JCI Accreditation

Important Information
&
Frequently Asked Questions
“ 2- JCI chapters &
Frequently Asked Questions
”
 “
Quality Improvement and
Patient Safety (QPS)
”
What is quality?

 Doing the right things right the first time, and every time.
 Compliance with the standards.
 Achieving customers satisfaction.
Then, Who are your customers?

External Customers: Internal Customers:

 Patients  All employees e.g.
 Relatives  Doctors
 Visitors  Nurses
 Companies  Technicians, etc
 Governments
Who is responsible for Quality at your hospital?
What model is used to improve performance
at your hospital?

 FOCUS PDCA
FOCUS
PDCA
What is the culture of safety?

 Organizational culture
 Encourages any individual staff member (clinical or
administrative) to report concerns
 About safety or the quality of care
 Without retaliatory action from the hospital.
How does your hospital evaluate its culture of safety?

 By
the culture of safety survey to ensure that all staff
know how to report an incident and have no fair
while reporting incidents.
What is Incident Report/Occurrence Variance Report (OVR)

 Itis a form that is filled out in order to record details of

an unusual event that occurs at the facility, such as
Sentinel Events, Adverse Events and Near Misses.
Who can/should report such variances?

 Everybody
What is an Adverse Event?

 An unanticipated, undesirable, or potentially dangerous

occurrence in a health care organization.
 A “near miss” falls within the scope of the definition of an
adverse event.
What is a Near Miss?

 Any process variation that did not affect an outcome

But
 a recurrence carries a significant chance of a
serious adverse outcome.
What is a Sentinel Event?

 An
unanticipated occurrence involving death or
major permanent loss of function.
What are examples of a Sentinel Event?

 An unanticipated death e.g. from a postoperative

infection or a hospital-acquired pulmonary embolism,
death of a full-term infant; or suicide
 Major permanent loss of function unrelated to natural
course of illness or underlying condition;
 Wrong-site, wrong-procedure, wrong-patient surgery
What are examples of a Sentinel Event?

 Transmission of a chronic or fatal disease as a result of

infusing blood or blood products
 Infant abduction or an infant sent home with wrong parents
 Rape
 Workplace violence such as assault (leading to death or
permanent loss of function)
 Homicide (willful killing) of a patient, staff, visitor,….
What is a Root Cause Analysis (RCA)?

A process for identifying the basic or causal factor(s) that

underlies variation in performance, including the
occurrence or possible occurrence of a sentinel event.
How could you reach hospital wide policies, bill of rights,
OVR form, medical record forms and quality communications?

 At public share: Quality folder

 “
Patient and Family Rights (PFR)
”
What are patient rights you know?

 Know my identity, so I wear my ID badge at all times.

 Respect his values, beliefs, privacy & confidentiality
 Be protected from physical or non-physical assault
 Protect his possessions (submitting to the hospital security)
 Complaining /suggesting
What are patient rights you know?

 Participate in care decisions and sign informed consent

 Seek a second opinion without fear
 Refuse or discontinue treatment
 Assess and manage his pain
Does a patient have a right to refuse treatment?

 Of course yes.
When/How do you ensure patient’s right to Privacy?

 During all clinical interviews, procedures/treatments,

examinations, and transport.
 Knocking before entering a room
 keeping doors closed during treatments and times of care
 Keep curtains closed, exposing only areas needed during
surgery or any examination.
How do you ensure the patient’s right to Confidentiality?

 Not to post confidential information on the patient’s door

or at the nursing station.
 Not to hold patient-related discussions in public places.
 How does our hospital obtain informed consent?

The physician talks to the patient/family, and both sign the consent :
 Patient’s condition;
 Proposed treatment(s);
 Potential benefits and drawbacks.
 Possible alternatives.
 Likelihood of success.
 Possible problems related to recovery.
 Possible results of non-treatment.
‫• تتم كتابة التشخيص وليس ال ‪ Complaint‬أو إسم ال‬
‫‪Procedure‬‬

‫• إختيار نوع التخدير‬

‫• كتابة جميع بيانات المريض‬

‫• كتابة جميع بيانات الطبيب والشاهدين‬

‫اإلسم وال ‪ ، ID‬أو إستخدام ال ‪ ، Stamp‬إن وجد‬ ‫•‬
‫التوقيع ‪ ،‬وال يغنى عنه إستخدام ال ‪ ، Stamp‬إن وجد‬ ‫•‬

‫• تتم كتابة نفس التاريخ والوقت (‪ ) Military‬لكل من‬

‫المريض‪ ،‬الطبيب والشاهدين‬
How do you manage complaints from
patients/family member or visitors?

 First, I listen, so that the patient feels heard.

 Second, correct the situation, if I’m able.
 If not resolved, then or the patient/family feels unsatisfied,
I involve my supervisor.
 If still not resolved, I call the Patient Relations Section.
How could patients/ families present a complaint?

Contact Patient Relation Officers through:

 Hospital hotline: (19444)
 Make written complaints/suggestions through boxes
 Hospital website.
What if a female patient asked for female provider?

 We respect patient’s preferences of Male/Female

provider, so a female clinician shall be called to examine
the Patient, when available.
What will you do if a patient speaks French only?

 Follow Elaraby Hospital policies of: Overcoming Patient

Barriers and Patient Participation in Care Process
 Inform the call center, to use the list of staff with special
interpreting capabilities or contact embassy to get
interpreter.
How do you overcome patient barriers: (Hearing)

 Our hospital provides a free of charge patient associate

(e.g. a relative) with sign language interpreting capabilities.
How do you overcome patient barriers: (Sight)

 Our hospital provides a nurse to help the patient as

long as he/she is in the hospital or other-wise the
hospital provides a free of charge patient associate
(e.g. a relative) to help the patient.
How are patients informed about their Rights &
Responsibilities?

 Bill ofRights is displayed in Arabic & English:

 Banners in public areas of the hospital
 Included in the hospital website
 In waiting areas presented through TV screens.
 Each patient can get a copy of the Bill of Rights from
reception.