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Introduction to the JCI Standards © Copyright, Joint Commission International
Overview of Joint Commission International (JCI) Acreditation The Transparent JCI Process Dr Arjaty W Daud MARS
On-site Evaluation of Standards
Accreditation Certificate
International Standards CURICULUM VITAE
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Client name/ Presentation Name/ 12pt - 2
Nama Alamat Tmpt / tgl. Lahi Status Email Hp
: dr. Arjaty W. Daud, MARS : Jl Kemang Timur XIV / 56 Jakarta Selatan : Manado,17 Januari 1969 : Menikah :
[email protected], : 0812 1830 7169
© Copyright, Joint Commission International
Accreditation Decision Rules
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PENDIDIKAN S-1 Fakultas Kedokteran Universitas Sam Ratulangi - Manado , Lulus 1995 S-2 Fakultas Kesehatan Masyarakat, KARS Universitas Indonesia, Lulus 2005
PELATIHAN / SEMINAR 2015 : Practicum Acreditation JCI 5th edition Singapura 2011 : Practicum Acreditation JCI 4th edition Seoul Patient Safety Course, Singapura 2010 : Safety in Healthcare, Kuala Lumpur 2009 : Hospital Management Asia, Vietnam Course Risk Management PRMIA Jakarta 2007 : New Perspektif, Conferrence ASHRM, Chicago USA Certified Profesional Healthcare Risk Management course, Chicago USA Risk Management Base Training, Joint Commision Resources (JCR) Patient Safety Up Date, Joint Commision International (JCI) Singapura 2005 : Lead Audior ISO 9001 – 2000, International Registered Certificated Auditor (IRCA) 1/31/17
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PENGALAMAN KERJA 2016 : Konsultan JCI RS Sutomo 2015 : Konsultan JCI RS Islam Cempaka putih Jakarta, RS Advent Bandung, RS JMC Jakarta 2014 : Konsultan JCI RS MMC Jakarta, RS Kanujoso Blkppn, RS Sleman Jogja, RS Tarakan Kaltara 2013 : Konsultan JCI RS kanujoso Blkppn, RS Sleman 2012 : Konsultan JCI RSUP Fatmawati, RSUP Wahidin Sudirohusodo Makasar, RS Medistra 2011 : Konsultan JCI RSCM, Konsultan Manajemen Risiko & Keselamatan Pasien RS Tarakan Kaltim 2010 : Konsultan Manajemen risiko RSUP Fatmawati Jakarta, RS Bieuren, RS Lhoksemawe Aceh 2009 : Konsultan Manajemen risiko & Kes Pasien RS Wahidin Makasar, RS Pelni Jakarta Konsultan RS Aini, RS Sardjito 2007 : Direktur RS Zahirah Konsultan Manajemen risiko RS Persahabatan, RS Dharmais 2006 Konsultan Manajemen RS Asri, Konsultan Manajemen RS Medika BSD, 2004 - 2005 : Manajer Operasional Medika Plaza International Clinic 2003 : General Manajer Cempaka Medical Centre 2003 - 2004 : Direktur Operasional RS Sentra Medika 2002 - 2003 : Wakil Direktur Medik & Asist Direktur RS Sentra Medika 2000 - 2001 : Kepala Bagian Humas RS MMC 1999 - 2000 : Kepala Bagian Rehabilitasi Medik RS MMC 1999 : Asisten Konsultan WHO Umbrella Project Depkes 1996 -1999 : Kepala Puskesmas Sindang Barang Kabupaten Cianjur ORGANISASI 2007 – 2012 : Ketua Bidang IV (Pelaporan Insiden) KKP RS PERSI , Sterring Committe KKP RS 2005 - Saat ini:Ketua Institut Manajemen Risiko Klinis (IMRK) / ICRMI Member of ASQ (American Quality Society), Member of Profesional Risk Management International Association
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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) 1/31/17
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Health Care Organization and 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)
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Academic Medical Center Standards* 1. Medical Professional Education (MPE) 2. Human Subject Research Programs (HRP)
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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. Sukarela -à Penghargaan
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STANDARD (STRUKTUR, PROSES, OUTCOME)
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The Accreditation Journey The Basics • Evaluate the commitment of leadership (Board, CEO, and clinical leaders) to a never ending journey. • Assess the purpose safe, high quality organization. • Set a clear understanding that the process will require significant leader time. • Assigning accreditation only to the quality department will not work.
