A complimentary publication exclusively for JCI-accredited organizations, dedicated solely to increasing the benefit of JCI accreditation membership.

Transcription

1 A complimentary publication exclusively for JCI-accredited organizations, dedicated solely to increasing the benefit of JCI accreditation membership. Welcome to JCI Accreditation Exclusive! As the name implies, this quarterly electronic bulletin is created exclusively for JCI-accredited organizations like yours. The goal of JCI Accreditation Exclusive is to keep you in compliance with quality and patient safety, as well as for your next survey, by featuring topics of relevance to you and your organization. We hope you enjoy JCI Accreditation Exclusive. Your comments, questions and suggestions are always welcome. Please send all comments to Anna Hanuszewicz, Marketing Manager, JCI/JCR at And, as always, congratulations on achieving JCI s Gold Seal of Approval! Featured in this issue: Implementation of the JCI Library of Measures JCI Success Story Eka Hospital BSD, Jakarta, Indonesia Implementation of the Joint Commission International Library of Measures The International Library of Measures is a first step in a multi-year effort to raise the bar on QPS standards requirements and bring JCI accreditation to the next level. In addition, JCI has undertaken several actions to strengthen our commitment to support accredited organizations in the pursuit of a robust quality improvement and patient safety program. In January of this year, a Measurement Specialist joined the Accreditation and Standards departments. Over the next several weeks, JCI will be asking for input from organizations in the form of a survey that will address the following: Most frequently selected measures Overlap with other measurement requirements Use of similar measures but differences in some data definitions, etc. Most common selection issues Organizations for which none or few measures are applicable What types of education and/or assistance is needed

2 Based on the results of the survey, the content of the Library will be refined through possible modification of some measures (if appropriate), addition of other tested measures that are commonly used in other countries, and development of translation tables as needed for the most frequently selected measures. In addition, JCI expects to plan and develop educational support and data collection tools to help assist organizations in their data collection efforts. All of this takes time. As a result, JCI will be phasing in the full implementation of the Library. Before introducing how the phase-in will occur, a quick overview of the relevant requirements in the Joint Commission International Accreditation Hospital Survey Process Guide, 4 th Edition would be helpful. The standard and measurable elements that apply include: QPS.3.1 The organization s leaders identify key measures for each of the organization s clinical structures, processes, and outcomes. ME#1 - The clinical leaders identify key measures for each clinical area identified in 1) through 11) in the intent statement. ME#2 - At least 5 of the 11 required clinical measures are selected from the Joint Commission International Library of Measures. Scoring QPS.3.1, ME#1 At all times there must be active measurement in all of the 11 clinical areas identified in ME#1 For initial surveys there is measurement in all 11 clinical areas, however, only 4 months of data is necessary for a fully met score For triennial surveys there is measurement in all 11 clinical areas with 12 months of data necessary for a fully met score Library measures will replace or be added to one or more of the 11 clinical areas during 2011 At all times during 2011 there is continuous measurement in all 11 clinical areas identified in ME#1 The following four tables describe the phasing in process for the Library requirements (QPS.3.1) that will occur in 2011 and identify the expectations for the next four quarters

3 2011 Quarter 1 (January through March) Organization in process of reviewing the Library of Measures. Library measures are shared with appropriate staff. Based on population and services provided, leaders determine library measures that match services and are important to care provision. Process for selection from the Library of Measures is underway, however, does not involve clinical leaders, or is limited to the quality department or a small number of the expected clinical departments. Organization has done nothing with the measures/library. Organization assesses if data are currently being collected for other purposes. Note: Score at Measurable Element # Quarter 2 (April through June) Leaders approve preliminary set of selected measures from the Library. Negotiation with JCI Central Office if selection is problematic. Organization develops data collection methodology. The selection process is underway; however, the preliminary set of measures selected from the Library is not ready for leadership review. Organization has not identified a preliminary set of measures from the Library nor contacted JCI Central Office with a problem. Test collection methodology. Note: Score at Measurable Element #2

