2009 Middle Eastern International Practicum on Quality Improvement and Accreditation Joint Commission International Amman, Jordan Grand Hyatt Amman 13 - 17 December 2009
Joint Commission International (JCI) would like to graciously thank the Jordanian Private Hospital Association for their assistance in hosting the 2009 Amman International Practicum. JCI would also like to thank our tracer demonstration hosts, The Specialty Hospital and the King Hussein Cancer Center, for their generous contribution of time and resources.
1
Table of Contents Day 1: The JCI Process and Standards Agenda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Overview of JCI and Practicum Logistics . . . . . . . . . . . . . . . . . . . . . . . . . 9 JCI Process 1: Introduction to the JCI Standards . . . . . . . . . . . . . . . . . . .25 JCI Process 2: Introduction to the Evaluation Methodology . . . . . . . . . .36 Patient-Centered Standards Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Organizational Management Standards Review. . . . . . . . . . . . . . . . . . . .61 Access to Care and Continuity of Care Standards. . . . . . . . . . . . . . . . . . .81 JCI Process 3: After the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Day 2: The Survey Process Tracer Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 The Survey Simulation: What to expect. . . . . . . . . . . . . . . . . . . . . . . . . . .114 Case Study 1: Answering Tracer Questions . . . . . . . . . . . . . . . . . . . . . . . 123 Root Cause Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Day 3: The Survey and Continual Improvement Failure Modes and Effects Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148 Failure Modes and Effects Analysis Example Sheets . . . . . . . . . . . . . . .169
Day 4: The Survey and International Patient Safety Goals Last Survey Simulation Discussion and Reflective Learning . . . . . . . . . .177 Four Steps for Continual Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Day 5: Tools and Techniques Communication Between Hospital Staff, Patients, and Families . . . . . . 191 International Patient Safety Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .205 How to Get Started with JCI Accreditation. . . . . . . . . . . . . . . . . . . . . . . . 214
Appendix Tracer Activity Data Collection Tool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Speaker Biographies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
2
2009 Amman Practicum Agenda
Day 1: The JCI Process and Standards
13 December
-
End 9:00
Session Registration
9:00
-
9:30
Welcome
Dr. Ashraf Ismail and Dr. Fawzi Al Hammouri, MD, President, Jordanian Private Hospital Association
9:30
-
9:45
Introduction of Joint Commission International and Practicum Overview
Mr. Matt Spurgeon
9:45
-
10:15
The JCI Process 1: Introduction to JCI Standards
Dr. Ashraf Ismail
10:15
-
10:30
Break
10:30
-
11:00
The JCI Process 2: Introduction to Evaluation Methodologies
Ms. Sherry Kaufield
11:00
-
12:15
Patient-Centered Standards Review
Dr. Ashraf Ismail
12:15
-
13:15
Lunch
13:15
-
14:30
Organizational Management Standards Review
14:30
-
14:45
Break
14:45
-
15:30
Standards in Detail: Access to Care and Continuity of Care (ACC)
Ms. Sherry Kaufield
15:30
-
16:15
The JCI Process 3: After the Survey
Dr. Ashraf Ismail
Start 7:30
Speaker
Ms. Sherry Kaufield
3
2009 Amman Practicum Agenda Day 2: The Survey Process Start
14 December
End
Session
Speaker
9:00
-
10:00
JCI Evaluation Methods: Tracer
Ms. Sherry Kaufield
10:00
-
10:30
The Survey Simulation
Ms. Sherry Kaufield
10:30
-
10:45
Break
10:45
-
11:45
Mock Opening Conference
11:45
-
13:15
Lunch and Travel
13:15
-
14:15
AM Goup: Case Study 1
14:15
-
15:15
Root Cause Analysis
15:15
-
16:30
The Speciality Hospital Leadership and Consultants, Moderator: Dr. Ashraf Ismail
Ms. Sherry Kaufield and Mr. Matt Spurgeon
PM Group: Introductory Tracer Simulation Ms. Sherry Kaufield and Mr. Matt Spurgeon
AM Group Adjourns at 3:15 PM
Day 3: The Survey and Continual Improvement Start
15 December Session
End
9:00
-
10:20
PM Group: Survey Simulation Discussion and Reflective Learning
10:20
-
10:40
Break PM Group: Advanced Quality Strategies: FMEA
10:40
-
12:00
12:00
-
13:30
13:30
-
14:50
14:50
-
15:10
15:10
-
16:30
Speaker
Ms. Sherry Kaufield and Mr. Matt Spurgeon AM Group: Introductory Tracer Simulation
Lunch and travel AM Group: Survey Simulation Discussion and Reflective Learning Break PM Group: Final Tracer Simulation AM Group: Advanced Quality Strategies: FMEA
Ms. Sherry Kaufield and Mr. Matt Spurgeon
Ms. Sherry Kaufield and Mr. Matt Spurgeon
Ms. Sherry Kaufield and Mr. Matt Spurgeon
4
2009 Amman Practicum Agenda
Day 4: The Survey and International Patient Safety Goals Start
16 December Session
End
Speaker
9:00
-
9:45
PM Group: Survey Simulation Discussion and Reflective Learning
9:45
-
10:00
Break
10:00
-
11:00
Root Cause Analysis
11:00
-
12:00
PM Group: Case Study 1
12:00
-
13:15
Lunch and Travel
13:15
-
14:00
Challenging Standards
14:00
-
14:15
Break
14:15
-
15:30
Lessons Learned From Local Accredited Organizations: King Hussein Cancer Center
Moderated by Ms. Sherry Kaufield
16:00
International Patient Safety Goals
Dr. Ashraf Ismail
15:30
16:00
-
16:45
Ms. Sherry Kaufield and Mr. Matt Spurgeon
AM Group: Final Tracer Simulation
Ms. Sherry Kaufield and Mr. Matt Spurgeon
Ms. Sherry Kaufield and Mr. Matt Spurgeon
AM Group: Survey Simulation Discussion and Reflective Learning
PM Group adjourns at 4:00 PM
Dr. Ashraf Ismail
Ms. Sherry Kaufield and Mr. Matt Spurgeon
Day 5: Tools and Techniques Start
17 December
End
Session
Speaker
All Faculty
9:00
-
10:00
Small Group Discussions
10:00
-
10:30
Check-Out Break
10:30
-
11:30
Communication Between Hosptial Staff, Patients, and Families
Dr. Ashraf Ismail
11:30
-
12:00
The Cost of Accreditation
Ms. Sherry Kaufield
12:00
-
13:00
Lunch
13:00
-
13:45
Lessons Learned From Local Accredited Organizations: The Specialty Hospital
Moderated by Dr. Ashraf Ismail
13:45
-
14:30
Getting Started: Advice for those seeking their first Accreditation
Ms. Sherry Kaufield
14:30
-
15:00
Closing Remarks and Presentation of Certificates
All Faculty
5
Learning Objectives 2009 Middle Eastern International Practicum on Quality Improvement and Accreditation Amman, Jordan 13 – 17 December Course Objectives Participants who complete this program will be able to: 1. Use the 3rd Edition of Hospital Standards to identify and understand accreditation requirements 2. Explain the most challenging and difficult standards 3. Implement needed measures to comply with JCI Accreditation Standards for Hospitals 4. Explain the activities that take place during a survey 5. Implement the processes necessary to reduce the risks for errors and improve safety
Specific Session Objectives Understanding the Tracer Methodology Survey Process Participants who complete this learning section will be able to: 1. Explain the major attributes of the tracer methodology process 2. Begin to use elements of the tracer methodology to improve the delivery of healthcare in their organization 3. Use the tracer methodology to assess relationships and communications among disciplines and across important functions Root Cause Analysis Participants who complete this learning section will be able to: 1. Explain the major attributes of the root cause analysis method 2. Use RCA to understand how and why adverse events occur in their organization 3. Use RCA data to minimize the repetition of similar adverse events Getting Started: The Road to Accreditation Participants who complete this learning section will be able to: 1. Explain how the accreditation process functions 2. Explain the timeline for accreditation 3. Develop a plan for meeting the requirements of accreditation
6
International Patient Safety Goals Participants who complete this learning section will be able to: 1. Explain how the International Patient Safety Goals (IPSGs) function within the context of the International Standards for Hospitals, 3rd Edition 2. Explain the changes that the IPSGs bring to the accreditation process 3. Explain the current set of IPSGs
7
Day 1: The JCI Process
8
© Copyright, Joint Commission International
Welcome to Joint Commission International
Matthew Spurgeon Associate Director, International Service Joint Commission International
© Copyright, Joint Commission International
Overview of JCI and Practicum Logistics
Welcome
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– We are pleased to welcome you to the first Amman Practicum
9
Mission of Joint Commission International
– Thank you for joining us in our shared mission to positively impact the lives of patients around the world. Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– To improve the safety and quality of care in the international community
What is JCI?
