JCI Overview Summary Update. Patcharin Boonyarungsun, Ph.D Director of Total Quality and Cost Improvement, Bangkok Hospital Head Quarter

Transcription

1 JCI Overview Summary Update Patcharin Boonyarungsun, Ph.D Director of Total Quality and Cost Improvement, Bangkok Hospital Head Quarter

2 Measurement : Measurable Elements Policies &Procedures Process Implementation Training Records Medical Record Outcome

3 Focus on Patient-Centered Care Supporting Organizational Management Patient - Centered

4 Patient Centered Standards 1. International Patient Safety Goals (IPSG) 2. Access to Care and Continuity of Care(ACC) 3. Patient and Family Rights(PFR) 4. Assessment of Patients(AOP) 5. Care of Patients(COP) 6. Anesthesia and Surgical Care(ASC) 7. Medication Management and Use (MMU) 8. Patient and Family Education(PFE)

5 Health Care Organization and Management Standards 9. Quality Improvement and Patient Safety 10. Prevention and Control of Infections 11. Governance, Leadership, and Direction 12. Facility Management and Safety 13. Staff Qualifications and Education 14. Management of Information Total Quality & Cost Improvement

6 Suggestions from JCI-accredited organizations, JCI surveyors and consultants, and the JCI Standards Advisory Panel for patient safety and quality of care issues not addressed in the 5th edition hospital standards; Communications with JCI-accredited organizations, JCI surveyors and consultants, and JCI staff regarding the need for clarification of requirements and expectations for specific standards; and Evolving health care practices and the changing health care environment.

7 Requirement changes (compared to their 5th edition versions), Some standards are new to the 6th edition, Revised for the purpose of clarifying expectations, combining similar requirements, and/or providing additional examples in the intents.

8 Chapter Standard Change New Standards New ME IPSG ACC 10 5 PFR 10 5 AOP COP 14 6 ASC 6 2 MMU PFE 1 1 QPS 6 5 PCI GLD 10 5 FMS SQE MOI Total

9 1. IPSG.6.1 :require screening outpatients for fall risk; 2. AOP : POCT 3. MMU.1.1 : organizations to develop and implement a program for antibiotic stewardship 4. PCI.8.2 : the need for hospitals to respond to the presentation of global communicable diseases 5. FMS : identifying the need for a preconstruction risk assessment (that is complimentary but different to PCI.7.5 an infection control risk assessment)

10 6. SQE : address staff vaccinations and developing strategies for minimizing patient exposure to health care associated infections, the hospital is responsible for identifying strategies that reduce the risk of exposure to patients of infectious diseases from unvaccinated staff 7. MOI : practice of copy-and-paste in organizations using electronic medical records 8. MOI.14 : the hospital to develop, maintain, and test a program for response to planned and unplanned downtime

11 Adds language to intent to clarify that two identifiers may be different for inpatients vs. outpatients Changes ME 3 to clarify requirements for hospitals to ensure correct identification of patients with special circumstances : OPD/ER might be different from inpatient Remember food trays, breast milk, etc.

12 Clarify communication concerns and tools that can be used IPSG.2.1 references new standard AOP related to critical results of POCT IPSG.2.2, ME 2 - Clarifies that standardized forms, tools, or methods are used to support IPSG.2.2 IPSG.2.2, ME 3 - Specify that adverse event data are tracked and used to identify improvements for handover communications.

13 Revises language in the intent to clarify definition of high-alert medications Revises IPSG.3, MEs 2 and 3 to separate requirements for high alert medications from look-alike/sound-alike medications Clarifies in IPSG.3.1, ME 3 the requirement to identify patient care units where concentrated electrolytes are necessary in their concentrated form

14 IPSG.4, ME 1 Previously ME 3 in 5th edition Adds blood products and implantable medical devices as items to verify as part of the Preoperative Verification Process Adds language : an X may not be ideal for use as the mark for the surgical/invasive site

15 Separates IPSG.6 (5th edition) into two standards (IPSG.6 and IPSG.6.1) to address inpatients and outpatients separately Adds language to IPSG.6, ME 1 to clarify that fall risk assessment tools and methods are appropriate to patient population Adds requirement to IPSG.6, ME 3 for fall risk interventions to be documented

16 Requirement Change: ACC.1 New ME 3 If the patient s needs do not match the hospital s mission and resources, the hospital will transfer, refer, or assist the patient in identifying and/or obtaining appropriate sources of care. Relates to patient-centered care

17 ACC.1.1 : Requirement Change PCI standards : global infections and segregating/isolating patients as needed. Clarifies in the intent that a recognized triage process is used in outpatient urgent/ immediate care settings as well as the emergency department. New ME 1 The hospital uses a recognized triage process that includes early recognition of communicable diseases, to prioritize patients with immediate needs.