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The Transparent JCI Process ON ATI
RM SFO Y N RA ALIT YT NE O QU R T JOU
ST CO
ACREDITATION CERTIFICATE
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Accreditation Preparation Process nal atio aniz ent g r O esm Ass
ur e yo luat Eva nt e r r u n c a ce orm perf ts the d in a g a s an nd a dart stan e plans ive r t a e to d cr e r u t ct Start stru vemen o r imp
cy & Poli dure ce o r P t men polices elop t Dev lop new res tha e Dev rocedu JCI p h d wit an ply com arts d s ta n
nt ume Doc view Re
cal hni Tec stance i Ass
r you ess d Ass ies an for c Poli edures with c o c pr plian e ts r com tanda s JCI
to erts sistant exp r Use ess pe r add ifficult or d lems b pro
s. plan
Moc
rvey k Su
t rren onths s cu ses nce 6 m allow s a Re orma vey to o r f t per r to su time h prio enoug inutes m u t o s y e la s mak tment JCIA y s e adju Surv
Create New Processes
Monitor progress and Adjust
Develop and implement new policies, plans, and procedures
Evaluate effectiveness of processes and refine ad necessary
18-24 Months
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ROAD MAP
Mock Survey Implementasi
Tindak AKREDITASI JCI lanjut hasil Mock Survey
Sosialisasi & Simulasi
Pra Sosialisa si Gap Analysis Review Dokume n
Scheduling your Mock Survey • Jika and ingin disurvey dipertengahan November) Track record period July
Aug
Sept
Oct
Nov
Survey • Start of 4 month track record
• Track Record Period: the period of time prior to your survey within which surveyors will examine compliance. (Track record period : periode waktu sebelum survey untuk menilai kepatuhan anda) arjaty / JCI Edisi 5 /2015
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Scheduling your Mock Survey Fix issued identified during the Mock Survey
Feb
March
April
Schedule your Mock survey
Mei
Juni
Mock survey
July
Aug
Sept
Oct
Start of 4 month track record
Nov
Survey
• Schedule your Mock Survey at least two months before the start of your track record to give you time to fix identified issues (jadwalkan Mock survey minimal dua bulan sebelum waktu mock survey yg diinginkan untuk membenahi isu yg ada) • . arjaty / JCI Edisi 5 /2015
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The Last 10 Moths Fix issued identified during the Mock Survey
Feb
March
Schedule your Mock survey
April
Mei
Juni
Mock survey
July
Track record period
Aug
Sept
Oct
Start of 4 month track record
Nov
Survey
Scheduled Actual survey
• • • •
4 months before survey: Track Record Starts 6 months before survey: Schedule your survey 6 - 8 months before survey: mock survey 10 months before survey: schedule your mock survey. arjaty / JCI Edisi 5 /2015
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Make Final Modifications • Make any final improvements using the information from your Mock Survey. (buat perbaikan final dengan menggunakan informasi dari hasil mock survey) • Don’t make improvements just to pass the survey, your improvements should be durable improvements to patient safety. (jangan buat perbaikan hanya untuk lulus akreditasi, PERBAIKAN ADALAH UNTUK MENINGKATKAN KESELAMATAN PASIEN) 1/31/17
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PENGORGANISASIAN AKREDITASI Core Team
Direktur Utama
• • • WALI 1 Wadir Yan Medik
WALI 2 wadir….
KA PANITIA AKREDITASI Sekretariat Koord Dokumen Koord sosialisasi Koord Telusur
WALI 3 Wadir …
WALI 4 Wa Dir …..