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– Joint Commission International (JCI) is the international arm of The Joint Commission (USA). – Both organizations are independent, non-profit, non-governmental agencies
– International Board of Directors (of JCR) – International Accreditation Committee – International Standards Committee – Regional Advisory Councils – Four International Offices
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
JCI’s International Structure
10
Mission Work at Three Levels – Individual organizations – accreditation, consultation, and education – assist Ministries of Health and Governmental Agencies to strengthen the role of quality oversight
– International level – build consensus; share quality and safety information Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– Country level efforts
Accreditation
Consulting
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
The Joint Commission Family of Organizations
Accreditation
Consulting
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
The Joint Commission Family of Organizations
11
The Joint Commission Family of Organizations
Consulting
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Accreditation
The Joint Commission Family of Organizations
Consulting
•Assist organizations in meeting their patient safety and accreditation goals
•Education for accredited organizations •Development of new standards
•Consulting service •Custom Education
© Copyright, Joint Commission International
Accreditation
•Accreditation survey
•Accreditation and Quality Improvement education for all organizations. Introduction to JCI and Accreditation
Accreditation – A Definition – Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions which meetS certain H standards that require continuous improvement in structures, processes, and outcomes. d
id
Vo HANGRI-LA OSPITAL id El Dorado, Republic of Freedonia Vo id Vo id Vo id
Vo id
am p
le
Sa mp le
Sa mp le
Sa mp le
S
Vo
Introduction to JCIamand ple Accreditation Sa mp le
© Copyright, Joint Commission International
Vo
12
JCI Accredited Organizations
Currently, JCI has accredited over 273 of the world’s best healthcare organizations
JCI Accredited Organizations Demark Ireland
Germany Cz. R. Aus Swz. Italy
Spain Turkey
S. Korea
China Lebanon Jordan
Bermuda
Pakistan
Egypt
Mexico
Qatar
Taiwan
India
UAE
Saudi Arabia
Bangladesh
Hong Kong
Thailand
Philippines
Barbados Costa Rica
Ethiopia Malaysia Singapore
Indonesia
Brazil
Chile
Currently, JCI has accredited over 273 of the world’s best healthcare organizations
JCI Accredited Organizations Demark Ireland
Germany
JCI European Office
Cz. R. Aus Swz.
Ferney-Voltaire, France
JCI Headquarters
Italy
Spain
Chicago, USA
Turkey
S. Korea
China Bermuda
Lebanon Jordan Pakistan
Egypt
Mexico
Qatar
Saudi Arabia
UAE
Taiwan
India Bangladesh
Hong Kong
JCI Middle East Office Dubai, UAE
Thailand
Philippines
Barbados Costa Rica
Ethiopia Malaysia Singapore
JCI Asia-Pacific Office Singapore Indonesia
Brazil
Chile
JCI’s work is supported by our headquarters and three regional offices
13
JCI Accreditation and Quality Improvement Assistance
© Copyright, Joint Commission International
Consulting, Education, Publications, Tools
– JCI recognizes that the accreditation and quality improvement process can be difficult and confusing. – JCI has assembled a global group of experts and resources to help organizations achieve our common goal: Increased patient safety and continuous quality improvement Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Assistance from JCI
Assistance from JCI – JCI’s assistance is separated into three categories:
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– Consulting Assistance – Education Programs – Publications
14
Accreditation
Consulting
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
The Joint Commission Firewall
The Firewall Consulting
– No sharing of organization-specific information – Neither side may share their “client” list. – Ensures the integrity of our accreditation decisions and consultation advice. Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Accreditation
JCI Consulting Assistance
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– JCI Consultants are available to provide expert education and advice. – JCI Consultants provide a wide scope of services, designed to meet the needs of our partner organizations.
15
Typical Preparation Process
in g go al On hnic e c c Te istan s s A
m cu Do
t en
ite f-s Of view e R
S ck Mo
IA JC y ve ur
y rve Su
in g go al On hnic e c c Te istan s As
18-24 Months Introduction to JCI and Accreditation
© Copyright, Joint Commission International
al on ati nt z i n me ga Or sess As
Matthew Spurgeon Associate Director, International Service Joint Commission International
© Copyright, Joint Commission International
Practicum Logistics
Learning Objectives 1. Use the 3rd Edition of Hospital Standards to identify and understand accreditation requirements 2. Explain the most challenging and difficult standards 3. Implement needed measures to comply with JCI Accreditation Standards for Hospitals 4. Explain the activities that take place during a survey 5. Implement the processes necessary to reduce the risks for errors and improve safety
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
After completing this course, participants will be able to:
16
– Overview of the entire accreditation process – Overview of the JCI’s methodology – Comprehensive review of individual standards replaced by overviews of challenging standards and case studies. Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Day 1: The JCI Process
Day 2: The Survey Process – In depth exploration of how JCI surveys organizations
– Our first “split session” is scheduled for Tuesday afternoon – AM group will break early Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– Tracer methodology – The survey – Mock leadership interview
How Are Participants Divided? Practicum Participants (100 ppl)
Green Morning Group (50)
Team 1 (8)
Team 3 (9) Team 2 (8)
B Section (25)
Team 4 (8)
Team 6 (9) Team 5 (8)
C Section (25)
Team 7 (8)
Team 9 (9) Team 8 (8)
D Section (25)
Team 10 (8)
© Copyright, Joint Commission International
A Section (25)
Blue Afternoon Group (50)
Team 12 (9) Team 11 (8)
Introduction to JCI and Accreditation
17
Your Name Badge
Elvis
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– Please note your group and team assignments – Unfortunately, we cannot change your group assignment – Please write your preferred name in the box
Tracer Demonstration Assignments Wednesday AM PM
Thursday AM PM
Tracer Team 1
C A D B
Tracer Team 2
D B C A Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Tuesday AM PM
Day 3: The Survey and Continual Improvement
– Discussion and reflective learning – Five steps for continual improvement
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– Both groups will participate in a tracer today – When not tracing patients, groups will:
18
– The Morning group finishes their second tracer – Mock closing conference – International Patient Safety Goals – Afternoon group breaks early Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Day 4: The Survey and International Patient Safety Goals
– Discuss how organizations prepare for the accreditation process – Advanced Quality Strategies – Closing remarks Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Day 5: Tools and Techniques
Help us…
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– Please complete an evaluation form – If we have spelled your name incorrectly on your name badge, please see us before the end of the day on Tuesday
19
Thank You
Next Presentation Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– Questions?
20
Notes
21
Notes
22
23
24
© Copyright, Joint Commission International
Introduction to the JCI Standards
The Transparent JCI Process d
Vo id
SHANGRI-LA HOSPITAL
Vo id El Dorado, Republic of Freedonia Vo id Vo id Vo id
On-site Evaluation of Standards
Vo
id Vo
am
ple
Sa m
ple
Sa m
ple
Sa mp le
Sa m
ple
Sa mp le
Accreditation Certificate
International Standards 2
Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
Accreditation Decision Rules
– Set optimum, achievable expectations – Focus on the patient – Designed to be interpreted/surveyed within the local culture and legal framework – Stimulates continuous improvement 3
Client name/ Presentation Name/ 12pt - 3
© Copyright, Joint Commission International
Joint Commission International Standards
25
– Scientific literature – Research findings – Survey compliance data – Input from field experts and key stakeholders – Regional Advisory Councils – JCI staff and surveyors
4
Client name/ Presentation Name/ 12pt - 4
© Copyright, Joint Commission International
Sources of Input for Standards
– Consensus of the Standards Subcommittee (12 members) – Review by individual experts or expert panels – Focus groups on select areas – Internet review by as many international users as possible – Final approval by Accreditation Committee and the Board of JCI
5
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
Review and Approval Process
Standards Subcommittee – – – – – – – – –
Singapore (2) - Chair Czech Republic United States (3) Brazil Saudi Arabia Denmark P. R. China South Africa A JCI Surveyor 6
Client name/ Presentation Name/ 12pt - 6
© Copyright, Joint Commission International
– Subcommittee members from:
26
A statement of the safety and quality expected
7
Client name/ Presentation Name/ 12pt - 7
© Copyright, Joint Commission International
What is a standard?
Types of Expectations in Standards – Inputs (Structures): Resource
– Outcomes: Results
8
Client name/ Presentation Name/ 12pt - 8
© Copyright, Joint Commission International
– Processes: Activities
Inputs
Processes
Outcomes
Personnel Equipment Supplies
Admission Test Procedures Patient Education Treatment
Improved health status Efficient services Patient satisfaction
9
Client name/ Presentation Name/ 12pt - 9
© Copyright, Joint Commission International
At the System Level
27
Inputs
Processes
Outcomes
Physician Midwife Clamps Drapes Gloves
Cut the umbilical cord Assess the newborn Deliver the placenta
A healthy baby is born Mother has no complications
10
Client name/ Presentation Name/ 12pt - 10
© Copyright, Joint Commission International
System Example Delivery
– International standards include all topics found in Joint Commission (USA) standards – International standards contain all the quality control and quality leadership ISO 9000 criteria – International standards include the criteria of the European (EFQM) and U.S. (Baldridge) quality awards 11
Client name/ Presentation Name/ 12pt - 11
© Copyright, Joint Commission International
Comparisons with other standards regimens
The JCI hospital standards have been translated into: –Portuguese – Chinese –Turkish – Spanish –Czech – German –Brazilian Portuguese – Danish –Arabic – Italian 12
Client name/ Presentation Name/ 12pt - 12
© Copyright, Joint Commission International
Translation of Standards
28
Hospital Standards-3rd Edition Chapters – Access to Care and Continuity of Care – Patient and Family Rights – Assessment of Patients – Care of Patients – Anesthesia and Surgical Care – Medication Management and Use – Patient and Family Education 13
Client name/ Presentation Name/ 12pt - 13
© Copyright, Joint Commission International
Patient-Centered Standards
Hospital Standards-3rd Edition Chapters – Quality Improvement and Patient Safety – Prevention and Control of Infections – Governance, Leadership, and Direction – Facility Management and Safety – Staff Qualifications and Education – Management of Communication and Information 14
Client name/ Presentation Name/ 12pt - 14
© Copyright, Joint Commission International
Health Care Organization and Management Standards
15
Client name/ Presentation Name/ 12pt - 15
© Copyright, Joint Commission International
Standards Components
29
Standards Content
– The standard represents the principle – The intent describes the rationale of the standard – The measurable elements are the detailed requirements from the standard and intent that are scored 16
Client name/ Presentation Name/ 12pt - 16
© Copyright, Joint Commission International
– Each JCI standard contains three components:
– Over 300 standards – Over 1000 criteria measured during the survey/evaluation process – Required compliance with the International Patient Safety Goals – International Core Measures are voluntary 17
Client name/ Presentation Name/ 12pt - 17
© Copyright, Joint Commission International
Hospital Standards and Requirements
Scoring of Lists in Intent Statements – The list may be all scored as part of one measurable element. – The list may be scored with each a separate measurable element
– The difference is the type of evidence of compliance or the critical nature of each item on the list 18
Client name/ Presentation Name/ 12pt - 18
© Copyright, Joint Commission International
– Note that there are two ways the lists in the Intent Statements are scored.
