David Jaimovich, MD Chief Medical Officer Joint Commission International

1. Association of Companies Health Insurance Funds 13 March 2009Prague, Czech RepublicJoint Commission International Standards and Survey Process David Jaimovich, MD Chief Medical Officer Joint Commission International

2. Objectives • Identify and describe the JCI Accreditation process • Describe and review tracer methodology • Discuss a hospital’s preparation for the JCI Accreditation process • Describe global standardization of healthcare services through the process of accreditation • Accreditation as part of a systems focus

3. JCI Standards • System framework • Checklist of all the important managerial and clinical functions or activities • Focus on patient perspective in context of their family • A balance of structure, process and outcomes standards • Optimal but achievable expectations • Measurable

4. Accreditation Represents a Risk Reduction Strategy • That an organization is doing the right things and doing them well; • Thereby significantly reducing the risk of harm in the delivery of care; and • Optimizing the likelihood of good outcomes.

5. Strengths of Accreditation • External, objective evaluation • Uses consensus standards • Involves the health professions • Proactive not reactive • Organization wide • Focus on systems not individuals • Stimulates quality culture in the organization • Periodic re-evaluation against standards • Strengthens public’s confidence

6. Accreditation Can Help: • Enhance staff recruitment, retention and satisfaction • Improve or expand sources of payment for patient care • Increase chances to enter networks and new provider arrangements • Provide greater independence from government oversight

7. Accreditation Can Help: • Build a quality measurement database • Provide comparison with self, others, and best practices • Provide a framework to improve patient safety

8. Quality Improvement and Patient Safety Programs • Are leadership driven • Seek to change the ethos of the organization • Proactively identify and reduce risk and variation • Use data to focus on priority issues • Seek to demonstrate sustainable improvement

9. Accreditation as Part of Continuous Quality Improvement • Accreditation is a milestone on the continuous journey of improvement • Accreditation Standards provide a common quality language and common set of expectations to point the way forward • Establishing a permanent organizational culture of safe, quality care is essential for sustaining improvement • The effort is for your patients, not the certificate

10. Starting to Prepare Available Resources: • JCI Accreditation Standards for Hospitals, 3rd Edition • Survey Process Guide (electronic version) • Web-based training on introduction to the international accreditation process (ISAS) • Newsletters and publications • print and electronic (e.g. Getting Started) • JCI Practicum four times a year • (Annual JCI Executive Briefings – networking opportunity with accredited organizations)

11. Begin with Education Organizational leaders and managers • Introduction to accreditation philosophy and approach • Accreditation as a quality improvement and risk reduction strategy • Review of the standards and measurable elements • Discussion of the survey process and what to expect • Project planning and next steps

12. Baseline Assessment Conduct a detailed baseline assessment of current adherence to the Standards and each Measurable Element: • Use knowledgeable and credible evaluators (either internal or external consultants) who will critically and objectively assess each area • Consider using ISAS as guide • Include all areas of the organization in the assessment

13. Baseline Assessmentcont. • Collect and analyze baseline quality data as required by the quality monitoring standards • Examples: medication errors, hospital-associated infection rates, antibiotic usage, surgical complications. • Establish an ongoing monitoring system for data collection to identify problem areas and track progress in improvement • Set frequency of data collection • Analyze data

14. Action Planning • Using the findings of the baseline assessment, develop a detailed project plan with assigned responsibilities, deliverables, and time frames. • Start with priority areas established by leadership • Example: Revise informed consent policy, develop a new informed consent statement, educate staff - to be completed in two months (specify exact date) • If available, use a software program such as MS Project or Excel to confirm project plan in writing • Hold leaders and staff accountable to the plan

15. Team Approach • Assignoversight of each chapter of standards to a respected champion/leader who will identify team members from throughout the hospital • Also includethose who may be skeptical of the process • Lookfor good people skills, time management skills, and consensus building skills • Bepreparedto change as new champions emerge, and some leaders drop out

16. Policies and Procedures • Compile a list of all required policies and procedures that will need development and revision • Hint: look for list in Survey Guide 2008 • These may take some time to get revise or develop, undergo organizational review, and obtain final approval • Be certain that your policy reflects your actual practice, as this is one of the yardsticks the surveyors will use to evaluate your performance

17. Mid-Point Strategies • Continue to monitor your progress in meeting the standards • Ex. Use a mini-evaluation of each chapter at regular intervals (e.g quarterly) • Don’t be afraid to adjust your project plan to be more realistic – change often takes longer than one expects • Continue to involve as many staff as possible in the process – make it an organizational quality goal that you are striving to achieve together

18. Strategies That Have Worked • Importance of physician commitment to the accreditation process cannot be overstated • They should see accreditation standards as framework by which hospital processes will be improve • Care will ultimately be of higher quality and safer for their patients • Reassure physicians that accreditation is not intended to tell them how to practice medicine! • But it does compel them to look collectively at their own practices and evaluate their own results

19. Strategies That Have WorkedCont. • Learn from what others have done well and adapt the experience to the needs of your organization • Ask JCIfor clarification with standards interpretation – don’t waste time going down the wrong path • Take advantage of resources (e.g. download electronic example policies and plans and adapt to your organization)