ACC
IPSG
SQE
AOP
PFE
MPE
FMS
COP
PFR
HRP
QPS
ASC
PCI
MMU
MOI
GLD
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Standards Content Each JCI standard contains three components: 1. The standard represents the principle 2. The intent describes the rationale of the standard 3. The measurable elements are the detailed requirements from the standard and intent that are scored
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What is a Standard? A statement of the safety and quality expected Types of Expectations in Standards – Inputs (Structures) : Resource – Processes : Activities – Outcomes : Results
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CHAPTER STANDAR 12 APR 10 IPSG 19 PFR 38 AOP 26 COP 16 ASC 19 MMU 5 PFE 12 QPS 20 PCI 33 GLD 23 FMS 24 SQE 16 MCI 7 MPE 10 HRP
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ME
30 76 162 107 54 77 17 53 72 184 91 99 63 30 42
CHAPTER STANDAR 6 IPSG 23 ACC 30 PFR 44 AOP 22 COP 14 ASC 21 MMU 7 PFE 23 QPS 24 PCI 27 GLD 27 FMS 24 SQE 28 MCI
1.157
320
ME
24 103 100 184 74 51 84 28 89 83 98 92 99 109
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Adaptable Standards Example STANDARD PFR.5.4 The hospital establishes a process, within the context of existing law and culture, for when others can grant consent. (RS --à Proses General Consent ) INTENT STATEMENT Informed consent for care sometimes requires that people other than (or in addition to) the patient be involved in decisions about the patient’s care. This is especially true when... culture or custom requires that others make care decisions... MEASURABLE ELEMENTS 1. The hospital has a process for when others can grant informed consent. ( RS à Proses general consent diberikan oleh selain pasien) 2. The process respects law, culture, and custom. (Proses sesuai hukum, budaya dan adat) 3. Individuals, other than the patient, granting consent are noted in the patient’s record. (Pemberi General consent selain pasien tercatat dlm RM) 1/31/17
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Contoh Komponen Standar
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Scoring of Lists in Intent Statements • Note that there are two ways the lists in the Intent Statements are scored. ( 2 cara skoring “intent”) – Lists that are designated by letters (e.g. a – h) or numbers (e.g. 1 – 11) are mandatory, and are referenced in MEs (list dgn huruf : mis a-h atau nomor 1-11à wajib) – Lists that are marked by bullet points () are advisory in nature (list dgn bullet à dianjurkan • The mandatory elements are reflected in the Measurable Elements and full compliance with them is required ( Elemen yg wajib -à ME à kepatuhan) • The bulleted elements are not scored as such, but ignoring them completely will lead surveyors to “drill down” and ask what else was considered in compliance with the standard (Elemen “bullet” tidak di skoring, tapi dapat menjadi pertanyaan surveyor untuk menilai kepatuhan standar) 1/31/17 22 Arjaty / JCI Edisi 5/2015
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abuse and neglect are shaped by the culture of the patient population. These assessments are not intended to be proactive case-finding processes. Rather, the assessment of these patients responds to their needs and condition in a culturally acceptable and confidential manner. The assessment process is modified to be consistent with local laws and regulations and professional standards related to such populations and situations and to involve the family when appropriate or necessary. (Also see AOP.1.2 and AOP.1.2.1)
Measurable Elements of AOP.1.6 1. The hospital identifies, in writing, those special patient groups and populations it serves that require modifications to its assessment.
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2. The assessment process for special-needs patient populations is modified to reflect their needs. 3. The modified assessment process is consistent with local laws and regulations and incorporates professional standards related to such populations.
Standard AOP.1.7
Dying patients and their families are assessed and reassessed according to their individualized needs.
