Post on 27-May-2015
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JCI Accreditation – International Standards of
Excellence for Primary Care
John Sweeney, Director HCI
Partner, Ireland
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1910
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1. Each hospital should have a medical staff.
2. The members of the medical staff should be
chosen based on graduation from medical
school, competency, and character.
3. There should be regular staff meetings to
review cases.
Ernest Codman
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4. Medical records should be written and filed
for all cases.
5. Each hospital should have a clinical
laboratory and radiology section.
Ernest Codman
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Waldorf Astoria New York
89 of 692
Burned
Unable to demonstrate Quality of Care
No framework for what that is ….
50 years….
Ernest Codman
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Today
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Building Control Authority Environmental Protection Agency Radiological Protection Institute of Ireland
Health & Safety Authority of Ireland Food Safety Authority of Ireland (EHO's)Pharmaceutical Society of
Ireland Health Services Executive CORU - Health and Social Care Professionals HIQA - Infection
Control Mental Health Commission National Disability Authority Clinical Indemnity Scheme Irish Medical
Council An Bord Altranais Opticians Board Dental Council Irish Medicines Board Irish Blood Transfusion
Service Royal College of Physicians in Ireland Faculty of Occupational Medicine Faculty of Paediatrics
Faculty of Public Health Medicine Institute of Obstetricians & Gynaecologists Royal College of Surgeons
in Ireland Faculty of Dentistry Faculty of Radiologists Irish College of Anaesthetists Irish College of
General Practitioners in Ireland Irish College of Psychiatrists Irish College of Ophthalmologists Irish
Society of Chartered Physiotherapists National Treatment Private Health Insurance Purchase Fund
Joint Assessment Group (GI )HIQA Pre-Hospital Emergency Care Council Fire Officers Excellence
Ireland National Standards Authority of Ireland Joint Commission International CHKS Accreditation
Centre for the Development of Nursing Policy and Practice, University of Leeds Irish National
Accreditation Board Clinical Pathology Accreditation (UK) Academy of Medical Laboratory Science
National Council for the Professional Development of Nursing and Midwifery NERA - National
Employment Rights Authority
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Gaps?
2006 – 75%
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9
Voluntary Process
Centers of Excellence
Framework for Clinical Care +
Demonstrable Evidence of Quality (VHI)
Not for all – NH – 3 of 700+
Accreditation – A Definition
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JCI
• Quality, Risk and Regulation• Ireland and Australia• Team of 20 MD including R&D• Compliance– HIQA, IMB, ISO, ACHS• Founded in 2005
Health Care Informed (HCI)
JCI
Transforming patient safety and quality of
care
• Leading accrediting body for health care institutions in the US
• Founded in 1951• >19,000 accredited institutions
The Joint Commission
• JCI is the international arm of the Joint Commission• Framework for Centers of Excellence• Work with health care orgs, NGOs, and governments• 400+ JCI accredited organizations – 85 Countries• Ireland 1999
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Mayo Clinic - Cleveland Clinic – John Hopkins -
Mount Sinai Medical Center – Mass. Gen Hospital
Ireland (22 +)– Mater Private, Hermitage Clinic, Blackrock,
Bon Secours, Galway Clinic, St Vincent’s UH, VHI Homecare, Ambulance Services, LTC….
Primary Care – Spain, Brazil, UAE, Singapore
JC Accreditation
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Community Involvement and Integration
Management of the Processes of Care
Patient and Family Rights
Assessment of Patients
Care of Patients
Patient and Family Education
Management Structure and Leadership
Primary Care Accreditation
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Management of Information
Facility Management and Safety
Staff Qualifications and Education
Surveillance, Prevention, and Control of Infection
Quality Improvement and Patient Safety
Adverse Event Identification, Analysis, and
Prevention
Primary Care Accreditation
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International Patient Safety Goals
1. Identify Patients Correctly
2. Improve Effective Communications
3. Improve the Safety of High-Alert, High Risk Medications
4. Eliminate Wrong-side, Wrong-patient, Wrong-procedure
Surgery
5. Reduce the Risk of Health Care-acquired Infections
6. Reduce the Risk of Patient Harm Resulting from Falls
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Measures for Improvement
Clinical Measure: associated with the delivery of health care; may be diagnosis or procedure specific
Health Status Measure: addresses the functional well-being of specific populations
Patient Satisfaction Measure: focus on the delivery of clinical care from the patient’s, family’s or caregiver’s perspective
Financial/Administrative Measures: addresses organisational structure, utilization rates, operations or financial management
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Tracer Evaluation
An effective way to assess a healthcare
organization’s performance of care and the
services provided as viewed or
experienced by the patient.
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JCI Network
Communication - Newsletters
Education and Support
Network Meetings
Leadership Seminar – Patient Safety
Information Exchange
Quality Initiatives
Promotion
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What does it Accomplish?
Improves Patient Care – Peer Review
Continuous – Centres of Excellence
Increase efficiency/reduce costs
Improve the management of business services
Enhance staff recruitment and retention
Public Confidence - Reputation
Other Stakeholders - Reputation
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Does it Work?
“A better way of structuring how we
provide care and run our business”
Nicky Jermyn, CEO St Vincent’s University
Hospital
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Tomorrow ..