20. Pitfalls to Avoid • Top leaders “support” the process, but are totally unrealistic in what it will take to achieve it in terms of time and resources • Staff end up feeling that accreditation is extra work for which they are not rewarded or recognized • Over-eager managers using the standards as a threat rather than as a goal – can make entire accreditation process feel punitive and inspecting rather than motivating

21. Final Mock Survey • Plan for a final “mock” or practice survey about 6-8 months in advance of the target date of the actual accreditation survey • Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organization with a fresh and objective eye • Plan final actions and corrections based on the findings of the final mock survey

22. JCI Hospital Standards 3rd Ed. • Standards in two sections: • Patient-Centered Standards • Healthcare Organization Management Standards

23. JCI Hospital Standards 3rd Ed.Cont. Patient-Centered Standards • Access to Care and Continuity of Care • Patient and Family Rights • Assessment of Patients • Care of Patients • Anesthesia and Surgical Care • Medication Management and Use • Patient and Family Education

24. Anesthesia and Surgical Care • Organization and Management • Sedation Care • Anesthesia Care • Surgical Care

25. Medication Management and Use • Organization and Management • Selection and Procurement • Storage • Ordering and Transcribing • Preparing and Dispensing • Administration • Monitoring

26. JCI Hospital Standards 3rd Ed. Cont. Healthcare Organization Management Standards • Quality Improvement and Patient Safety • Prevention and Control of Infections • Governance, Leadership, and Direction • Facility Management and Safety • Staff qualifications and Education • Management of Communications and Information

27. Staff Qualifications and Education • Planning • Orientation and Education • Medical Staff • Nursing Staff • Other Health Professional Staff

28. Management of Communication and Information • Communication with the Community • Communication with Patients and Families • Communication Between Providers Within and Outside the Organization • Leadership and Planning • Patient Clinical Record • Aggregate Data and Information

29. Standards Content Each JCI standard contains three components: • The standard represents the principle • The intentdescribes the rationale of the standard • The measurable elements are the detailed requirements from the standard and intent that are scored

30. Standards Content (sample)

31. International Patient Safety Goals • Identify patients correctly at risk points • Improve effective communication of critical information • Improve safety of high-alert medications • Ensure correct-site, correct-patient, correct-procedure surgery • Reduce the risk of healthcare-associated infection • Reduce the risk of patient harm from falls

32. Approach and Philosophy to the On Site Survey • A Survey is not intended to be punitive, a “got you” exercise, or an inspection • Tracer Methodology is a process of identifying imperfections, flaws, or broken systems • Surveyors will “drill down” or focus on areas where a potential risk area is identified • Based on common problem areas in many hospitals • High risk or high volume services • They have identified a vulnerable area

33. On-Site Evaluation Process • Opening conference • Orientation • Document review • Leadership session • Assessment activities • Tracer activities – patient • Tracer activities – systems • Facility tour • Special interview / issue resolution • Feedback sessions • Daily briefings • Leadership exit conference

34. Tracer Methodology Is an effective evaluation method that is used to assess a healthcare organization’s performance of care and the services provided as viewed or experienced by the patient

35. Objectives of Tracer Activity • Follow entire course of care and services provided to the patient • Assess relationships among disciplines and important functions • Evaluate performance of processes provided to the patient

36. Types of Tracers • Patient Tracer – Follows the patient • System Tracer – Follows the system • Data use • Medication management • Infection Control

37. Conducting Tracers • Selection of patients • Diagnoses • High volume • Procedures • High volume • High risk • Low volume • Selection of units • Diagnoses/procedures • Special care

38. Sample Patient Tracer Hospital Setting • Patient – Mr. Ramponi • Cardiac-surgery related diagnosis (cardiac bypass surgery) • Pulmonary complications (pneumonia) • Surveyor • Reviews patient record • Notes what services and transfers occurred

39. Surveyor Reviews Medical Record 72-year old man presented to ER with chest pain • An electrocardiogram showed signs of sinus tachycardia • Staff administered aspirin and drew blood • Mr. Ramponi • Treated for diabetes and hypertension • Recently quit smoking after 33 years • Sent to cardiac catheterization lab for an angiogram, which revealed 5 blockages • Put on IV heparin, nitroglycerin and beta-blocker • Transferred to ICU • Hypertension was an issue. So medications were adjusted to lower his blood pressure • Surgery for a coronary artery bypass graft was scheduled for the next morning

40. At Emergency Department Communication, assessment, performance improvement, and medication management issues. Step 1 Surveyor speaks with ED Staff “A little over 2 weeks ago, Mr. Ramponi came into the ED with chest pains and a history of hypertension and diabetes. What processes were followed for triaging and treating him?” “I see that a cardiac catheterization was necessary; how was informed consent obtained from Mr. Ramponi?” “You’ve said that like many heart attack victims, Mr. Ramponi delayed seeking help after experiencing the first symptoms. Has your ED conducted any performance improvement projects to decrease the time to begin treatment?”

