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The Value of Accreditation: the JCI Experience

Claudia Jorgenson, RN, MSNDirector, Standards DevelopmentJoint Commission International

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Presentation Topics

Some facts about Joint Commission International (JCI)

Accreditation and Licensure basics

The JCI accreditation process

The drivers for accreditation

Potential return on the investment

Quality, Safety, and Accreditation

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Organizational Base

Joint Commission International (JCI) is the international arm of The Joint Commission (TJC). Established 1997

TJC and JCI are independent, non-profit, non-governmental agencies

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Mission of Joint Commission International To improve the safety and quality of care in the international community through the provision of education, publications, consultation, evaluation, and accreditation services

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International Accreditation and Certification Programs

Hospitals – 5th Edition effective 2014 Laboratories – 2nd Edition (2009) Medical Transport (2002) Ambulatory Care – 2nd Edition (2009) Primary Care (July 2008) Disease-Condition-Service Certification (2009) Home Care – 1st Edition (2012) Long Term Care – 1st Edition (2012)

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6

Mexico

Chile

Costa Rica

Singapore

China

Hong Kong

Taiwan

S. Korea

Indonesia

Saudi Arabia

QatarUAE

Ireland

JCI HeadquartersChicago, USA

JCI Middle East Office

Dubai, UAE

JCI Asia-Pacific OfficeSingapore

Eastern Europe

Belgium

Current JCIA =

56 Countries as 1 July 2013

541 Accredited IHCOs50 CCPC Certificated Programs

2 Accredited Networks

Countries with JCI Accreditations

Mauritius

Russia

Japan

Kazakhstan

Brazil

Nigeria

Egypt

Ethopia

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Accreditation – A Definition

Usually a voluntary process by which a

government or non-government agency grants

recognition to health care institutions which meet

certain standards that require continuous

improvement in structures, processes,

and outcomes.

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SHANGRI-LA HOSPITALEl Dorado, Republic of Freedonia

ampleSample Sample Sample Sample Sample

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SHANGRI-LA HOSPITALEl Dorado, Republic of Freedonia

ampleSample Sample Sample Sample Sample

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Accreditation – A Definition

Accreditation is often confused with:

– Licensure-governmental activity that sets minimum standards to protect the public

– Certification- evaluates special capability or unique skills/ability

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International Structure

International Board of Directors (of JCR)

International Accreditation Committee

International Standards Committee

Regional Advisory Councils

Four International Offices

International translations of many products

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Hospital Standards

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

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Hospital Standards Health Care Organization and 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 Communication and Information

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Hospital Standards

4th Edition of the Hospital Standards Contains 320 standards Over 1200 criteria measured during the survey/evaluation process

5th Edition of the Hospital Standards (Due in September) 285 Standards 1160 Measurable Elements

Required compliance with the International Patient Safety

Goals

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Evaluation Methodology Teams of peers gather information on-site

Teams trace patients through the organizations

to evaluate systems of care

The compliance elements and scoring method

is transparent

Decisions on accreditation are rule based

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Patient Tracer

Follows the care and needs of the patient

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Drivers for Accreditation

Aging populations with multiple chronic diseases have

raised costs of care

Emergence of new diseases and HAIs

Movement of patients and health care practitioners

across borders

Globalization of service and manufacturing sectors NA

HA

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How safe is healthcare?

Dangerous(>1/1000)

Risky Safe(<1/100K)

Healthcare

Mountain climbing

Bungee jumping

Driving

Chemical industry

Charter flights

Regular air transport

European railways

Nuclear power

Contacts / 1 death

Dea

ths

/ yea

r

1

100,000

1000

100

10

10,000

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“Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous.”

Sir Cyril Chantler, former Dean Guy’s, King and St. Thomas’s Medical and Dental School, Lancet1999

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Potential Returns on Accreditation

Improved care – fewer complications

Better reputation -- increased number of new patients

More satisfied staff – better retention and lower

recruitment and training costs

More efficient, cost effective work processes

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Potential Returns on Accreditation

Better preventive maintenance program – longer life of biomedical equipment

Special recognition from payment sources and insurance companies

Greater clarity to leadership structure and quality oversight

Better safety management, risk reduction, and reduced liability exposure

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Questions to Ask

How does accreditation lead to enhancement of patient and staff safety?

– Is it a result of compliance of standards?– Or is it a function of the survey methodology?

Do you have the data to prove what you aretelling us?