30
19
© Copyright, Joint Commission International
Next Presentation Client name/ Presentation Name/ 12pt - 19
31
Notes
32
Notes
33
34
35
© Copyright, Joint Commission International
Introduction to the JCI Standards Evaluation Methodology
The Transparent JCI Process d Vo id
SHANGRI-LA HOSPITAL
Vo id El Dorado, Republic of Freedonia Vo id Vo id Vo id
On-site Evaluation of Standards
Vo
id Vo
am
ple
Sa m
ple
Sa m
ple
Sa mp le
Sa m
ple
Sa mp le
Accreditation Certificate
International Standards 2
© Copyright, Joint Commission International
Accreditation Decision Rules
– Covers all portions of an organization and all systems of care and management – Is focused on what happens to patients – patient tracers used – Is proactive – evaluates the likely quality and safety of patient care in the future
3
© Copyright, Joint Commission International
The JCI Evaluation Process
36
An evaluation method that is an effective way to assess a healthcare organization’s performance of care and the services provided as viewed or experienced by the patient.
4
© Copyright, Joint Commission International
What is the Tracer Methodology?
Tracers provide the methodology 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. – It is about areas for improvement 5
© Copyright, Joint Commission International
Tracer Methodology
¾ Top diagnoses and procedures. (surgical, medical, intensive care) ¾ A patient on dialysis. ¾ A psychiatric patient. ¾ A pediatric patient. ¾ A patient receiving lab/imaging services. ¾ A patient receiving rehabilitation services. ¾ Patients due for discharge that day or the next day ¾ System tracers. 6
© Copyright, Joint Commission International
Tracer Selection Criteria
37
Opening Conference – Introductions – Staff – Hospital leadership
– Review agenda – Discussion of key survey activities
– Surveyor Scoring Process – Orientation of surveyors by hospital (30 min) – The hospital and its scope of services – QI model used by hospital & a process that had been improved 7
© Copyright, Joint Commission International
– Patient and System Tracers – Process for requesting staff files for review – Daily briefings
– Set of components that work together toward common goal – Evaluation of how - and how well - the organization’s systems function – Addresses interrelationships of elements – Translates standards compliance issues into potential vulnerabilities as far as patient quality and safety
8
© Copyright, Joint Commission International
Patient Tracer: Systems Analysis
System Tracers – Medication Management – Traces: – medication management processes – processes in use of medications of a patient
– Traces: – infection control process – hospital practice in prevention of health-care associated infections – use of a particular antibiotic 9
© Copyright, Joint Commission International
– Infection Control
38
Tracer of Use of Data
– Validate implementation of QI plan – Review analysis and use of measurement data – Determine improvements in quality of care and patient safety
10
© Copyright, Joint Commission International
– Evaluates effectiveness of data gathering and analysis in improving processes
Tracer of Use of Data – The Processes
– Data use in proactive risk reduction
11
© Copyright, Joint Commission International
– Data collection – Data analysis – Use of information to improve processes – Sustainment of improvements
Facility Tour –Addresses issues related to Physical facility Security Medical and other equipment Hazardous waste Fire safety Utility systems Patient and visitor safety Infection control 12
© Copyright, Joint Commission International
– – – – – – – –
39
Staff Qualifications and Education Interviews –Reviews processes for – – – –
Recruitment; Orientation; Education; Evaluation of staff
Separate interviews for medical staff and nursing & other health care staff
– Surveyors will request specific files after tracers on 1st day of survey
13
© Copyright, Joint Commission International
–Review of staff files
Assessment of Complaints
14
© Copyright, Joint Commission International
– Any complaint about the hospital received by JCI before the survey will be assessed by the survey team – The team will be provided with specific complaint information
Assessment of Complaints
– During scheduled activities or in special sessions, as appropriate – Team leader will share pertinent information with the CEO at an appropriate time and report assessment findings – Findings included in the survey report to JCI
15
© Copyright, Joint Commission International
– Surveyors address issues identified in the complaint during the survey
40
– Conducted each morning except first day – Provides senior leaders with pertinent observations from previous day’s activities – Allows organization to clarify issues or provide additional needed documents for consideration 16
© Copyright, Joint Commission International
Feedback Sessions: Daily Briefings
17
Next Presentation 18
© Copyright, Joint Commission International
– Surveyors confer with organization’s CEO and other leaders at end of survey – Provides strictly preliminary information about findings – Written preliminary report
© Copyright, Joint Commission International
Feedback Sessions: Exit Conference
41
Notes
42
Notes
43
44
45
© Copyright, Joint Commission International
Standards Review
Hospital Standards-3rd Edition Chapters – Access to Care and Continuity of Care – Patient and Family Rights – Assessment of Patients – Care of Patients – Anesthesia and Surgical Care – Medication Management and Use – Patient and Family Education 2
Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
Patient-Centered Standards
© Copyright, Joint Commission International
Access to Care and Continuity of Care (ACC)
46
– Care should be seamless from when a patient enters the org to discharge. – Care should be seamless to both the care provider and the patient. – The patient’s health needs should match the services available. – Services provided should be coordinated. – Discharge should be planned and followed-up 4
Client name/ Presentation Name/ 12pt - 4
© Copyright, Joint Commission International
Intent
1. 2. 3. 4. 5.
Admission to the Organization Continuity of Care Discharge, Referral, and Follow-up Transfer of Patients Transportation
5
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
ACC-Five Areas of Focus
Questions
7
Client name/ Presentation Name/ 12pt - 7
© Copyright, Joint Commission International
– Is there a type of patient that you would not admit to your organization? – Is there a standard that would support or prohibit this policy?
47
© Copyright, Joint Commission International
Patient and Family Rights (PFR)
Intent
13
Client name/ Presentation Name/ 12pt - 13
© Copyright, Joint Commission International
– Patients are unique and should be treated as individuals. – Their rights should be respected.
1. 2. 3. 4.
Identify, Protect and Promote Patient Rights Informed Consent Research Organ Donation
14
Client name/ Presentation Name/ 12pt - 14
© Copyright, Joint Commission International
PFR – Four Areas of Focus
48
Questions
15
Client name/ Presentation Name/ 12pt - 15
© Copyright, Joint Commission International
– Is there a right that is missing from the PFR chapter? – Why is it important?
20
Client name/ Presentation Name/ 12pt - 20
© Copyright, Joint Commission International
Assessment of Patients (AOP)
Intent
– Collecting patient information – Analyzing this information – Developing a plan of care 21
Client name/ Presentation Name/ 12pt - 21
© Copyright, Joint Commission International
– Effective patient assessment process results in decisions about the patient's immediate and continuing treatment needs. – Patient assessment consists of:
49
– What is your personal role in patient assessment/reassessment in your organization? – List the specific tasks you perform – Open the manual, and find at least three standards that explain what you might be accountable for doing or documenting.
22
Client name/ Presentation Name/ 12pt - 22
© Copyright, Joint Commission International
Questions
1. Collecting and Analyzing Patient Data and Information 2. Laboratory Services 3. Radiology and Diagnostic Imaging Services
23
Client name/ Presentation Name/ 12pt - 23
© Copyright, Joint Commission International
AOP – Three Areas of Focus
© Copyright, Joint Commission International
Care of Patients (COP)
50
Intent
– Plan and deliver care – Monitor the patients to understand the results of care – Modify care when necessary – Complete the care – Plan follow-up
28
Client name/ Presentation Name/ 12pt - 28
© Copyright, Joint Commission International
– Patient care is a health care organization’s main purpose. To provide the best possible care, organizations must:
Questions – If you take care of patients…stand up. – What do you do to take care of patients? – I need two people that both treat patients in the same organization. – Find standard that relates to refusing or discontinuing treatment – Has anyone disagreed with a patient that refused treatment? What did you do? What do the standards say? Is there another chapter that might apply?
– For those of you not standing, what do you do? 29
Client name/ Presentation Name/ 12pt - 29
© Copyright, Joint Commission International
– How do you know that you are giving the same care to the same type of patient?
