Joint Commission International Joint Commission International Key Elements Key Elements By Mahboob Ali Khan MHA CPHQ By Mahboob Ali Khan MHA CPHQ
Oct 20, 2014
Joint Commission International Key Joint Commission International Key ElementsElements
By Mahboob Ali Khan MHA CPHQ By Mahboob Ali Khan MHA CPHQ
Joint commission international Joint commission international (JCI)(JCI)
Who JCI isWho JCI is
Joint Commission International (JCI) was (JCI) was founded in the late 1990s to survey founded in the late 1990s to survey hospitals outside of the United States. hospitals outside of the United States. JCI, which is also not-for- profit, JCI, which is also not-for- profit, currently accredits facilities in Asia, currently accredits facilities in Asia, Europe, the Middle East, and South Europe, the Middle East, and South America. A count of JCI-accredited America. A count of JCI-accredited hospitals worldwide (as listed on the JCI hospitals worldwide (as listed on the JCI website in June 2012) shows 375 website in June 2012) shows 375 hospitals in 47 countries. hospitals in 47 countries.
JCIA Global PresenceJCIA Global Presence
Our JCI team:Our JCI team:
World headquarters in North AmericaWorld headquarters in North America
Regional offices in Asia-Pacific, Europe, and the Middle Regional offices in Asia-Pacific, Europe, and the Middle EastEast
A full service headquarters staffA full service headquarters staff
More than 200 international consultants and More than 200 international consultants and accreditation surveyorsaccreditation surveyors
Services of JCIServices of JCI
Advance certificationAdvance certification HospitalsHospitals Ambulatory healthcareAmbulatory healthcare Behavioral healthcareBehavioral healthcare Critical Access HospitalCritical Access Hospital Disease Specific CareDisease Specific Care
Services Of JCI (contd…)Services Of JCI (contd…)
Home careHome care Health Care Staffing ServiceHealth Care Staffing Service Laboratory ServicesLaboratory Services Long term careLong term care Nursing care centerNursing care center Office based SurgeryOffice based Surgery
JCI 5JCI 5THTH Edition Edition
Will be effective from 1Will be effective from 1stst April 2014 April 2014 Will consists of four sections Will consists of four sections Section one consists of accreditation Section one consists of accreditation
participation requirements APRparticipation requirements APR Section two Patient centered standards Section two Patient centered standards 1.IPSG1.IPSG 2. ACC (Access to care and continuity 2. ACC (Access to care and continuity
of care)of care)
JCI 5JCI 5thth Edition Edition
3. PFR (Patient and Family Rights)3. PFR (Patient and Family Rights) 4. AOP (Assessment Of Patients)4. AOP (Assessment Of Patients) 5. COP (Care Of Patients) ambulatory5. COP (Care Of Patients) ambulatory 6. ASC (Anesthesia and Surgical 6. ASC (Anesthesia and Surgical
Care)Care) 7. MMU (Medication Management 7. MMU (Medication Management
and Use)and Use) 8. PFE (Patient and Family Education)8. PFE (Patient and Family Education)
JCI 5JCI 5THTH edition edition
Section three consists of Health care Section three consists of Health care organization management standardsorganization management standards
9. QPS (Quality improvement and 9. QPS (Quality improvement and Patient Safety)Patient Safety)
10. PCI (Prevention and Control of 10. PCI (Prevention and Control of Infections) laboratoryInfections) laboratory
11. GLD (Governance, Leadership and 11. GLD (Governance, Leadership and Direction) for hospitals and academic Direction) for hospitals and academic medical institutionsmedical institutions
JCI 5JCI 5thth edition edition
12.FMS (Facility Management and Safety)12.FMS (Facility Management and Safety) 13.Staff qualification and education SQE13.Staff qualification and education SQE 14.Management of Information MOI14.Management of Information MOI Section four academic medical center Section four academic medical center
hospitals standardshospitals standards 15.Medical profession education MPE15.Medical profession education MPE 16.Human subjects research Programs 16.Human subjects research Programs
HRPHRP
JCI 5th edition JCI 5th edition
5th edition of the Hospital Standards contains
285 Standards 1160 Measurable Elements4thEdition of the Hospital Standards Contains 320 standards Over 1200 criteria measured during
the survey/evaluation process
JCI survey methodologyJCI survey methodology
Thorough survey process becomes Thorough survey process becomes Operational:Operational:
Typical survey team consists of a physician, Typical survey team consists of a physician, nurse, and administratornurse, and administrator
Surveyors evaluate various units within an Surveyors evaluate various units within an organization and meet to discuss their finding organization and meet to discuss their finding
Surveys conduct a complete system analysis on Surveys conduct a complete system analysis on integration and coordination of care processesintegration and coordination of care processes
10-14 Months
JCI survey methodologyJCI survey methodology
Organizational
Assessment
Ongoing
Technical
Assistance
Off-site
Document
Review
Mock Survey
Hospital
Accreditatio
n
Survey
Ongoing
Technical
Assistance
JCI Tracer MethodologyJCI Tracer Methodology
Patient tracer Patient tracer Allows a surveyor to assess an organization’s systems and processes by
Following the treatment path an individual patient has taken in the hospital, or
Following a process in the hospital from a beginning to an endpoint
Tracer Patient SelectionTracer Patient Selection
JCI Surveyors typically select a patient from a list of current admissions, after consultation with the hospital staff.
op diagnoses and procedures (surgical, medical, obstetrical, intensive care)
A patient on dialysis (if applicable)A patient on dialysis (if applicable) A psychiatric patient (if applicable) A pediatric patient (if applicable) A patient receiving lab/imaging services A patient receiving rehabilitation services Patients due for discharge that day or the next day
Scoring the Survey Results
Each standard must have a scoring of Each standard must have a scoring of at least 5at least 5
Each chapter must have a score of at Each chapter must have a score of at least 8least 8
All standards must together average All standards must together average for at least 9for at least 9
All measurable elements are averaged to obtain the score for the standard
Scoring survey resultsScoring survey results
Each Measurable Element (ME) is scored
Met (10) Partially Met (5) Not Met (0) All Standards are averaged to obtain
the score of the chapter All Chapters are averaged to obtain
the overall score
Thank YouThank You