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Medication error rate at Indraprasthra Apollo Hospital, Delhi, India

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

45.00

50.00

Jan Feb Mar Aprl May Jun July Aug Sep Oct Nov Dec

05 06 UCL CR

Decreases in Medication Errors

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Trend on Non Compliance of Allergy Documentation at

11.07

6.404.74

1.900.93 0.5 0.3 0 00

2

4

6

8

10

12

No

v-0

6

Dec-0

6

Jan

-07

Feb

-07

Mar-0

7

Ap

r-07

May-0

7

Ju

n-0

7

Ju

l-07

% N

on

co

mp

lian

ce

Desired Outcome

Improvement in Documentation

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Reduction of Complications at American Hospital, Dubai, UAE

During preparation for re-accreditation:– Emphasis on prevention of hospital associated

infections– New Clinical guidelines introduced

0

2

4

6

8

10

12

VAP UTI BSI Post-C/SInfx (%)

20052006

N/1

00 d

evic

e da

ys

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Reduction of Ventilator-Associated Pneumonia

Moving Average - VAP - Year 2005

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05

Month

Rat

e/10

00 v

enti

lato

r d

ays

QIP

ON

VA

P R

ED

UC

TIO

CO

MP

LE

TE

D

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Reduction of Ventilator-Associated Pneumonia

Month wise Hospital Acquired Infection Survelliance Data (VAP)

47.2

33.71

44.12

7.09

9.435.61

000

10.75

49.2

11.7

43.4

0

10

20

30

40

50

60

Month

VAP (No./1000 days) 43.4 11.7 49.2 47.2 9.43 33.71 44.12 10.75 7.09 0 0 0 5.61

Average 20.17 20.17 20.17 20.17 20.17 20.17 20.17 20.17 20.17 20.17 20.17 20.17 20.17

NNIS 90 percentile 8.9 8.9 8.9 8.9 8.9 8.9 8.9 8.9 8.9 8.9 8.9 8.9 8.9

Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06

*(Number of ventilator-associated pneumonias / Number of ventilator-days) X 1000 ** Source: National Nosocomial Infections Surveillance(NNIS) System Report, October 2004

NNIS

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Incidence of VAP in MSICU - 2000 to Q2 05

25.9

19.617.44

9.129.878.448.82

7.047.62

12.19.669.36

6.13

3.194.81

2.63.864.874.264.58

0

5

10

15

20

25

30

Q3 200

0

Q4 200

0Q1 0

1Q2 0

1Q3 0

1Q4 0

1Q1 0

2Q2 0

2Q3 0

2Q4 0

2Q1 0

3Q2 0

3Q3 0

3Q4 0

3Q1 0

4Q2 0

4Q3 0

4Q4 0

4Q1 0

5Q2 0

5

Per

thou

sand

ven

tilat

or d

ays

Target ________ NNIS ------------

Reduction in VAP Rates –National University Hospital, Singapore

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Reduction of Complications at “Istituto Giannina Gaslini” NI/PICU

27.2

4.92.6

03.6

0.90

5

10

15

20

25

30

2006 2007

******

* Mortality (%) from hosp acq. Infections** Hosp acq. Infections (per 1000 pt days)*** Hosp acq. Pneumonia (per 1000 pt days)

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Improved Patient SafetyPatient Incidents per 100 Discharges

0

0.5

1

1.5

2

2.5

Jan

Feb Mar Apr

May Ju

n Jul

AugSep Oct Nov Dec

20052006

Indraprastha Apollo Hospital, New Delhi, India

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Unscheduled Returns to ICU Rates in National University Hospital, Singapore

Comparison With Project-Wide & S'pore Public Hospital Rates

7.956.63

5.67

4.094.63 4.77 4.265.61 5.35

4.684.05 4.54

3.82

3.11

8.09

10.34

7.618.01

4.35

1.47 1.88

3.663.47 3.663.643.50 3.443.39 3.47 3.65 3.57 3.80 3.41

3.99 3.684.23

0.0

2.0

4.0

6.0

8.0

10.0

12.0

Q102 Q202 Q302 Q402 Q103 Q203 Q303 Q403 Q104 Q204 Q304 Q404

NUH S'pore Public Hospitals Project-Wide

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Handwashing Compliance

Trend on Hand Hygiene Compliace Rate in ICUs

77

95 95

68.1

74

40.84

30.26

20.34

45.47

6764.1263.22

95

0

20

40

60

80

100

% Co

mplia

nce R

ate

Compliance 20.34 30.26 45.47 40.84 63.22 64.12 67 74 68.1 77

JCAHO Benchmark 95 95 95 95 95 95 95 95 95 95

38935 38966 38996 39027 39057 39089 39120 39148 39179 39209

JCAHO Benchmark

DesiredOutcome

n=100 n=100 n=250 n=250 n=250 n=250 n=250 n=400 n=400 n=400n = No. of Observations

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Patient Falls (%)

0

5

10

15

20

25

30

35

40

45

2004 2005 2006 2007

Apollo Hospitalstouching lives

INDIA

Indraprastha Apollo Hospital, New Delhi, India

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Laboratory Staff SafetyHospital Clinica Biblica, Costa Rica

171

0 0 0020406080

100120140160180

Q1 Q2 Q3 Q4

Preventable staff accidents 2007

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Needlestick Injuries –Changi General Hospital, Singapore