41. Surveyor reviews Medical Record • Antibiotics were begun at the time of surgery • Sent to ICU with ventilator which was removed 5 hours later • Developed pneumonia within 2 days • IV antibiotic was changed, but history of smoking has weakened his lungs • Placed on ventilator • Wean from ventilator within 6 days • Received pulmonary treatment regimen of nebulizer treatments, incentive spirometry, and assisted cough • Transferred to a general medical unit with telemetry after 3 days • Scheduled to be discharged for continued outpatient rehabilitation

42. Emergency Department points of discussion • Triage process • Patient assessment • Communication prior to patient transfer • Medication process, including for high risk concentrated medications and IV solutions • Communication needs for elderly patients • Competency of medical and nursing staff in emergency care

43. At Cardiac Catheterization Lab Verbal orders, assessment and emergency care issues Step 2 Surveyor talks with Staff Nurse and Cardiologist “What communication took place between the catheterization lab and the ED before Mr. Ramponi arrived for his procedure?” “What process was used for ensuring medical equipment safety?” “How did you make certain Mr. Ramponi had no allergies to the contrast medium being used for the procedure?”

44. Catheterization Labpoints of discussion • Pre-procedural patient assessment • Patient identification process • Informed consent • Patient privacy and confidentiality • Infection control • Patient monitoring during and after procedure • Use and maintenance of equipment • Sedation and anesthesia use and safety • Frequency of cancellation of procedures and reasons (Quality Improvement project)

45. At Operating Room Medication use, anesthesia care, informed consent, site verification, emergency care issues and infection control. “Patients undergoing bypass surgery are at increased risk of developing a surgical site infection. What preventive measures did you take to help reduce that risk for the patient?” “What processes do you follow to verify that you had the correct patient and procedure before you started Mr. Ramponi’s surgery?” Step 3 Surveyor talks to the Staff, Circulating Nurse, Anesthesiologist “What assessments had been performed and what information did you receive before Mr. Ramponi arrived in the OR?” “During open-heart surgery, concentrated potassium was used. How is access to this undiluted concentrated electrolyte controlled?” “Can you explain the process to obtain informed consent for Mr. Ramponi for this surgery?” Surveyor also requests credentialling files for the anesthesiologist and cardiac surgeon. “How was the placement of Mr. Ramponi’s pulmonary artery catheter confirmed?” “What do you do in the event of fire?” “How do you maintain this equipment? How were you trained to use it?”

46. At Recovery Room Verbal orders, clinical practice guidelines and equipment management Step 4 “Following Mr. Ramponi’s surgery, he started on an IV infusion pump for pain management. What checks did you perform on the equipment before starting him on the pump?” At OR Recovery Area “What guidelines did you follow for post-anesthesia monitoring of Mr. Ramponi?” “Who made the decision to discharge Mr. Ramponi from the Recovery, OT?”

47. At Cardiac ICU Communication, assessment, clinical practice guidelines, credentialling, infection control, equipment management and medication management Step 5 Surveyor talks with attending Physician, ICU Nurse, Respiratory Therapist, Infection Control Practitioner “Mr. Ramponi was receiving IV pain medication following surgery. Can you show me where you documented Mr. Ramponi’s pain assessment, treatment and reassessment?” “Was Mr. Ramponi restrained while on ventilator? How was the decision made to remove Mr. Ramponi from the ventilator?” “How did the OR communicate what procedures took place when Mr. Ramponi was transferred to the ICU?

48. Cardiac ICUpoints of discussion • Communications received from Recovery Room • Patient assessment and monitoring • Patient privacy and confidentiality • Infection control • Use and maintenance of equipment, especially clinical alarm systems • Staff competency based on patient populations cared for in ICU • End-of-life issues • Medication management • Handling of verbal orders

49. At Medical - Surgical Unit Equipment management, patient education, rights & ethics, discharge planning, continuum of care. “What written information will Mr. Ramponi receive about his medications when he is discharged this afternoon? Does the patient know about his medications? When did you educate him? How?” “Can you describe Mr. Ramponi’s medication protocols?” “What process was followed for ordering respiratory therapy for Mr. Ramponi?” Step 6 Surveyor talks to Staff Nurse, Cardiac Rehab Nurse, Respiratory Therapist, Nutritionist, Patient Educator “How was nutrition and weight management education provided to the patient?” “What is your plan for Mr. Ramponi’s discharge?” “I see that Mr. Ramponi was on telemetry. How would you know if the equipment is working? Can you explain how the patient is monitored on this system?” Surveyor reviews patient education materials. Speaks with Mr. Ramponi and his wife about ongoing education, informed consent process and the care provided.

50. Patient TracerSummary • Surveyor visits areas within the organization where the tracer patient was physically treated. • Wherever the surveyor is, he/she is assessing numerous standards. • Surveyor might also tour other areas, e.g., laboratory and pharmacy to explore issues such as diagnostics and medication management. • Surveyor could theoretically visit any location in the organization if it related to the care provided to the patient, including registration, dietary dept, physical therapy, outpatient pharmacy, etc.