1. Care Delivery for All Patients 2. Care of High – Risk Patients and Provision of High – Risk Services 3. Food and Nutrition Therapy 4. Pain Management and End-of Life Care
30
Client name/ Presentation Name/ 12pt - 30
© Copyright, Joint Commission International
COP-Four Areas of Focus
51
Care of Patients
31
Client name/ Presentation Name/ 12pt - 31
© Copyright, Joint Commission International
– Treatments – Feeding – Meeting their needs – Any interaction with patients
© Copyright, Joint Commission International
Anesthesia and Surgical Care (ASC)
Intent
– – – –
Complete and comprehensive assessment Integrated care planning Continued patient monitoring Criteria-determined transfer for continuing care – Rehabilitation – Eventual transfer and discharge 37
Client name/ Presentation Name/ 12pt - 37
© Copyright, Joint Commission International
– Anesthesia, sedation, and surgical interventions are common and complex. – They require:
52
– How many of you use anesthesia in your organization? – How many do so in different places in the org? – What are the biggest risk factors in delivering anesthesia?
38
Client name/ Presentation Name/ 12pt - 38
© Copyright, Joint Commission International
Questions
ASC-Four Areas of Focus Organization and Management Sedation Care Anesthesia Care Surgical Care
40
Client name/ Presentation Name/ 12pt - 40
© Copyright, Joint Commission International
1. 2. 3. 4.
Moderate Sedation:
Deep Sedation:
•Patients respond purposefully to verbal commands •No interventions are needed to maintain a patent airway •Cardiovascular function is usually maintained
•Patients cannot be easily aroused but respond purposefully after repeated or painful stimulation •Airway may be impaired •Cardiovascular function is usually maintained
42
Client name/ Presentation Name/ 12pt - 42
© Copyright, Joint Commission International
Sedation
53
© Copyright, Joint Commission International
Medication Management and Use (MMU)
Intent
– – – – – –
Coordinated staff efforts Effective process design Procurement and storage Transcribing Dispensing Monitoring 47
Client name/ Presentation Name/ 12pt - 47
© Copyright, Joint Commission International
– Medication Management encompasses the system and processes an organization uses to provide pharmacotherapies to its patients. – This usually includes:
The Medication Management Processes
Procurement
Monitoring
Storage
Administration
Ordering and Transcribing
Preparing and Dispensing
48
Client name/ Presentation Name/ 12pt - 48
© Copyright, Joint Commission International
Selection and
54
The Medication Use Process Order Review
Prepare
Dispense
Administer
Monitor
49
Client name/ Presentation Name/ 12pt - 49
© Copyright, Joint Commission International
Verify
© Copyright, Joint Commission International
Patient and Family Education (PFE)
Intent
– Use a multidisciplinary approach – Suits an individual’s learning preferences, values, and language skills – Provide education at an appropriate time 54
Client name/ Presentation Name/ 12pt - 54
© Copyright, Joint Commission International
– Patient education helps patients and their families make informed care decisions. – The best processes:
55
PFE – Four Areas of Focus Education to Support Patient Decisions Education Tailored to Each Patient Collaborative Delivery of Education Education to Support Care at Home
55
Client name/ Presentation Name/ 12pt - 55
© Copyright, Joint Commission International
1. 2. 3. 4.
– Stand up if you educate patients in your organization – Nurses: What are most important things that physicians can teach their patients? – Physicians: What are most important things that nurses can teach their patients? – Others?
56
Client name/ Presentation Name/ 12pt - 56
© Copyright, Joint Commission International
Questions
Final Discussion – Are there any chapters that you think do not apply to your job or role?
61
Client name/ Presentation Name/ 12pt - 61
© Copyright, Joint Commission International
– Find the standard that deals with…
56
Notes
57
Notes
58
59
60
© Copyright, Joint Commission International
Standards Review
Hospital Standards-3rd Edition Chapters – Quality Improvement and Patient Safety – Prevention and Control of Infections – Governance, Leadership, and Direction – Facility Management and Safety – Staff Qualifications and Education – Management of Communication and Information 2
Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
Health Care Organization and Management Standards
© Copyright, Joint Commission International
Quality Improvement and Patient Safety (QPS)
61
Intent
– Leading and planning the quality improvement and patient safety process – Designing effective clinical and managerial processes – Monitoring how well processes work – Analyzing this data – Implementing and sustaining improvements
4
Client name/ Presentation Name/ 12pt - 4
© Copyright, Joint Commission International
– Integral to overall improvement in quality is the ongoing reduction of risk to patients and staff – Risks may be found in clinical processes and the physical environment – The approach includes:
1. Leadership and Planning 2. Design of New and Modified Processes 3. Data Collection for Quality Monitoring 4. Analysis of Data 5. Process Improvement 5
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
QPS - Five Areas of Focus
Key concepts: – Those at the highest levels of the organization are very involved in all aspects of planning and monitoring the quality and patient safety program – Leader prioritize activities – Leaders provide the resources needed
6
Client name/ Presentation Name/ 12pt - 6
© Copyright, Joint Commission International
Leadership and Planning
62
Key concepts: – Information on how safe, quality processes should work comes from many sources – Clinical practice guidelines and clinical paths are to be used
7
Client name/ Presentation Name/ 12pt - 7
© Copyright, Joint Commission International
Design of New and Modified Processes
Key concepts: – Leaders set priorities and select measures – Contracted services are monitored as well
8
Client name/ Presentation Name/ 12pt - 8
© Copyright, Joint Commission International
Data Collection for Quality Monitoring
Required Clinical Measures I
– – – –
Aspects of patient assessment Aspects of laboratory services Aspects of radiology services Aspects of surgical procedures
– Aspects of antibiotic and other medication use
Continued on next slide
9
Client name/ Presentation Name/ 12pt - 9
© Copyright, Joint Commission International
Clinical monitoring includes the following selected by the leaders:
63
– Monitoring of medication errors and near misses – Aspects of anesthesia and sedation use – Aspects of the use of blood and blood products – Aspects of availability, content, and use of patient records – Aspects of infection control, surveillance, and reporting – Aspects of clinical research 10
Client name/ Presentation Name/ 12pt - 10
© Copyright, Joint Commission International
Required Clinical Measures II
Required Managerial Measures Managerial monitoring includes aspects of the following selected by the leaders:
11
Client name/ Presentation Name/ 12pt - 11
© Copyright, Joint Commission International
– procurement of routinely required supplies and medications essential to meet patient needs – reporting of activities as required by law and regulation – risk management – utilization management – patient and family expectations and satisfaction – staff expectations and satisfaction – patient demographics and clinical diagnoses – financial management – prevention and control of events that jeopardize the safety of patients, families, and staff, including the IPSGs
Key concepts: – You will need individuals with experience in data display and analysis – Comparison with self, others and best practices is essential – Root cause analysis of sentinel events – Analysis of all adverse events – Monitoring near misses
12
Client name/ Presentation Name/ 12pt - 12
© Copyright, Joint Commission International
Analysis of Data
64
Key concepts: – Consider priority areas – Ensure that improvement actually occurred and was maintained – Use proactive risk reduction strategies to identify needed improvements 13
Client name/ Presentation Name/ 12pt - 13
© Copyright, Joint Commission International
Process Improvement
© Copyright, Joint Commission International
Prevention and Control of Infections (PCI)
Intent
– Identified leaders – Well-trained staff – Methods to identify and proactively address infection risks – Appropraite policies and procedures – Staff education – Coordination throughout the organization 15
Client name/ Presentation Name/ 12pt - 15
© Copyright, Joint Commission International
– Infection prevention and control programs seek to reduce the risk of acquiring and transmitting infection. – Effective programs have:
65
1. Program Leadership and Coordination 2. Focus of the Program 3. Isolation Procedures 4. Barrier Techniques and Hand Hygiene 5. Integration of Program with Quality Improvement and Patient Safety 6. Education of Staff About the Program 16
Client name/ Presentation Name/ 12pt - 16
© Copyright, Joint Commission International
PCI - Six Areas of Focus
Key questions: – Who will lead the program and what are their qualifications? – Who and what mechanism will we use to coordinate activities? – What is the science on which to base the program? – What resources will the program need to be effective? 17
Client name/ Presentation Name/ 12pt - 17
© Copyright, Joint Commission International
Program Leadership and Coordination
Key questions: – What is the scope of the program in terms of places and people? – On what types of medical devices, and clinical procedures, will we focus? – What are the essential elements of our sterilization program? – How do we need to handle infectious waste, sharps and needles? – What are the risks during construction? 18
Client name/ Presentation Name/ 12pt - 18
© Copyright, Joint Commission International
Focus of the Program
66
Key questions: – What types of precautions and procedures are needed to manage infectious patients? – How about immunosuppressed patients? – What do we do with many patients with a contagious disease? 19
Client name/ Presentation Name/ 12pt - 19
© Copyright, Joint Commission International
Isolation Procedures
Key questions: – What supplies and equipment do we need and where should they be located? – How can we stimulate and monitor use? – What guidelines for hand hygiene will we use? – See IPSG 20
Client name/ Presentation Name/ 12pt - 20
© Copyright, Joint Commission International
Barrier Techniques and Hand Hygiene
Key questions: – What do we monitor? – How does this fit with other quality monitoring going on? – How do we know if our program is weak or strong? – What and when do we communicate infection control information to all staff? 21
Client name/ Presentation Name/ 12pt - 21
© Copyright, Joint Commission International
Integration of Program with Quality Improvement and Patient Safety
67
Key questions: – Who will provide the education? – What must all staff know about infections? – How do we educate and involve the patient and their family in infection control? – How should we communicate infection trends and other information to all staff? 22
Client name/ Presentation Name/ 12pt - 22
© Copyright, Joint Commission International
Education of Staff About the Program
© Copyright, Joint Commission International
Governance, Leadership, and Direction (GLD)
Intent
– Identify the organization’s mission and ensure the resources needed to meet it. – Coordinate and integrate activities – Understand how staff members work together, along with their respective responsibilities – Overcome barriers and disputes between departments
24
Client name/ Presentation Name/ 12pt - 24
© Copyright, Joint Commission International
– Excellent care requires effective leadership – Leadership should:
68
1. Governance of the Organization 2. Leadership of the Organization 3. Direction of Departments and Services 4. Organizational Ethics
25
Client name/ Presentation Name/ 12pt - 25
© Copyright, Joint Commission International
GLD - Four Areas of Focus
Terminology: – Governance-the highest accountable group – Leadership-the senior mangers – Direction-the department or unit directors Key decisions regarding governance: – The assignment of accountabilities to the governance structure – The written documents that support this structure and accountabilities
26
Client name/ Presentation Name/ 12pt - 26
© Copyright, Joint Commission International
Governance of the Organization
Key decisions regarding leadership: – Identification of the leadership structure – Assignment of responsibilities – Planning with community leaders – Determination of services and supplies and equipment to deliver the services – Management of contracts – Establish uniform HR programs 27
Client name/ Presentation Name/ 12pt - 27
© Copyright, Joint Commission International
Leadership of the Organization
69
Key decisions regarding directors: – Their responsibilities for managing the departments and units of the organization – The process for recommending space, equipment and staff – The process for monitoring quality and staff performance 28
Client name/ Presentation Name/ 12pt - 28
© Copyright, Joint Commission International
Direction of Departments and Services
Key decisions regarding organizational ethics: – The framework and ethical and legal norms for operation – The content of the guiding documents – The application of the framework and guiding documents to ethical dilemmas in patient care
29
Client name/ Presentation Name/ 12pt - 29
© Copyright, Joint Commission International
Organizational Ethics
© Copyright, Joint Commission International
Facility Management (FMS)
70
Intent
– Reduce and control risks and hazards – Prevent accidents and injuries – Maintain safe conditions 31
Client name/ Presentation Name/ 12pt - 31
© Copyright, Joint Commission International
– In order to provide a safe and functional facility for all, the physical facility, medical equipment, and people must be effectively managed. – Management must strive to:
1. 2. 3. 4. 5. 6. 7. 8.