No. of Needlestick Injury per 1000 CGH Healthcare Workers

0.53

2.80

1.72

0.59

0.001.20

1.17

2.922.88

1.74

2.29

2.85

2.36

5.93

1.192.982.39

2.99

2.36

2.45

3.454.80

2.97

5.96

4.29

6.136.25

2.48

1.871.88

0

2

4

6

8

Jan-0

3

Feb-0

3

Mar-03

Apr-0

3

May-03

Jun-0

3

Jul-0

3Au

g-03

Sep-0

3

Oct-03

Nov-03

Dec-03

Jan-0

4

Feb-0

4

Mar-04

Apr-0

4

May-04

Jun-0

4

Jul-0

4Au

g-04

Sep-0

4

Oct-04

Nov-04

Dec-04

Jan-0

5

Feb-0

5

Mar-05

Apr-0

5

May-05

Jun-0

5

Rate

of Ne

edles

tick I

njury

(CGH) No. of needlestick injury per 1000 CGH healthcare workers

The rate of needlestick injuries per 1000 healthcare workers was reduced from 7.91 in 2003 to 3.48 in 1st 6 months of 2005, an improvement of 127%

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So Far So Good

These are individual reports, dealing with segments of hospital operations – Anecdotal accounts

To study it systematically, – One Middle East hospital embarked on a study of the effect of

the process, not of the outcome, before and after JCI accreditation

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Study Details 400 bed Government Hospital Accredited in 2007 Studied before start of project to comply with JCI standards Repeat study 15 months later (before survey) Perceptions of stakeholders studied by questionnaires 100 point indices

Hassan, DK & Kanji, GK: Measuring Quality Performance in Healthcare 2007. Kingsham Press, Chichester, UK

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Findings of Study All stakeholder groups reported improvement in every dimension measured Overall improvement: 49% over baseline

Main Areas of ImprovementLeadership & managementQuality improvementPatient safetyPt satisfaction & “delight”Ethical performanceDocumentationOrganizational learningOrganizational excellence

Areas of Lesser ImprovementCorporate structureHuman resources managementStaff satisfaction

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Value Study in JordanObjective and Study Design

To quantify the value (expressed in monetary terms) and impact (expressed in physical terms) of implementing selected JCI standards

Retrospective

3-year period

Compare two groups of acute general hospitals– Accredited group consisted of 3 private hospitals that received

JCI accreditation in 2007 or 2008

– Non-accredited consisted of 2 similar private hospitals (not obtained nor sought accreditation during that time)

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Results

Net impact of hospital accreditation, 2006-2008

0.6%

27.6%

0.9%

13.0%

1.6%

30.1%

-0.1%-3.0%-0.1%-0.1% -2.5%-0.1%1.1%

-1.8%

-16.0%

0.0%-1.0%-0.5%

-20%

-10%

0%

10%

20%

30%

40%

Readmission to

hospital within 30

days

Return to ICUw

ithin 24 hours^

Return tosurgery w

ithin 24hours

Staff turnoverper year^

Admission of

internationalpatients

Completeness of

medical records^

Accredited hospitals+

Control hospitals (trend)+

Net impact of accreditation+

+ Variable is the change from the before year (2006) to the average of after accreditation years (2007-8). The greatest negative changes are best for hospital readmission, return to surgery, and return to ICU. The greatest positive changes are best for completeness of records and admission of international patients.^Statistically significant (at p<0.05)

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Conclusions

Total saving over two monetary measures US $87,600 per accredited hospital per year

Saving over 2 years follow up equals US $175,200 per hospital

Accreditation demonstrated statistically significant improvement in quality as well as cost saving in key areas

Both accredited and non-accredited hospitals valued study for contribution to staff skills in measuring quality

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JCI Standards Address Key IssuesRelevant to Quality, Safety and Satisfaction

Communication Issues (MCI) The organization seeks to reduce physical,

language, cultural, and other barriers to access and delivery of services.

The patient and family are taught in a format and language they understand.

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Rights as Patients (PFR) Care is considerate and respectful of the patient’s

values and beliefs.

Care is respectful of the patient’s need for privacy.

Patient information is confidential.

Patient informed consent is obtained.

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Continuity of Care (ACC) Continuity and coordination are evident throughout

all phases of patient care.

Referrals outside the organization are to specific individuals and agencies in the patient’s home community.

A copy of the discharge summary is provided to the practitioner responsible for the patient’s continuing or follow-up care.

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Truth in admission policies (ACC) Patients are admitted for care only if the

organization can provide the necessary services and settings for care.

At admission patients and families are provided information on the proposed care, expected results of care, and expected costs.

The organization has established and implemented a framework for ethical management.

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Professional Competence (SQE) The organization has an effective process to

authorize all medical staff members to admit and treat patients and provide other clinical services consistent with their qualifications.

The credentials of medical staff members are reevaluated at least every three years to determine their qualifications to continue to provide patient care services in the organization.

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JCI Standards Address Key IssuesRelevant to Quality, Safety, and Satisfaction

Evidence of quality (QPS) The organization monitors its clinical and

managerial structures, processes, and outcomes including:Laboratory and radiation safety and qualitySurgical proceduresUse of antibiotics and other medicationsUse of blood and blood products’InfectionsAnd 13 other areas including patient safety

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Complaints (PFR)

The organization informs patients and families about its process to receive and act on complaints, conflicts, and differences of opinion about patient care.

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Conclusions

There are many drivers for quality evaluation however, patient safety is one of the strongest

The accreditation process is an investment in the long-term health of an organization

The accreditation process can provide cost savings in key areas as well as improve the quality and safety in an organization

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Questions?

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