. Examples Essential Safety Requirements (ESRs)
• HR.5 The hospital has a process for proper credentialing of
staff members licensed to provide patient care.
• MS.6 The hospital has clearly defined and documented
processes used to credential, appoint, and grant clinical
privileges to medical staff.
• MS.9 Medical staff leaders make use of the data and
information resulting from the medical staff performance
review.
• PC.26 Patients at risk for developing venous
thromboembolism are identified and managed.
• PC.28 Policies and procedures guide the care of psychiatric
patients.
17. • Support CBAHI Surveyors in the accreditation process .
• It is the operational manual for the CBAHI surveyors
• It covers the technical protocols, sample agenda, activity
requirements as well as the forms used during the
execution of surveys.
17
Hospital Accreditation Guide - HAG
18. Hospital Accreditation Guide - HAG
All the resources that hospitals need for
preparing for Accreditation are available
online.
SUPPORT: hospital preparation for accreditation surveys
18
20. On-Site Survey Activities
Opening
Conference
Closed Medical
Record Review
Personnel File
Review
Formal/committee
Interviews
Medical Exec
P&T
Infection Control
Safety
Quality & Data session
Contracted Services
Building tour
Unit visit
Staff interview
Observation
Open medical record
Documented Evidence
Exit Conference
Leadership Interview
Document
Review
20
21. New Survey Process Statistics
21
21%
5%
10%
59%
5%
0%
Document Review
Closed Medical Record
Review
Personnel File Review
Unit Visit
Formal/Committees
Interviews
Leadership Interview
23. Scoring Guidelines
• Each sub-standard has equal weight and is scored on a three
point scale as follows:
0 = < 50% Compliance
1 = >= 50% - < 80% Compliance
2 = >= 80% Compliance
N/A = Not Applicable
23
25. Accreditation Policies
• Accreditation decisions are communicated to the
hospital within (30) days after the conclusion of the
survey visit.
• Accreditation decision making process is basically
based on:
• The findings of the survey team members as recorded in
the survey report.
• Discussions regarding the survey findings between the
surveyor and the specialty team leader (STL).
• Review of the draft report by the participating hospital
for feedback.
• Review/discussion during the meeting of the
Accreditation Decision Committee (ADC).
25
26. Accreditation Policies
• Other factors are:
• Criticality of the non-compliant standard(s), i.e.
the degree of severity and immediacy of risk to
patients, visitors or staff safety.
• Any concerns regarding the compliance of the
hospital with the Essential Safety Requirements
(ESRs).
26
27. Accreditation Decision Rules
• Accredited:
• Overall score 85% or above and
• All essential safety requirements are in
satisfactory compliance and
• No other issues of concern related to the safety
of patients, visitors or staff.
27
28. Accreditation Decision Rules
• Conditional Accreditation:
• Overall score 75% or above and less than 85%
and/or
• Some of the essential safety requirements (but
not exceeding 25% of them) are not in
satisfactory compliance.
28
29. Accreditation Decision Rules
• Preliminary Denial of Accreditation (PDA):
• Presence of an immediate threat to the safety that is observed
during the on-site survey.
• Significant noncompliance with the accreditation standards at the
time of the on-site survey.
• Failure of timely submission of the post survey requirements after
conditional accreditation.
• The hospital has received conditional accreditation and was
subjected to a follow up focused survey but still could not meet the
requirements for accreditation.
• Reasonable evidence exists of fraud, plagiarism, or falsified
information related to the accreditation process
• Refusal by the hospital to receive the survey team and conduct a
survey.
29
30. Accreditation Decision Rules
• Denial of Accreditation:
• Overall score less than 75% and/or
• More than 25% of the essential safety
requirements are not in satisfactory compliance.
30
31. Appeal against Accreditation Decision
• A surveyed healthcare facility can appeal against the
following accreditation outcomes:
• Preliminary Denial of Accreditation (provided it is not
due to failure of timely submission of the post survey
requirements after granting accreditation or after
conditional accreditation, or due to the facility remains
conditionally accredited after a follow up focused
survey).
• Suspension/Revocation of Accreditation.
• All appeals shall be made within maximum of (15)
calendar days from receiving the official survey
report
31
32. Appeal against Accreditation Decision
• Grounds for appeals
• Relevant and significant information which was available
to the survey team was not considered in the making of
the accreditation decision.
• The report of the surveyors(s) was inconsistent with the
information presented to the survey team.
• Perceived bias of a surveyor(s).
• Information provided by the survey team was not duly
considered in the survey report.
• The outcome of the appeal –if comes in favor of the
appealer- will result in changing the accreditation status.
• Appeals that will not result in changing the status of
accreditation will not be considered by CBAHI.
32
34. Standing Requirements for Accreditation Maintenance
• Corrective Action Plan (CAP)
• When accreditation is awarded, a (CAP) addressing all standards
that were not in satisfactory compliance should be received within
(120) days from the date of the accreditation decision
• Standards Compliance Progress Report (SPR)
• When a hospital is conditionally accredited, an (SPR) should be
received within (60) days from the date of the accreditation
decision.
• The hospital compliance is going to be validated through a follow up
focused survey within (30) days from the date of receiving the SPR.
• Midterm Self-Assessment
• Accredited hospitals are required to participate in a mid-cycle self-
evaluation of standards compliance, Fifteen months from the date
of accreditation awarding.
34