Leadership and Planning Safety and Security Hazardous Materials Emergency Management Fire Safety Medical Equipment Utility Systems Staff Education 32
Client name/ Presentation Name/ 12pt - 32
© Copyright, Joint Commission International
FMS - Eight Areas of Focus
– Relevant laws and regulations – Separate plans or one overall plan – Knowledge of the type and location of risks for each area – Plans to reduce or mitigate risks – Integration of facility quality and safety information with all other such information – Ensuring that the right staff have correct information to ensure safety of staff and patients 33
Client name/ Presentation Name/ 12pt - 33
© Copyright, Joint Commission International
Considerations for All Areas
71
© Copyright, Joint Commission International
Staff Qualifications and Education (SQE)
Intent
– – – – –
Applicant skills Knowledge Education Previous work experience Credential review (for clinical staff) 35
Client name/ Presentation Name/ 12pt - 35
© Copyright, Joint Commission International
– Leaders collaborate to identify the numbers and types of staff needed to fulfill the organization’s mission – Recruiting, evaluating, and appointing staff are best accomplished through a coordinated and uniform process – Documentation is a critical part of this process:
1. 2. 3. 4. 5.
Planning Orientation and Education Medical Staff Nursing Staff Other Professional Staff
36
Client name/ Presentation Name/ 12pt - 36
© Copyright, Joint Commission International
SQE - Five Areas of Focus
72
Key considerations: – How to determine and define the desired number and skill level for all staff – What will job descriptions look like and contain – Defining the processes for recruitment, etc. – Setting up staff files – Final judgment that staff capabilities are consistent with patient need 37
Client name/ Presentation Name/ 12pt - 37
© Copyright, Joint Commission International
Planning
Key considerations: – Process to orient everyone to the organization, his/her department and actual job responsibilities – Provision on ongoing staff education – The management of student education in the organization – Special education such as resuscitative techniques 38
Client name/ Presentation Name/ 12pt - 38
© Copyright, Joint Commission International
Orientation and Education
Key considerations: – Setting up a process to gather and verify (from the primary source) all the credentials of the physician – Setting up the decision process to decide staff membership and what services they will provide – Using a process for ongoing clinical practice evaluation 39
Client name/ Presentation Name/ 12pt - 39
© Copyright, Joint Commission International
Medical Staff
73
Key considerations: – Setting up a process to gather and verify (from the primary source) all the credentials of the nurse – Setting up the decision process to decide competencies and job description or assignment – Choosing a procedure to evaluate participation in the quality program 40
Client name/ Presentation Name/ 12pt - 40
© Copyright, Joint Commission International
Nursing Staff
41
Client name/ Presentation Name/ 12pt - 41
Management of Communication and Information (MCI)
© Copyright, Joint Commission International
Key considerations: – Setting up a process to gather and verify (from the primary source) all the credentials of the individual – Setting up the decision process to decide competencies and job description or assignment – Choosing a procedure to evaluate participation in the quality program
© Copyright, Joint Commission International
Other Professional Staff
74
Intent
– – – –
Identify information needs Design an information management system Define and capture data and information Analyze data and transform it into information that can be reported – Integrating and using information
43
Client name/ Presentation Name/ 12pt - 43
© Copyright, Joint Commission International
– Failures in communication is one of the most common root causes of patient safety incidents. – Over time, organizations should increase their ability to:
1. 2. 3. 4. 5. 6.
Communication with the Community Communication with Patients and Families Communication Between Providers Within and Outside the Organization Leadership and Planning Patient Clinical Record Aggregate Data and Information 44
Client name/ Presentation Name/ 12pt - 44
© Copyright, Joint Commission International
MCI – Six Areas of Focus
– Open communications are key with clear content in an understandable format to enhance patient safety – Special considerations for the communication of patient information such as confidentiality and security – Patient records with a consistent format and content – Understanding the importance of data and the use of data for quality and safety 45
Client name/ Presentation Name/ 12pt - 45
© Copyright, Joint Commission International
Major Considerations for All Focus Areas
75
46
© Copyright, Joint Commission International
Next Presentation Client name/ Presentation Name/ 12pt - 46
76
Notes
77
Notes
78
79
80
© Copyright, Joint Commission International
Access to Care and Continuity of Care (ACC)
1. 2. 3. 4. 5.
Admission to the Organization Continuity of Care Discharge, Referral, and Follow-up Transfer of Patients Transportation
2
Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
ACC-Five Areas of Focus
– Screening at point of first contact – Determine if care can be provided – Diagnostic test are available for decision making-standardized by policy – Patients are informed if any wait or delay and reasons (waiting list) 3
Client name/ Presentation Name/ 12pt - 3
© Copyright, Joint Commission International
ACC.1 “ADMISSION” of In-Patients & “REGISTRATION” of Out-Patients
81
– Policies & Procedures (PP) standardize admission and registration – PP Admitting Emergency patients – PP Holding patients for observation – PP Managing patients when bed space not available
4
Client name/ Presentation Name/ 12pt - 4
© Copyright, Joint Commission International
ACC.1.1 Process of Admission or Registration
ACC.1.1.1 Emergency Patients
5
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
– Criteria are developed and used to prioritize patients with immediate needs (“triage”) – Criteria are physiologic-based whenever possible – Staff use criteria to prioritize patients based on urgency of needs
ACC.1.1.2 Needs are Prioritized for In-patients – Screening Assessment focuses on deciding which service to meet the patient first Preventative Palliative Curative Rehabilitative
–Appropriate selection of services of treatment unit
6
Client name/ Presentation Name/ 12pt - 6
© Copyright, Joint Commission International
– – – –
82
– Patient and Family receive information during the admission process on: – Proposed care – Expected out comes of care – Expected costs – Sufficient information to make knowledgeable decisions
7
Client name/ Presentation Name/ 12pt - 7
© Copyright, Joint Commission International
ACC.1.2 Information Provided
ACC.1.3 Reduction of Barriers – Leaders and staff understand most common barriers for patients Physical Language Cultural Other
– A process is identified and implemented – to overcome or limit identified barriers – to limit impact of barriers on delivery of services 8
Client name/ Presentation Name/ 12pt - 8
© Copyright, Joint Commission International
– – – –
– Admission/transfer criteria established for Intensive and Specialized Units – Criteria are physiologic-based – Appropriate individuals are involved in developing and implementing the criteria – Patients meet the criteria (documented) – Patients are discharged/transferred when they no longer meet criteria
9
Client name/ Presentation Name/ 12pt - 9
© Copyright, Joint Commission International
ACC.1.4 Criteria for Admission or Transfer to Intensive Care
83
ACC.2 Continuity of Patient Care – Leaders design and support continuity (coordination & resources) – Criteria or policies determine transfers within the organization – Processes support continuity and coordination of care and are implemented between/among: (reference to – – – –
Emergency and Inpatient care Surgical and Non-surgical care The Organization and other care settings Ambulatory Care Programs
– Continuity and coordination is evident to the patient – (coordinator).
