Indonesia MoH - March 2021.KLeonhardt - Final

The Future of Health Care Quality-
and how accreditation can take you there!
Indonesia Ministry of Health

Kathy Leonhardt, MD, MPH, CPHQ, CPPS
JCI Principal Consultant, Quality and Patient Safety
March 2021
Our Presenter
Kathy Leonhardt, MD, MPH, CPHQ, CPPS
Principal Consultant
 Over 30 years experience as a physician
executive, providing leadership, research and
education in public, private and academic settings
 Expertise includes quality management; patient
safety; process improvement; patient experience
 Board Certified in Preventive Medicine/Public Health;
certifications in quality, patient safety, teamwork,
Six Sigma Green Belt
2
© 2021 The Joint Commission International. All Rights Reserved.
Key Topics
By the end of this presentation, you will be able to:
Define quality today
Identify key elements of an effective

quality management system
Recognize the role of accreditation
3
Where are you going?
4
5
When asked to describe the greatest challenges faced, staffing issues, obtaining supplies/supply shortages,
and safety protocols were most likely to be mentioned organically by survey participants.
Greatest Organizational Challenges Faced Due to COVID-19

Unprompted responses among customers of The enterprise
Most Common Challenges Other Challenges Less Common Challenges
Safety protocols Facility

Staff 54% (Implementing safety 35% (Implementing telehealth services)
23%
protocols/CDC guidelines)
Staff Retention
31%
(Staffing shortage) Information/Policies Testing
Staff Emotional (Frequently changing 28% (COVID-19 testing/Testing 18%
Response 16% requirements/guidelines) reliability)
(Addressing staff concerns
about COVID)
Finances
Patient/Patient care
28% 13%
Supplies/Equipment 50% (Decline in patient volume) (Financial impact)
Obtaining PPE
39%
equipment
Supply shortages 21%
Base: All Joint Commission Customers (n=700) 6

QA1a. What are the greatest challenges impacting protocol, resources, or operations your organization © 2021 The Joint Commission International. All Rights Reserved.
has faced as a result of the COVID pandemic? | Note: Only showing mentions 10% or greater
6
How do you define Quality today?
7
Definition of Quality
− “The degree to which health care services for
individuals and populations increase the probability
of desired health outcomes and are consistent with
current professional knowledge of best practice.”
− National Academies of Sciences, Engineering and Medicine (formerly Institute of

Medicine)
8
Six Dimensions of Quality
A. Safety
B. Timeliness
C. Efficiency
D. Effectiveness
E. Equity
F. Person-centered
9
Adapted from “Crossing the Global Quality Chasm”, 2018

Patient Safety
Patient Safety
Event
Hazardous or Close call, Adverse event

“unsafe” “near miss,” or No-harm event Sentinel
condition “good catch” Event
Did not reach the patient Reached the patient
JCI Hospital Standards, 7th Ed: Glossary, QPS.7, 7.1

10
Patient Safety: Culture
Uses data for learning,
Learning Culture willing to implement major
reforms/adjustments
Trusting, with clear defined

Just Culture lines between acceptable
and unacceptable behavior
Safety Nimble, responsive,
Flexible Culture innovative approach to
Culture continuous improvement
Active, robust reporting of

Reporting Culture events and near misses
Recognition of system
Informed Culture (systems thinking)
11
James Reason; © 2021 The Joint Commission International. All Rights Reserved.
JCI Hospital Standards 7th Ed.: GLD.13, 13.1

Patient Safety
Sentinel Events, 2020 (US Data)
Source: The Joint Commission,

US-based voluntarily reported
SE (n=794)
12
Top 10 Patient Safety Concerns, 2021
1. Racial and ethnic disparities in healthcare

2. Emergency preparedness and response in aging services
3. Pandemic preparedness across the health system
4. Supply chain interruptions
5. Drug shortages
6. Telehealth workflow challenges
7. Improvised use of medical devices
8. Methotrexate therapy
9. Peripheral vascular harm
10. Infection risk from aerosol-generating procedures
13
From: ECRI at www.ecri.org © 2021 The Joint Commission International. All Rights Reserved.
Goal: Quadruple Aim
Improved Improved
Health Patient
Outcomes Experience
Improved Reduced
Staff
Experience Costs
14
Source: (Modified) The Value Transformation Framework: An Approach to Value-Based Care in Federally© 2021 The Joint Commission International. All Rights Reserved.
Qualified Health Centers The Journal for Healthcare Quality (JHQ)42(2):106-112, March/April 2020.
What do you need to get there?
15
Systems Thinking in Healthcare
Hazard
Incident
16
Systems Thinking in Healthcare
Structure Process Outcomes
• Leadership/ • Patient • Patient