Intent of AOP.1.7 Assessments and reassessments need to be individualized to meet patients’ and families’ needs when patients are at the end of life. Assessments and reassessments should evaluate, as indicated by the patient’s condition, a) such symptoms as nausea and respiratory distress; b) factors that alleviate or exacerbate physical symptoms; c) current symptom management and the patient’s response; d) patient and family spiritual orientation and, as appropriate, any involvement in a religious group; e) patient and family spiritual concerns or needs, such as despair, suffering, guilt, or forgiveness; f) patient and family psychosocial status, such as family relationships, the adequacy of the home environment if care is provided there, coping mechanisms, and the patient’s and family’s reactions to illness; JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 5TH EDITION g) the need for support or respite services for the patient, family, or other caregivers; h) the need for an alternative setting or level of care; and i) survivor risk factors, such as family coping mechanisms and the potential for pathological grief reactions.
Measurable Elements of AOP.1.7
1. 1.A discharge summary is prepared qualifiedand individual. Dying patients and their familiesbyarea assessed reassessed for those elements in a) through i) of the
intent, according to their identified needs. 2. A copy of the discharge summary is provided to the practitioner responsible for the patient’s continuing 2.or follow-up Assessmentcare. findings guide the care and services provided. (Also see AOP.2, ME 2) 3. Assessment findings are documented in the patient record.
3. A copy of the discharge summary is provided to the patient in cases in which information regarding the 23 practitioner responsible for theArjaty patient’s continuing or follow-up care is unknown. / JCI Edisi 5/2015 Standard 4. A copy of theAOP.1.8 completed discharge summary is placed in the patient's record in a time frame identified The initial assessment includes determining the need for discharge planning. by the hospital.
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Assessment of Patients (AOP)
Measurable Elements of ACC.4.3.2
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Access to Care and Continuity of Care (ACC)
Standard ACC.4.4
The records of outpatients requiring complex care or with complex diagnoses contain profiles of the medical care and are made available to health care practitioners providing care to those patients.
Intent of ACC.4.4 When the hospital provides ongoing care and treatment for outpatients with complex diagnoses and/or who need complex care (for example, patients seen several times for multiple problems, multiple treatments, in multiple clinics, and/or the like), there may be an accumulated number of diagnoses and medications and an evolving clinical history and physical examination findings. It is important for any health care practitioner in all settings providing care to that outpatient to have access to information about the care being provided. The process for providing this information to health care professionals includes identifying the types of patients receiving complex care and/or with complex diagnoses (such as patients seen in the cardiac clinic with multiple comorbidities, or patients with end-stage renal failure); identifying the information needed by the clinicians who treat those patients; determining what process will be used to ensure that the medical information needed by the clinicians is available in an easy-to-retrieve and easy-to-review format; and evaluating the implementation results to verify that the information and process meet the needs of the clinicians and improve the quality and safety of outpatient clinical services. Arjaty / JCI Edisi 5/2015 Measurable Elements of ACC.4.4
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1. The hospital identifies the types of outpatients receiving complex care and/or with complex diagnoses who require an outpatient profile. 2. The information to be included in the outpatient profile is identified by the clinicians who treat those patients. 3. The hospital uses a process that will ensure the outpatient profile is available in an easy to retrieve and review format. 4. The process is evaluated to see if it meets the needs of the clinicians and improves the quality and safety of outpatient clinical visits.
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Policy Requirements • Some standards require organizations to have a written policy or procedure for a specific process. (Standardà RS buat Kebijakan & SPO) • These standards will be marked with our “policy required” symbol.
P
• All policies and procedures will be scored at MOI.9 and MOI.9.1 232 (Kebijakan & SPO di skor di MOI 9, 9.1) 1/31/17
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DOCUMENT REVIEW • Tujuan : survei kepatuhan pada standar. • Peserta : – staf yang paham dokumen yang akan disurvei, – penerjemah yang profesional. • Tim surveyor dapat menunjuk sejumlah staf yg hadir / (dibatasi ) dalam sesi Dokumen Review. • Sesi adalah wawancara dengan staf tentang dokumen. • Hampir semua chapter membuat Plans, Policies, and Procedures tertulis.