10
Client name/ Presentation Name/ 12pt - 10
© Copyright, Joint Commission International
bullet points in intent statement)
– There is an individual responsible for patient’s care who is – a physician or other person – qualified to assume responsibility for care – identified to the hospital staff
11
Client name/ Presentation Name/ 12pt - 11
© Copyright, Joint Commission International
ACC.2.1 Individual Responsible
ACC.3 Referral and Discharge Policy
– Based on patient’s needs for continuing care – The patient’s readiness for discharge – Discharge planning begins early and includes the family as appropriate – Policy guides patients “on pass” for a defined period of time 12
Client name/ Presentation Name/ 12pt - 12
© Copyright, Joint Commission International
– Policy for the appropriate referral or discharge of patients
84
– Discharge planning for both supportive and continuing medical services – Community providers, organizations and individuals are identified – Appropriate referrals are made (in the patient’s home community whenever possible)
13
Client name/ Presentation Name/ 12pt - 13
© Copyright, Joint Commission International
ACC.3.1 Cooperation with Community Practitioners
ACC.3.2 Discharge Summary – – – – – – –
Reason for admission Significant physical and other findings Significant diagnoses and co-morbidities Diagnostic and therapeutic procedures Significant medication and treatments Condition at discharge Discharge medications and all medications to be taken at home – Follow up instructions Continued on next page…..
14
Client name/ Presentation Name/ 12pt - 14
© Copyright, Joint Commission International
– Prepared at discharge, documented in the patient’s record and contains:
– Unless contrary to policy, laws, or culture, patients are given a copy – A copy is provided to the practitioner responsible for patient’s continuing or follow-up care
15
Client name/ Presentation Name/ 12pt - 15
© Copyright, Joint Commission International
ACC.3.2 Discharge Summary
85
ACC.3.3 Follow-up Instructions – are provided in an understandable form and manner – include any return for follow-up care – include when to obtain urgent care – are appropriate to the patient’s condition
16
Client name/ Presentation Name/ 12pt - 16
© Copyright, Joint Commission International
– Patients and/or family receive followup instructions that:
ACC.4 Transfer Policy – Appropriateness of transfer using criteria – Based on need for continuing care – Transfer of responsibility to another provider or setting – Criteria define when transfer is appropriate – Who is responsible during transfer – Situations where transfer is not possible
17
Client name/ Presentation Name/ 12pt - 17
© Copyright, Joint Commission International
– Guiding policy for transferring patients to include:
ACC.4.1 Referring and Receiving Organizations – Referring organization determines whether receiving organization can meet patient’s needs – Arrangements (formal or informal) are in place when patients are frequently transferred
–
– – –
Clinical summary is transferred with patient & includes: Patient status Procedures and other interventions provided Patient’s continuing care needs 18
Client name/ Presentation Name/ 12pt - 18
© Copyright, Joint Commission International
ACC.4.2 Written Summary
86
– All patients are monitored during direct transfer – Qualifications of the staff member doing the monitoring are appropriate for patient’s condition
19
Client name/ Presentation Name/ 12pt - 19
© Copyright, Joint Commission International
ACC.4.3 Monitoring Patients during Transfer
ACC.4.4 Documentation of Transfer – Name of organization and individual agreeing to receive patient – Reason for transfer – Any special conditions related to transfer – Any change of patient’s condition or status during transfer – Any other notes require by the transferring organization 20
Client name/ Presentation Name/ 12pt - 20
© Copyright, Joint Commission International
– Documentation includes:
– Transportation is appropriate to the patient’s need – Transportation needs are considered when: – Referring – Transferring – Discharging
21
Client name/ Presentation Name/ 12pt - 21
© Copyright, Joint Commission International
ACC.5 Transportation Needs
87
ACC.6 – ACC.6.1 Medical Transport – Standards are relevant only if the medical transport services are owned and operated by the
ACC.6 Meeting Legal Requirements – Service meets relevant laws & regulations – Current license maintained when required 22
Client name/ Presentation Name/ 12pt - 22
© Copyright, Joint Commission International
hospital
ACC.6.1 Safety and Quality – Qualified individual directs the service – Medical oversight during transfer for:
Quality and safety are monitored Qualified individuals triage patients Regular inspection of vehicles Included in infection control program – Exposures to biologic and chemical agents
– Patient’s rights are respected during transport
23
Client name/ Presentation Name/ 12pt - 23
Next Presentation 24
Client name/ Presentation Name/ 12pt - 24
© Copyright, Joint Commission International
– – – –
© Copyright, Joint Commission International
– Patient Assessment – Medical Services
88
Notes
89
Notes
90
91
92
Joint Commission International Hospital Accreditation Program Accreditation Decision Rules Effective Date 1 January 2009
After the Survey: The Decision
3.The organization demonstrates overall acceptable compliance. Acceptable compliance is: An aggregate score of at least “9” on all standards. 4. The total number of measurable elements found to be “Not Met” or “Partially Met” is not above the mean (three or more standard deviations) for organizations surveyed under the hospital accreditation standards within the previous 24 months. 5. The organization submits an acceptable Strategic Improvement Plan (SIP). B. ACCREDITATION DENIED This decision results when an organization meets one or more of the following conditions at the end of any required Focus Survey subsequent to an initial or triennial full survey, or during the period of accreditation as a result of a Focus Survey for the evaluation of one or more policy related conditions that may place the organization At Risk for Denial of Accreditation.*
© Copyright, Joint Commission International
I ACCREDITATION DECISIONS INTRODUCTION The Accreditation Committee considers all information from the initial or triennial full survey and any required follow-up Focused Survey in making its decision regarding accreditation. The outcome is that the organization meets the criteria for accreditation or does not meet the criteria and is denied accreditation. The criteria for these two potential outcomes are as follows: A. ACCREDITED This decision results when an organization meets all the following conditions. 1. The organization demonstrates acceptable compliance with each standard. Acceptable compliance is: A score of at least “5” on each standard. 2. The organization demonstrates acceptable compliance with the standards in each chapter. The International Patient Safety Goals are considered a Chapter. Acceptable compliance is: An aggregate score of at least “8” for each chapter of standards.
The Transparent JCI Process d Vo id
SHANGRI-LA HOSPITAL
Vo id El Dorado, Republic of Freedonia Vo id Vo id Vo id
On-site Evaluation of Standards
Vo
id Vo
am
ple
Sa m
ple
Sa m
ple
Sa mp le
Sa m
ple
Sa mp le
Accreditation Certificate
International Standards Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Accreditation Decision Rules
Scoring the Survey Results – Each Measurable Element (ME) is scored
– All Measurable Elements are averaged to obtain the score for the standard – All Standards are averaged to obtain the score of the chapter – All Chapters are averaged to obtain the overall score Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– Met (10) – Partially Met (5) – Not Met (0)
93
– Each Standard must have a score of at least 5 – Each Chapter must have a score of at least 8 – All standards together must average at least 9
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Accreditation Decision Rules
– Surveyors complete their findings and leave a final copy with the surveyed organization – If the organization disagrees with a finding and feels that proof of inaccuracy exists, appeal may be filed with JCIA, together with documentation that proves that the surveyors were in error Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Surveyor Report
JCIA Communication – Ten (10) days after receipt of the surveyors’ report, JCIA notifies the organization whether a focused repeat survey or other follow up condition will be required – If a focused resurvey or other follow up condition is not required, the organization will be notified that Strategic Improvement Plans (SIPs) must be submitted for each Measurable Element that received a score of “Not Met” or Zero (0).
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– In which case the decision regarding accreditation will be postponed.
94
Strategic Improvement Plans
– If the decision is that they are all adequate, AND the Standards Scores and Averages meet the Decision Rules, the finding will be that there has been “Acceptable Compliance” with the standards (for exception see “Rule No. 4” or “Outlier Rule”) – If the decision is that they are not all adequate, JCIA declare the organization “At Risk of Denial of Accreditation” (see later) .
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– Due date of the SIPs is 45 days after notification. – JCI will evaluate the SIPs for adequacy.
– Focused visit will occur at 60 days from Initial or Triennial Survey – There will be one or (rarely) two surveyors – Focused survey will be restricted to areas or standards that have been identified
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Focused Resurvey for Inadequate Compliance with Standards
Accreditation Decisions
– Acceptable compliance with all Standards – If there are follow-up conditions, they are all met
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– ACCREDITED
95
ACCREDITATION DENIED 1. One or more standard is scored less than a “5”. 2. The aggregate score of one or more chapter of standards is less than a “8”. 3. The aggregate score for all standards is less than “9”. For 1., 2., and 3. see item 5. for additional condition of Denial. 4. The total number of measurable elements found to be “Not Met” or “Partially Met” is above the mean (three or more standard deviations) for organizations surveyed under the hospital accreditation standards within the previous 24 months (statistics updated every Quarter). Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Accreditation Decisions
ACCREDITATION DENIED 5. A required Focused Survey subsequent to an initial or triennial full survey has not resulted in acceptable compliance with applicable standards. . 6. One or more of the conditions that place the organization At Risk for Denial of Accreditation have not been resolved at the time of the Focused Survey to evaluate the condition. 7. The organization voluntarily withdraws from the accreditation process. 8. The organization does not permit the performance of any survey by Joint Commission International
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Accreditation Decisions
The total number of measurable elements found to be “Not Met” or “Partially Met” is not above the mean (three or more standard deviations) for organizations surveyed under the hospital accreditation standards within the previous 24 months.