4 2011 Quarter 3 (July through September) Organization begins to collect data on measures chosen from the Library. Organization begins to collect data on some of the measures chosen from the Library. No data has been collected on the measures from the Library. Note: Score at Measurable Element # Quarter 4 (October through December) Organization has data for all five of the chosen measures from the Library. Organization has data for less than five of the chosen measures from the Library. No data has been collected on the measures from the Library. Note: Score at Measurable Element #6 Some specialty organizations, such as pediatric cancer centers or ophthalmology hospitals, may find that none or only one or two of the 36 measures are appropriate to the services they provide. In other circumstances, organizations may be collecting government or ministry required measures that are similar but not exactly the same as the measures contained in the Library. In such cases, organizations will be responsible for contacting JCI Central Office to notify them PRIOR TO their survey when one or more of these issues occur. JCI Central Office staff will review each situation on a case-by-case basis. Accreditation programs around the world are moving toward more objective measurements of quality and patient safety. Measures provide health care professionals and organizations with valuable information about their performance. The inclusion of the Joint Commission International Library of Measures in the Joint Commission International Accreditation Hospital Survey Process Guide, 4 th Edition is the first step in beginning to standardize measurement among organizations. By standardizing the measures that are collected, and the details of how they are collected, organizations can use this information to make comparisons with other organizations or with themselves over time. Comparisons help organizations see where they may be falling short and when processes may be breaking down; thus helping to facilitate improved performance. Over time, the on-

5 site evaluation process will be adjusted to reflect priority evaluation issues gleaned from measurement data. All of this requires reduction in the variations between organizations in terms of what they collect and how they collect it. Accreditation becomes continuous when a flow of objective data comes to JCI between on-site evaluations. JCI Success Story Eka Hospital, BSD, Jakarta, Indonesia Eka Hospital BSD is a private general hospital near Jakarta, Indonesia. It is part of a small health system that includes 40 outpatient clinics and Eka Hospital PKU in Sumatra. The hospital also serves as a referral center in neurology, cardiology, women s and children s health, and minimally invasive surgery. Since opening its doors in August 2008, Eka Hospital BSD has adhered to the highest standards in the provision of care to become a prominent hospital in Indonesia. The hospital received full certification from the Ministry of Health of the Republic of Indonesia within its first year of operation. In 2010, Eka Hospital BSD became one of the few hospitals in the region to achieve JCI accreditation. According to hospital spokesperson Sumiwaty Phan, JCI accreditation is further testament to Eka Hospital s commitment to patient safety. JCI accreditation is in line with our vision and mission, and very applicable to our unique culture. After going through the whole accreditation process, we understand why JCI is the benchmark for other accreditation standards. It is relevant and lasting. As a result of becoming JCI accredited Eka Hospital has seen enhancements in all aspects of service. Within the span of a year: Patient satisfaction has increased and staff morale has improved Changes in hospital management have strengthened the organizational structure Adverse event reports have declined from 18 per month to 1 incident Rates of phlebitis and decubitus ulcers have declined Staff compliance with hand washing has increased A non-punitive culture has replaced a culture of blame Being open and truthful about the delivery of care helps to identify potential areas for improvement, allows for better care and safety, and can reduce the overall cost of patient care, says Mr. Phan. Most importantly, the patient is no longer treated only as a party receiving a service, but also a part of the treatment plan.

6 Eka Hospital s community was also excited and proud of its achievement. Mr. Phan reports that the community was aware and observant of Eka Hospital and all its work toward JCI accreditation. The day we received confirmation, the word of mouth in the community spread before the formal announcement. In addition, Eka Hospital also hopes to inspire other hospitals in Indonesia to improve the quality of services related to patient safety as it works to provide better health care throughout the region. Eka Hospital is proud to be a new member of JCI s prestigious list of accredited hospitals. This milestone has confirmed that we have the right culture, attitude, and tools to provide better care for our patients, concludes Mr. Phan. The journey to provide better health care does not stop here. As a part of the JCI community, we will continuously strive to provide a true world-class standard of care. Visit Eka Hospital BSD on the web: