JCI Accreditation

Important Information
&
Frequently Asked Questions
“ 1- Important Information
&
General questions ”
Important Information & General questions

 What is JCI?
 What is JCI Accreditation for Hospitals?
 What are the surveyors looking to find?
 What do the surveyors want to know and how?
 What is a “tracer?”
 How should I act if a surveyor started to ask me?
 What are chapters of JCI standards?
What is JCI?

 Accreditation body

 Joint Commission International

 U.S. based
 Not-for-profit

 Sets
standards to create a culture of safety and quality
within an organization.
What is JCI Accreditation for Hospitals?

A voluntary process
 JCI surveyors assess the hospital
 To determine if it meets a set of requirement (standards)
 Which means a visible commitment by hospital to safety &
quality of care.
What do the surveyors want to know?

 How well do our systems work and our processes

function
 What you do and how you do it.
 Communication inconsistencies.
How do the surveyors know that?

 They will usethe tracer methodology.

 Surveyor(s) will ask for a list of:
 Patients presently in the hospital
 Their names
 Current locations in the hospital
 Diagnoses
What is a “tracer?”

 Surveyors will select a patient (probably a complicated case)

and literally trace that patient’s course of care and service
from department to department, through the entire
hospital.
 The surveyor(s) may start a tracer where the patient is
currently located
Individual Patient Tracer Selection Criteria

 Patients who receive complex services

(often those close to discharge)
 Patients who cross programs.
 Top five diagnoses groups.
How should I act if a surveyor started to ask me?

 Don’t attempt to hide, ignore, avoid or run from them.

 Don’t be afraid and remain calm and friendly.
 Respond to questions with confidence, be empowered!
 Relax – surveyors are physicians, nurses, bio-medical
engineers, or others who have worked in hospitals. They’ve
“been there!”
How should I act if a surveyor started to ask me?

 Askto repeat or rephrase questions if unclear.

 Limit your answer to the question (not more not less).
 Keep your answers short and to the point.
 KISS = Keep It Short and Simple
How should I act if a surveyor started to ask me?

 Greet the surveyor (good morning/afternoon).

 Use appropriate language and behaviors.
 NEVER argue with the surveyors.
 Don’t blame others or other departments, they are
evaluating the whole hospital system not you.
What should I do if I don’t know the answer?

Be honest: just tell the surveyor that you don’t know the
answer and you know where to find that information:
 “I would rather talk with my supervisor or check the
policy…”
 “I can get this information through the public/department
share policies.
 What are chapters of JCI standards?
1- Patient-Centered Standards

1. International Patient Safety Goals (IPSG)

2. Access to Care and Continuity of Care (ACC)

3. Patient and Family Rights (PFR)

4. Assessment of Patients (AOP)

5. Care of Patients (COP)

6. Anesthesia and Surgical Care (ASC)

7. Medication Management and Use (MMU)

8. Patient and Family Education (PFE)

 What are chapters of JCI standards?
2- Health Care Organization Management Standards

1. Quality Improvement and Patient Safety (QPS)

2. Prevention and Control of Infections (PCI)

3. Governance, Leadership, and Direction (GLD)

4. Facility Management and Safety (FMS)

5. Staff Qualifications and Education (SQE)

6. Management of Information (MOI)

“ 2- JCI chapters &
Frequently Asked Questions
”
 “
International Patient Safety Goals (IPSG)
”
Who is responsible for Patient Safety?

 Each of us is!
Goal 1: Identify Patients Correctly
How do you identify a patient?

 Use2 patient identifiers (Full name “3 names”, Medical

Record Number).
 Never use the patient’s room number or location.
How do you identify a patient?

 Asking him to tell his name.

 Verifying with the name on ID.
 Verify ID Name and MRN to patient’s MR.
 If a patient cannot tell his name, verify ID band/card
data to patient’s MR.
How do you identify a newborn?
Identification

 If in need to remove at OR, replacement before patient

leaves OR.
 Unidentified Patients got a temporary name (Emergency 1,
2, 3…) with unique MRN, until identification
 For foreigners the name is used as it is in the passport plus
MRN.
How do you identify a patient?

 For OPD card with the 2identifiers. (3 Names & MRN).

 Nurse places an ID band:
 All inpatients, at admission.
 In ED, at registration.
 OPD:
 General Anesthesia (Dental)
 Stress ECG.
 Pediatric Echo.
 Pediatric EEG.
 Day cases
 Contrast and invasive radiological procedures.
When do you identify a patient?

Before:
 Providing treatments (such as administering medications,
blood; serving diet tray; or providing radiation therapy).
 Performing procedures (e.g. IV line or hemodialysis).
 Performing any diagnostic procedures (e.g. taking blood
and other specimens, or performing a cardiac cath. or
diagnostic radiology procedure).
Goal 2: Improve Effective Communication
Goal 2: Improve Effective Communication

The rule is to execute:

 A written order.
 Done by an attending physician to a nurse.
 And nurse signs.
Goal 2: Improve Effective Communication

 Verbaland/or telephone communication among caregivers.