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Rule No. 4 (“Outlier Rule”)
96
2008 Surveys (Initial and Triennial) 60
1
1
1
1
1
1
UCL=43.28
40
_ C=27.54
30
LCL=11.80
10
1
1
0
1
1
1
21 12 21 12 02 07 14 06 04 14 01 03 04 05 06 07 09 10 11 12 08 08 08 08 08 08 08 08 08 08 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 N = 87 Introduction to JCI and Accreditation
© Copyright, Joint Commission International
20
Reporting Requirements – For all accredited organizations – Interim self-assessment report on status of standards compliance at 18 months – Response to annual query about updated contact addresses – – – –
Change of ownership or top management Establishment of new service covered by JCI standards Discontinuation of existing service Increased volume (>25%) or contraction (>25%) of service (e.g. number of beds, OPD clinics, etc.) – New location or significant change in current location of at least 25% of services – Development of more intensive services – Merger with or acquisition of organization that provides services for which JCI has standards Introduction to JCI and Accreditation
© Copyright, Joint Commission International
– For accredited organizations that meet the following:
Types of Focused Surveys – Follow-up: performed after a full initial or triennial survey to evaluate selected standards noted at the time of the survey. – Conducted at 90 days following the original survey
– For Cause: performed whenever – JCI is persuaded that there is a risk to patients and staff or – JCI receives a quality incident report that requires on-site evaluation or – organization has been placed “At Risk of Denial of Accreditation.”
– Focused Surveys evaluate a preset group of standards
Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Sample Count
50
1
97
1. An immediate threat to patient/public health or staff safety exists within the organization. 2. An individual who does not possess a license, registration, or certification is providing or has provided health care services in the organization that would, under applicable law or regulation, require such a license, registration, or certification and which placed the organization’s patients at risk for a serious adverse outcome. 3. Joint Commission International is reasonably persuaded that the organization submitted falsified documents or misrepresented information in seeking to achieve or retain accreditation, as required by the Information Accuracy and Truthfulness Policy. 4. A number of not compliant standards (Not Met or Partially Met) at the time of survey is above the mean (three or more standard deviations) for organizations in the same program surveyed during the previous 24 months. 5. The organization does not possess a license, certificate, and/or permit, as, or when, required by applicable law and regulation, to provide the health care services for which the organization is seeking accreditation. 6. The organization has not met the accreditation policy for “Reporting Requirements between Surveys”. 7. The organization fails to submit an acceptable Strategic Improvement Plan (SIP) within 45 days of the organization’s survey. Introduction to JCI and Accreditation
© Copyright, Joint Commission International
Conditions that Place an Organization “At Risk for Denial of Accreditation”
98
Day 2: The Survey Process
99
© Copyright, Joint Commission International
Tracer Methodology
What is a Tracer? – JCI’s key assessment method
– Along the path, JCI observes and assess compliance with the standards – Allows us to understand hospital’s performance from patient’s perspective 2
Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
– “Traces” a real patient’s journey through the hospital, using their record as a guide
Why Conduct Tracers? – Complex organizations (like those found in healthcare) are made up of a series of systems and subsystems.
– If we can identify the imperfections or flaws within a system, we can understand how to correct errors that may cause patient harm.
3
Client name/ Presentation Name/ 12pt - 3
© Copyright, Joint Commission International
– Tracers are an effective way to study complex systems.
100
Outcomes of Tracers • Integrated and cross sectional review of those areas most critical to quality and safety of the patient
• Organizational specific information that can be used to design and target improvements 4
Client name/ Presentation Name/ 12pt - 4
© Copyright, Joint Commission International
• Patient focused analysis of standard compliance
Types of Tracers Two types of Tracers
2. System Tracer: Follow a process in the hospital from beginning to end.
5
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
1. Patient Tracer: Follow the treatment path of an individual patient within the hospital
Patient Tracer
– Illustrates the relationship between a patient’s care and the JCI standards 6
Client name/ Presentation Name/ 12pt - 6
© Copyright, Joint Commission International
An individual patient tracer: – Follows the experiences of a patient throughout the healthcare system.
101
System Tracers – A system tracer follows a complex process throughout the healthcare system. – Traces the path of a complex process
– Medication Management System – Infection Control Management System – Data Management System
7
Client name/ Presentation Name/ 12pt - 7
© Copyright, Joint Commission International
Examples:
Medication Management System Tracer
•
• •
•
Allergy reconciliation IT support for verification
Controlled substance storage, monitoring and use
•High-risk therapy • IV mixing, TPN prep, chemo agents prep • Concentrated electrolytes • Look alike, sound alike drugs
• Preparation • Dispensing •Pharmacy role in discharge planning and patient/family education
8
Client name/ Presentation Name/ 12pt - 8
© Copyright, Joint Commission International
• •
Selection of medications Procurement of medications Storage of medications Medication ordering Policy & Procedure Verifying prescriptions
Medication Management System Tracer Includes: ¾ Group discussion • Explore the process ; identify concerns • Discuss medication occurrences or errors • Review International Pt. Safety Goals (INPSG 1, 2, 3, 5, and 6)
¾ Focused Medication Tracer • Explore the path of a selected high risk medication based on the group discussion or previous information identified through patient tracers 9
Client name/ Presentation Name/ 12pt - 9
© Copyright, Joint Commission International
• •
102
• Selection • Procurement • Storage • Prescribing and Ordering • Preparation • Dispensing • Administration • Monitoring 10
Client name/ Presentation Name/ 12pt - 10
© Copyright, Joint Commission International
Medication Management Functions
© Copyright, Joint Commission International
Tracing
Determine Your Purpose • What is the purpose of your tracer?
• Your purpose will determine where you go and what you do
14
Client name/ Presentation Name/ 12pt - 14
© Copyright, Joint Commission International
• Assess overall JCI standards compliance • Assess organizational policy compliance • Learn more about a specific process
103
• At first, do not plan to do tracers within your own department • Know and interpret the standards correctly • Understand the intent of the standard • Consider pre-determining types of questions (i.e. a focused topic area) until you are proficient at free-flowing 15
Client name/ Presentation Name/ 12pt - 15
© Copyright, Joint Commission International
Pre-Work
• Don’t review the medical record by yourself—review with a staff member, so that you can ask for the “patient’s story.” • Don’t conduct “peer” review. • Don’t indicate staff did something “wrong” • Don’t assess best practices, focus on what the standards require 16
Client name/ Presentation Name/ 12pt - 16
© Copyright, Joint Commission International
Effective Tracing Tips
• Follow the path of the patient or process • Assess standards based on the patient’s experience of care • Observe patient care, procedures, and processes • Use the patient record to identify “system” issues based on the patient’s journey.
17
Client name/ Presentation Name/ 12pt - 17
© Copyright, Joint Commission International
Effective Tracing Tips
104
• Seize the moment, but don’t interrupt patient care • Stay time aware and topic focused • Remain flexible • Maintain patient confidentiality • Set the proper tone
18
Client name/ Presentation Name/ 12pt - 18
© Copyright, Joint Commission International
Effective Tracing Tips
• • • • • •
Put the staff at ease Explain purpose of tracer Dress professionally Use a serious but approachable style Educate and evaluate Pretend you do not know the staff members you are interviewing • Thank staff for participating 19
Client name/ Presentation Name/ 12pt - 19
© Copyright, Joint Commission International
Set the Overall Tone
© Copyright, Joint Commission International
Interviewing Strategy
105
Questions to Keep in Mind While Tracing Any Process 1. 2. 3. 4. 5. 6. 7.
Is this step standardized? If not, why? Does the step occur consistently? Does it need improvement? Is it an unnecessary or impractical step? Is something absent that should be present? What are the risk points? How are the risk points mitigated?
21
Client name/ Presentation Name/ 12pt - 21
© Copyright, Joint Commission International
Think about asking questions that will help you know the following:
• Use active listening. • Drill down until issues are fully developed • Don’t pursue one standard; focus on several standards related to a process. • Avoid hypothetical situations—pose questions around the patient being traced. • Base questions and findings on the standards. • Question staff, not management • Question patients when feasible 22
Client name/ Presentation Name/ 12pt - 22
© Copyright, Joint Commission International
Questioning Strategies
• Ask questions based on your review of the patient’s medical record (diet, education). • Talk to patients/families about relevant issues/experiences; use caution not to alarm the patient. • Observe environment of care in the patient’s room. • Don’t “quiz” patient but engage in conversation. 23
Client name/ Presentation Name/ 12pt - 23
© Copyright, Joint Commission International
Interviewing Patients
106
How are Questions Asked? • Use “I” statements
• Avoid a confrontational tone; the goal is to gather information, not “catch” someone • Use opening question followed by “drilldowns.” • The same question, asked slightly different, may deepen understanding of compliance
24
Client name/ Presentation Name/ 12pt - 24
© Copyright, Joint Commission International
• “I see that the patient was given Aspirin” • Not, “You gave the patient Aspirin.”
Leading Questions
• “Do you always wash your hands before interacting with a patient?” • “I assume you would put this type of patient in a negative-pressure room. • You keep this door locked, right? Whenever possible, surveyors avoid this type of question. 25
Client name/ Presentation Name/ 12pt - 25
© Copyright, Joint Commission International
Leading Questions: The question suggests the correct answer
Leading vs. Neutral Questions Leading questions suggest the correct answer Neutral questions do not suggest the correct answer Leading “Do you always wash your hands before interacting with a patient?”