Governance • Microsystem health
• Service • Organization • Risk
Delivery • Environment reduction
• Workforce • Operational
• Health efficiencies
information
systems
• Access
• Financing
17
Adapted from “Crossing the Global Quality Chasm”, 2018 © 2021 The Joint Commission International. All Rights Reserved.
Who has the ultimate responsibility for
the effectiveness of quality improvement
and patient safety within an organization?
1. Quality improvement director
2. Medical director
3. CEO
4. Governing entity
18
JCI Quality Management & Patient Safety
JCI ACCREDITATION
QUALITY
MANAGEMENT
PATIENT
SAFETY
PERFORMANCE
IMPROVEMENT IDENTIFY ASSESS SELECT SUSTAIN
THE PROBLEM THE PROCESS THE SOLUTION THE GAINS DATA
MANAGEMENT
DATA
“House of Quality” Framework

19
How will you build it?
20
Joint Commission International
Mission: to improve the safety and quality of care in the international community
#1 10 100+ 1000+
The world leader Highest number Countries JCI-accredited
in health care of programs served organizations
accreditation approved and
endorsed by
ISQua
21
Based on evidence published in peer-review
literature, accreditation is associated with which of
the following:
1. Improved process performance (i.e., patient
monitoring, diagnostic testing)
2. Sustained compliance with surgical time-out
3. Reduction in staff turnover rate
4. Reduction in readmission rates within 30 days
22
How Does Accreditation Help?
1. STANDARDS
Identify risk areas
— Evidence-based
— Comprehensive
Reduce patient safety risks
— Integrated
Benchmark
Achieve care excellence
2. SURVEY Increase operational efficiency
— Evaluate policies Standardize processes

Create a learning culture
and procedures
— Assess implementation
Develop critical thinking
23
Accreditation Challenges
Top Findings, JCIA (6th Ed.) Asia-Pacific Region, 2019
1 FMS.7 Fire Safety

2 PCI.7 Equipment and Device Infection Risk
3 MOI.4 Standardized codes, approved abbreviations
4 FMS.5 Facilities Management Program data monitoring
5 FMS.4 Safe physical facility
6 MMU.3 Medication safe storage
7 PCI.5 Comprehensive Infection Prevention Program
8 QPS.4.1 Qualified quality professionals to analyze data
8 SQE.11 Medical staff ongoing monitoring
10 PCI.7.4 Food service infection prevention program
24
Coronavirus Disease (COVID-19)
25
Role of Accreditation during Pandemic
Key themes from pandemic
Preparation
Strong Leadership
Data-driven
Collaboration and communication
Resiliency
All of these are described in JCI Standards 26

What does the future look like?
27
A New Era for Quality
28
Reframing Quality
Quality 3.0 Quality 4.0
− Fix a broken process − Find a new way
− Linear thinking − Creative thinking
− Process + Technology
− Process separate from
together
Technology
− Improve how people
− Improve the Process interact with process
− Continuous improvement − Disruptive innovation
− Improvement teams − Diverse Teams
− Data aggregation and − Advanced analytics
analysis (machine learning,
artificial intelligence)
29
The Evolution of Quality
High
Reliability
Quality
Improvement
Quality
Assurance
Standardization
30
High Reliability
Zero falls
Zero complications of care
Zero infections
Zero missed opportunities
Zero overuse
Zero lost revenue
Zero harm events of any kind
31
Conclusions
Quality and
Our ‘new normal’ safety are Accreditation A cultural shift
is accelerating CORE provides an in quality can
change ELEMENTS evidence-based take health care
of the pandemic framework to zero harm
response
32
Thank You
33

Indonesia MoH - March 2021.KLeonhardt - Final

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Indonesia MoH - March 2021.KLeonhardt - Final

Uploaded by

Copyright:

Available Formats

The Future of Health Care Quality-

and how accreditation can take you there!

Indonesia Ministry of Health

Define quality today

Identify key elements of an effective

Recognize the role of accreditation

Greatest Organizational Challenges Faced Due to COVID-19

Most Common Challenges Other Challenges Less Common Challenges

Safety protocols Facility

Base: All Joint Commission Customers (n=700) 6

− National Academies of Sciences, Engineering and Medicine (formerly Institute of

Adapted from “Crossing the Global Quality Chasm”, 2018

Hazardous or Close call, Adverse event

JCI Hospital Standards, 7th Ed: Glossary, QPS.7, 7.1

Trusting, with clear defined

Active, robust reporting of

JCI Hospital Standards 7th Ed.: GLD.13, 13.1

Source: The Joint Commission,

1. Racial and ethnic disparities in healthcare

• Leadership/ • Patient • Patient

“House of Quality” Framework

2. SURVEY Increase operational efficiency

— Evaluate policies Standardize processes

Develop critical thinking

1 FMS.7 Fire Safety

Collaboration and communication

All of these are described in JCI Standards 26

You might also like