Document Review
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Dokumen yang harus di translate ke Bahasa Inggris
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How to Prepare • Banyak dokumen yang diperlukan menjadi bagian dari dokumen lain. RS tidak perlu fotokopi bagian dokumen2 ini. Sebaliknya, dokumen2 dapat diidentifikasi menggunakan bookmark / daftar dokumen. • Notulen dan laporan2 dari Komite2, bisa diberikan dokumen asli / fotokopi. Beberapa contoh dokumen, seperti Notulen2 komite dari beberapa pertemuan terakhir. • Jika RS memiliki contoh2 yang banyak pada topik tertentu, harus dipilih yang paling representatif atau contoh yang paling relevan. Surveyor tidak ada waktu untuk meninjau semua dokumen 1/31/17
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• Organization of the Materials • Dokumen di buat Daftar agar memudahkan pencariannya saat dibutuhkan surveyor & harus tersedia. • Pengelompokan dokumen sesuai dengan tiga daftar berikut ini: 1. Data Mutu yg dipersyaratkan 2. Program RS yg dipersyaratkan 3. Kebijakan RS yg di persyaratkan • Dokumen2 dapat dikelompokkan dalam binder atau folder, atau cara lain yang dapat digunakan untuk memudahkan pencariannya 1/31/17
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Evaluation of the Policies and Procedures by the Survey Team • Evaluasi Dokumen tujuanya agar Surveyor mendapat gambaran apa yang diharapkan saat Tracer. Misalnya, ketika ada SPO baru tentang pembuangan limbah infeksius : A P A K A H ??? – Staf telah di sosialisasikan tentang SPO baru tsb – ︎(Special skills) keahlian khusus / pelatihan yang dibutuhkan telah dilakukan – Pembuangan limbah sudah dibuang sesuai prosedur baru – ︎Dokumen2 yang diperlukan sesuai SPO tersedia untuk direview • The “Management and Implementation of Documents” bagian dari chapter MOI akan digunakan untuk mengevaluasi kepatuhan dalam mengembangkan dan menerapkan kebijakan 31 dan SPO. (MOI 9) 1/31/17 arjaty/JCI/2015
• Kebijakan / SPO saja tidak dapat menentukan skor . • Sebaliknya, skor ditentukan oleh implementasi terhadap kebijakan atau SPO. • Tim survei akan mencari bukti implementasi terkait kebijakan / SPO, apakah diterapkan dengan baik, secara menyeluruh dan konsisten • Tidak adanya satu kebijakan atau kurangnya implementasi dari salah satu kebijakan kemungkinan besar tidak dapat di skor.. • Jika beberapa kebijakan tidak ada / beberapa kebijakan belum sepenuhnya dilaksanakan, -à indikasi Systemwide problem related to policy . • Scoring dari MOI.9.1 akan didasarkan pada persentase kebijakan yang tidak dibuat dan / atau tidak sepenuhnya dilaksanakan 1/31/17
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Penilaian surveyor meliputi : 1. Dokumen : 3P ? 2. Dokumen sesuai standard yg di syaratkan? 3. Implementasi sesuai dokumen standard ? 4. Implementasi Konsisten & menyeluruh di semua are RS ?
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• Secara umum, lamanya waktu kebijakan telah diimplementasikan disebut “Track record.” • Tim survei akan mencari 4 bulan Track record untuk standar terkait kebijakan selama survei awal dan untuk Track record 12- bulan selama survei tiga tahunan. • Untuk standar terkait kebijakan akan diberi skor fully met jika persyaratan track record dipenuhi. • Jika waktu track record belum terpenuhi, namun Tim survei menemukan bahwa kebijakan tersebut telah dilaksanakan secara berkelanjutan, tim memiliki hak prerogatif untuk memberi skor fully met 1/31/17
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• Track record untuk standar yang baru di hitung dari "tanggal efektif" dengan tanggal survei. • Sebagai contoh, jika sebuah standar baru / (ME) efektif pada 1 Januari, dan survei berlangsung pada 1 Juni di tahun yang sama, track record yang diperlukan untuk standar baru / ME adalah 5 bulan untuk “fully met”
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