18 ACC.2.2 : Requirement Change New ME 1 On admission as an inpatient, the patient and family receive education and orientation to the inpatient ward

19 ACC.4.4 : Clarification Clarifies requirements of outpatient profiles Identifies that the profile is required in both hard copy and electronic records Identifies the need for the information to be readily available and easily retrieved

20 ACC.6 : Requirement Change New ME 3 Staff responsible for monitoring the patient or providing other patient care during transport have the qualifications required for the type of patient being transferred. (Also see ACC.5.1, ME 2) Applies to transfer out in vehicles Could require Paramedics, Nurses, or Physicians Remember monitors, defibrillators, meds, etc. Remember to standardize transfers also within the building especially for critical patients

21 Requirement Changes: AOP.1.7 Modified ME 1 Dying patients are assessed and reassessed for symptoms, conditions, and health care needs, as indicated by and according to their identified needs. New ME 2 Dying patients and their families are assessed, and reassessed as applicable, for spiritual, psychosocial, and support service needs, as appropriate and according to their individualized needs and cultural preferences. As appropriate added to ME as some elements may not be acceptable in some cultures.

22 New Standard: AOP Moves requirement for oversight of point of care testing (POCT) from AOP.5.1 (5th edition) into this new standard. ME 1 The person responsible for managing the laboratory services, or designee, provides oversight and supervision of the POCT program. ME 2 Staff performing point of care testing have the required qualifications and training and are competent to perform POCT

23 New Standard: AOP ME 3 The POCT program includes a defined process for reporting abnormal test results, including reporting of critical results. ME 4 The POCT program includes quality control performance, documentation, and evaluation. ME 5 The POCT program is monitored and evaluated and included in quality improvement activities

24 AOP.6.3 : Requirement Change Adds language to the intent clarifying the need for safe use of diagnostic imaging. Adds language to ME 1 requiring a comprehensive radiation safety program that includes both patients and staff. New ME 2 The radiation safety program includes education about dosing in imaging departments

25 AOP.6.3 : Requirement Change New ME 3 Protocols that identify the maximum dose of radiation for each type of study are adopted and implemented. Adds a requirement to ME 6 to provide reports to the hospital safety structure

26 COP.2.2 : Requirement Change Clarifying requirements for the safe use of texting orders, if used by the hospital. New ME 2 The process identifies orders that may be received verbally, via telephone, and via text. New ME 5 requires hospital to ensure process secure platform that includes 7 elements New ME 6 requires hospitals using text messaging to collect data and monitor the process. Process must comply with MMU.4 and MMU.4.1

27 Clarification: COP.3 Clarifies that monitoring high risk patients includes proper use of alarms Adds language to include the following additional special populations: care of patients at risk for suicide; care of patients receiving an organ or tissue transplant; and care of living organ donor patients Clarifies that tools used to help direct care may include guidelines and/or procedures ME 4 clarifies requirements related to additional risks ME 5 clarifies requirements for monitoring

28 Miscellaneous Clarifications COP.2.3 Clarifies in standard and ME 1 : orders and treatments are carried out and documented COP.4 Clarifies the requirement : food brought in by family is stored under conditions to prevent contamination

29 Clarifications: COP.8 through COP.9.3 COP.8.1 New ME 1 to identify requirement for infrastructure to support Transplant Program COP.8.2 Adds infection control and rehabilitative services COP.8.4 Clarifies that transplant candidate must be clinically, socially and psychologically suitable COP.8.5, ME 4 Clarifies requirements for disclosing 1-year survival rates COP.8.5, ME 5 Adds requirement to disclose potential rejections rates

30 Clarifications: COP.8 through COP.9.3 COP.8.6, MEs 3 and 4 clarify that the information related to verifying blood type and compatibility is done by two people and documented is documented COP.8.7, ME 4 clarifies who can perform the psychological evaluation of the transplant candidate COP.9 adds language to the standard and ME 1 regarding the need for the living organ donor program to meet laws and regulations COP.9.2, ME 5 adds language regarding who may conduct the psychological evaluation

31 Clarification: ASC.3 Adds a definition of procedural sedation to the intent and clarifies that medication and/or dose does not determine definition Clarifies in ME 3: emergency equipment and supplies are readily available Clarifies in ME 4 the requirement for an individual with Advanced Life Support (ALS) training appropriate to age and history of patient is immediately available

32 ASC.7.4 : Requirement Changes Definition of implantable medical device added to intent New letter e) added to the list in the intent, requiring reporting of implantable device malfunctions to regulatory agencies Letter g) moved out of the list in the intent to its own measurable element New ME 3: The hospital has a process for tracing implantable medical devices.

33 ASC.7.4 : Requirement Changes New ME 4 The hospital develops and implements a process for contacting and following up with patients in a defined timeframe after receiving notification of a recall of an implantable medical device. Hospital determines follow-up timeframe for life-saving devices and non-lifesaving devices. Process takes into account follow up with international patients.

34 New Requirements: PFR.1.2 New ME 1: Staff provide care that is respectful and considerate of the patient s dignity and selfworth. Respect for dignity and self-worth Terminal care patients Male-female situations (caregivers, spouse) Psychiatry/dementia/stroke patients

35 Requirement Change: PFR.5 Language added to intent and ME : information must be communicated regardless of whether or not the organization uses a general consent process New ME 4: Whether or not general consent is obtained, all patients receive information about the likelihood of students and trainees participating in care processes. Tests which require separate informed consent ICU general consents may be too broad, or omit something

36 New Standard: MMU.1.1 Introduces a new standard for antibiotic stewardship Requirements of the program include: involving all staff and includes patients and families is based on scientific evidence proper use of prophylactic antibiotics oversight of the program monitoring the effectiveness of the program

37 Clarification: MMU.3.1 Adds language : specifying requirements for medications and nutritional products needing special consideration Provides examples of products that are included in the requirement Adds language to MEs 1-4 identifying the requirements of the process for proper labeling and control Problem areas: breast milk, meds brought in from home, and samples

38 Clarification: MMU.3.2 Clarify ME 2 : emergency medications are stored uniformly to facilitate quick access to the correct medications Uniform storage of medications emergency carts Potential differences with pediatric emergency carts Intent : clarify issues associated with security and access to emergency medication

39 Clarification: MMU.3.3 Intent and ME 2 : clarify requirements for expired and outdated medications Defines the following terms: Expired medication Outdated medication Shelf life Identifies need for expiry date for opened medication

40 Clarifications: MMU.4.1 Intent and ME 1 to clarify requirements including: Rates of administration for IV infusions Special orders such as titration, tapering, or range orders. Clarifies the need to identify precautions for ordering medication with look-alike or soundalike names

41 Clarifications: MMU.5.1 Intent and ME 2 clarifying who may perform an appropriateness review New ME 4 and language to the intent identifying: Critical aspects of an appropriateness review When the appropriateness review for the critical aspects may be performed Time frame for the full appropriateness review to be conducted ME 6 : clarifying that print reference materials as well as computer programs for cross-checking drugs must be current and updated

42 Clarifications: MMU.5.2 Intent clarifying what is meant by medications dispensed in the most ready to use format New ME 3 requiring a system to support accurate and timely dispensing and documentation of dispensing practices ME 4 (formerly ME 2, 5th edition) requiring use of two patient identifiers when labeling medications prepared but not immediately administered

43 New Requirement: MMU.6.1 Requires patients to be informed of medications they will be given and gives them an opportunity to ask questions (ME 4) Can be documented in different places on a PFE sheet, progress notes, unit orientation for patients/families. Can be at different times on rounds, prior to administration, among others.

44 PCI.7: Requirement Change Industry trends identify increased infections related to improper cleaning/ disinfecting/ sterilizing Defines and adds examples for terms: cleaning, disinfecting, and sterilizing Requires use of professional practice guidelines related to low- and high-level disinfection Requires staff to be oriented, trained, competent, and supervised Discusses principles of proper storage Identifies requirements for managing expired supplies

45 PCI.8.2: New Standard Hospital preparedness for presentation of global communicable diseases Developed in response to evolving health care environment Requires development of a program that includes 5 areas: Communication re: worldwide surveillance activities Segregation and isolation strategies Training and demonstration on the use of PPE Communication strategies Assignment of staff roles and responsibilities

46 PCI.8.2: New Standard Identify first points of contact/entry and target education to those areas Test the program annually Require debriefing from annual test (or an actual event) Identification and implementation of any follow-up actions from testing/annual event

47 Requirement Change: QPS.7 New ME 3 The root cause analysis identifies the origins of the event that may lead to improvements and/or actions to prevent or reduce the risk of the sentinel event recurring.

48 Requirement Change: QPS.8 New ME 1 related to developing and implementing processes for data gathering and analysis New ME 4 related to using analysis to make improvements New ME 5 related to reporting outcomes to governance

49 Requirement Change: QPS.11 Intent : expands the risk management program to include six categories of risks that can have an impact on hospitals and clarifies the need for developing a risk management program. New ME 2:Leadership identifies and prioritizes potential risks associated with at least the strategic, financial, and operational functions of the hospital.

50 Requirement Changes: GLD.1.1 Adds language to ME 5 requiring the evaluation of the chief executive to be documented. Revises language throughout standard for consistency in use of the term governing entity to refer to the hospital s governance Remember that if the CEO (or CMO, etc.) also provide patient care, they would need a job description plus privileges, and then a twopart annual performance appraisal

51 Requirement Changes: GLD.1.2 Intent regarding documenting the credible effort a hospital makes to obtain input and actions from their governing entity when they do not respond (also see GLD.1). Hard to track communication of QPS issues up and down Ensure meeting minutes reflect communication and actions

52 Requirement Changes: GLD.7.1 Uses the terminology supplies at most risk instead of critical supplies ; provides a description in the intent. ME 1 requiring hospitals to outline the steps in the supply chains for supplies at most risk. ME 2 requiring hospitals to identify significant risk points in the steps of the supply chains. New ME 4 The hospital has a process for performing retrospective tracing of supplies found to be unstable, contaminated, defective, or counterfeit. New ME 5 The hospital notifies the manufacturer and/or distributor when unstable, contaminated, defective, or counterfeit supplies are identified.

53 Requirement Changes: SQE.8.2 Change in the standard that requires the staff health and safety program to address the physical and mental health of staff and safe working conditions for staff New requirements identified as a) through g) of the intent and found in ME 2 New ME 5 The hospital provides education, counseling, and follow-up for staff who are second victims of adverse or sentinel events.

54 Requirement Changes: SQE New standard to address staff vaccinations and development of strategies for minimizing patient (and staff) exposure to health care associated infections, (previously a requirement of SQE.8.2, ME 2, 5th edition) Introduces the concept that the hospital is responsible for identifying strategies that reduce the risk of exposure to patients of infectious diseases from unvaccinated staff

55 Requirement Changes: SQE Identify epidemiologically significant infections, as well as staff who are at high risk for exposure to and transmission of infections; then implement a staff vaccination and immunization program. Identify strategies for reducing the patient s risk of exposure to infections from unvaccinated staff. Provide evaluation, counseling, and follow-up of staff exposed to infectious diseases; coordinate with PCI program

56 New Standard: FMS New standard identifying the need for a pre-construction risk assessment (PCRA) New standard is complimentary but different from PCI.7.5 an infection control risk assessment for new construction (ICRA) ME 2 - Requires the hospital to take action to minimize risks during construction, based on the assessment ME 3 - Requires the hospital to ensure contractor compliance is monitored, enforced, and documented

57 Requirement Change: FMS.9.3 ME 1 requiring testing of potable water and documentation of testing results. New ME 2: Quality of non-potable water is tested at least every 6months or more frequently based on local laws and regulations, conditions of the sources for water, and previous experience with water quality problems. The testing results are documented.

58 Requirement Change: FMS.9.3 ME 3 to specify testing requirements for water used in renal dialysis: Bacteria and Endotoxins: Monthly Chemicals: Annually New ME 4: Measures are implemented to prevent and reduce the risks of contamination and growth of bacteria in water. The effectiveness of the measures are monitored.

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61 Q&A