 Reporting critical results of diagnostic tests.
 Handover communication.
NO Verbal and/or telephone orders for:

 High-alert medications including look alike sound alike.

 Starting Narcotic.
 Chemotherapy Ordering.
 Initiating TPN Therapy.
 Blood transfusion.
 Withdrawal of Life Support.
 Physical Restraints.
Verbal and/or telephone orders

 Correct identification and full details

 Physician or sender sign the verbal / telephone order with
24 hours
Goal 2: Improve Effective Communication

 Write Down

 Read Back

 Confirm
Telephone orders

 Accepted only
in situation where the doctor is not
immediately available.
Verbal orders

 Accepted only during situations of difficult or impossible

for hard-copy, e.g. during CPR, and during sterile
procedures.
 Write Down .. Read Back .. Confirm
 In emergency situations: Repeat Back .. Confirm
Reporting critical results of diagnostic tests.

 Any values/ interpretations for which delays in reporting

can result in serious adverse outcomes for patients
 Must be reported immediately to healthcare practitioners
 Require appropriate and timely intervention.
 Also referred to as panic values.
Reporting critical results communication.

Through the call center as witness:

1. By whom (The Sender):
a. Laboratory
b. Radiology
c. Nurse (if point of care testing)
2. To whom (The Receiver):
a. Primary Physician (or designee).
b. In outpatient patient himself/herself and Physician.
What is “Point-of-Care Testing (POCT)”?

 Analytical testing performed

at sites outside the traditional
laboratory environment, usually at or near where care is
delivered to individuals.
Handover communication

 Handover is the transition of a patient from one healthcare

provider to another.
 Also known as a handoff or a transition of care.
 Shift endorsement: between healthcare providers, such as
 Between physicians.
 Between nurses.
 Individual endorsement:
 Between different levels of care in the same hospital: Such as
when the patient is moved from ICU to a medical unit or from
an ED to OR.
 From inpatient units to diagnostic or other treatment
departments: Such as radiology or physiotherapy.
Goal 3: Improve the Safety of High-Alert Medications
Goal 4: Ensure Correct-Site, Correct- Procedure,
Correct-Patient Surgery.
How do your hospital ensure safe surgery:

 Surgical site
marking.
 Preoperative verification process.
 Time-out
Surgical site marking

 An arrow pointing to the site used allover the hospital.

 Made by surgeon/physician who performs procedure
 Must be visible after the patient is prepared.
 Cases of laterality, multiple structures (fingers,
toes, lesions), or multiple levels (spine).
 With patient involved, awake and aware, if possible.
Preoperative verification process.

 In
Ward / ICU, nurse will check patient preparation by using
Ward Pre-Operative Verification Process Checklist.
 InOR / procedure room, OR nurse / procedure room nurse
assess the patient, using Pre-Operative / Procedure
Verification Process Checklist
Time-out

A pause, just prior to performing a surgical or other procedure.

 Held immediately before the start of a procedure.
 Permits any unanswered questions or confusion to be
resolved, before the start of surgery/invasive procedure.
 Even when there is only one person doing the procedure, a
brief pause is appropriate.
Goal 5: Reduce the Risk of Health Care– Associated
Infections

 Before touching a patient.

 Before clean/aseptic procedure.
 After body fluid exposure.
 After touching a patient.
 After touching patient surroundings
Goal 6: Reduce the Risk of Patient Harm Resulting
from Falls
What you will do if you noticed a patient fall or an
opportunity for fall?

 Help and correct the situation.

 Fill in an OVR form.
Inpatient Fall Risk Assessment

 Assessment of fall risk is made by nurses, followed by

precautions according to the level of risk; low, moderate or
severe.
 Who to assess?

 All inpatients will be assessed on admission, EXCEPT all

neonates.
 Inpatients will be reassessed for the risk of fall:
1. If any change in condition that may alter patient consciousness.
2. If patient receive any medication affecting consciousness.
3. After surgery and/or anesthesia.
4. Transfer between different units.
5. Change in patient ambulation.
Inpatient Fall Risk Assessment

 After fall risk assessment:

 If patient is moderate or high risk, precautions will be
implemented and not be assessed during his hospital stay.
 If patient is low risk, precautions will be implemented and
reassessed in the situations mentioned above.
OPD/ED Fall Risk Assessment

 All OPD patients

 All ED patients EXCEPT for category 1 of triage.
Reassessment of OPD/ED Fall Risk

 Any change in condition that may alter the patient’s

Consciousness.
 If the patient receives any medication affecting his/ her
consciousness.
 Post Procedural.