© Copyright, Joint Commission International
Neutral “What kind of hand-washing protocols have you adopted? How effective have hand-washing protocols been?”
Leading “I assume you would put this type of patient in a negative-pressure room. How would you treat this patient?” Neutral “There are many different ways to treat this type of patient. How would 26 Client name/ Presentation Name/ 12pt - 26 you handle this case?”
107
Closed Questions
• Have you been trained to operate this equipment? • Did you follow your organization’s policy when admitting this patient? • Do you educate patients on their treatment? • The respondent supplies a very limited amount of information to the questioner. 27
Client name/ Presentation Name/ 12pt - 27
© Copyright, Joint Commission International
Closed Questions: Only allow a choice of two options, typically “yes” or “no.”
Closed Vs. Open Questions Closed questions have very few responses (yes/no) Open questions require a full, elaborative response Closed “Have you been trained to operate this equipment?” Open
Closed Did you follow your organization’s policy when admitting this patient? Open How did you admit this patient? What is your organization’s admission 28 Client name/ Presentation Name/ 12pt - 28 policy?
© Copyright, Joint Commission International
How do you know the correct way to operate this equipment?
• Make sure the question was understood. • Restate answers for clarification. • Pause after an answer to encourage more information. • Give positive feedback for well-thought out answers. • Ask for more information if you need it in order to understand the answer.
29
Client name/ Presentation Name/ 12pt - 29
© Copyright, Joint Commission International
After the Question
108
When you notice a policy violation or an inconsistency in clinical practice, you should: • Drill down Ask probing questions to more fully understand the problem • Validate Look for examples of the problem in other settings or with other practitioners. Is this an isolated incident, or a trend? 30
Client name/ Presentation Name/ 12pt - 30
© Copyright, Joint Commission International
Validate
After the Tracer: Share your Findings • Share with leadership • Share all findings to lay groundwork for new improvements; communicate incremental responses to changes
• Share successes and challenges • The clearest and most accurate picture creates respect for the tracer process • Issues should be shared in a non-punitive, positive, and educational manner
38
Client name/ Presentation Name/ 12pt - 38
© Copyright, Joint Commission International
• Share with staff
39
Client name/ Presentation Name/ 12pt - 39
© Copyright, Joint Commission International
Questions?
109
Notes
110
Notes
111
112
113
© Copyright, Joint Commission International
The Survey Simulation: What to expect
The Purpose of the Survey Simulation
– The purpose is to demonstrate the Tracer methodology and Tracer process, so that you might be able to better prepare for your upcoming survey.
2
Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
– You will observe the consultant/surveyor gathering information about how the organization complies with JCI standards.
– Our host hospitals have been very generous to allow us to visit their facility. – Please respect their staff and patients by following the following guidelines:
3
Client name/ Presentation Name/ 12pt - 3
© Copyright, Joint Commission International
Inside the Host Hospital
114
– Only the JCI faculty member that serves as the “surveyor” should ask questions of the staff, patients, or administration. – Any questions you have should be directed to your faculty member.
4
Client name/ Presentation Name/ 12pt - 4
© Copyright, Joint Commission International
1. Appropriate Questioning
– Please also remember that the objective of this session is to help you understand the survey process, not to survey this particular organization. – It takes a full survey to have sufficient information to draw any conclusions about the organization. 5
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
1. Appropriate Questioning
– During the course of the simulation, you may be shown a great many different forms, policies, and other resources that may be useful to you. – Please do not ask the hospital staff for these resources directly. – You may ask your JCI faculty member to acquire these documents. If possible and appropriate, they will attempt to secure these documents for you. 6
Client name/ Presentation Name/ 12pt - 6
© Copyright, Joint Commission International
2. Requests
115
– In order to move through the simulation as efficiently as possible, please stay with your group and group leader at all times. – We have already arranged to “survey” certain specific areas. Straying into other areas tests the goodwill of our hosts. 7
Client name/ Presentation Name/ 12pt - 7
© Copyright, Joint Commission International
3. Stay with the Group
4. Minimize Impact – No cell phones
– No photos/videos – Please feel free to take notes, but photos and videos are not permitted. 8
Client name/ Presentation Name/ 12pt - 8
© Copyright, Joint Commission International
– Please turn your phones off, or set them on silent. – Please also refrain from taking calls during the session.
Discussion Questions
– What kind of conclusions can be drawn from this process?
9
Client name/ Presentation Name/ 12pt - 9
© Copyright, Joint Commission International
– When do we have enough data to draw conclusions?
116
What you should hear
10
Client name/ Presentation Name/ 12pt - 10
© Copyright, Joint Commission International
– The neutral tone in which the questions are asked – The way the same question, asked slightly differently, moves deeper into understanding compliance
What you should hear, see, and discover
– The survey simulator’s method – Those being interviewed by the survey simulator 15
Client name/ Presentation Name/ 12pt - 15
© Copyright, Joint Commission International
– We will discuss your observations when we return. – During your first tracer demonstration session, observe as much as you can about:
1. How the consultant discovered information that resulted in a modification to the tracer and a change in direction? 2. Inconsistencies in the responses to similar questions that would lead you to suspect that all staff were not trained in the same way or the same content. 19
Client name/ Presentation Name/ 12pt - 19
© Copyright, Joint Commission International
See if you discover…
117
3. Any portion of the building where you could not identify a safe exit in the event of an emergency 4. Characteristics of a patient record that made it easy to trace a patient’s journey 5. The primary ways the hospital’s staff demonstrated compliance – data, verbal explanation, policies, procedures, etc.
20
Client name/ Presentation Name/ 12pt - 20
© Copyright, Joint Commission International
See if you discover
© Copyright, Joint Commission International
QUESTIONS?
118
Notes
119
Notes
120
121
122
Case Study 1
© Copyright, Joint Commission International
Answering Tracer Questions
– For this exercise, we will be taking you on a “virtual” tracer. – For your first case study, we want you to think carefully about what are the best answers you can give to a surveyor’s questions.
2
© Copyright, Joint Commission International
Case Study Overview
Tracer Patient Selection – Mrs. Kale – admitted one week ago via the Emergency Department (ED). – Admitted with: – slurred speech – poor gait – completely dependent on help for all her needs. – CT scan of the brain showed a right brain Ischemic Stroke.
3
© Copyright, Joint Commission International
–City Centre Medical Center –Surveyor traces a 68-year-old female patient:
123
Medical Record Information – History and Physical
– No bed available at the medical unit – Placed in a holding area for observations. – Her 70-year-old husband was with her and provided relevant information.
4
© Copyright, Joint Commission International
– she was treated for: – hypertension, – Hyperlipidemia – diabetes mellitus. – She was on diet control for the management of her diabetes.
Continued The surveyor noted from the nursing chart that Mrs. Kale was assessed to be at risk for the following:
Mrs. Kale's husband has also shared with her nurse yesterday that they have no means to pay for the hospital bill.
7
© Copyright, Joint Commission International
o Fall o Bed sores o Aspiration o Deep vein thrombosis
Surveyor visits Emergency Department
–After reviewing the medical record, surveyor visits ED –Discussions cover triage criteria, admission criteria, patient and family communication. 8
© Copyright, Joint Commission International
Step 1: Surveyor Speaks with the ED Staff
124
Surveyor visits Emergency Department Step 1: Surveyors Speaks with the ED Staff
A. What processes were followed for admitting Mrs. Kale to the medical unit? B. What was the reason why she had to be in the ED for 6 hours? C. How did you communicate the reasons for her delayed admission?
•Select one question.
(ACC.1.1 ME 5-6; MCI.2 ME 1; MCI.4 ME 4)
•What is the worst answer you can give? 9
© Copyright, Joint Commission International
Exercise
Medical Unit
–Discussions cover assessment, reassessment, emergency care issues, IPSG.
16
© Copyright, Joint Commission International
Step 2: Surveyor Speaks with Nurse and Physician
Medical Unit Step 2: Surveyor Speaks with Nurse and Physician
Exercise
B. Who has access to patient’s medical record? C. What is your organization policy on health information ? (MCI.7 ME 1; MCI.10 ME 4) D. What process do you have in place to address Mrs. Kale's risk for fall? (IPSG Goal 6 ME 1-3)
•Select one question.
•What are the elements of a good answer? 17
© Copyright, Joint Commission International
A. What communication took place between the ED and the unit before Mrs. Kale arrived? (IPSG Goal 2 ME 1-4, MCI 8, ME 1-7)
125
Bad Answers – Give too much information – Highlight a deficiency that was not otherwise apparent – Ramble – Untruthful or misleading
18
© Copyright, Joint Commission International
– “Bad” answers:
Medical Unit
–Discussions cover assessment and reassessment, clinical practice guidelines and pathways
19
© Copyright, Joint Commission International
Step 3: Surveyor Speaks with the Physician
Medical Unit Step 3: Surveyor Speaks with the Physician
A. I noticed Mrs. Kale is on a stroke pathway. How is this pathway established? B. Who was involved in this decision? (QPS.2.1 ME 1-3) C. I noticed that there was no entry in the patient’s medical record by a physician on the weekend that Mrs. Kale was admitted. What is the hospital policy for assessment and reassessment of patients? (AOP.2 ME 4)
•Which question is the hardest to answer? •What is an ideal answer to this question? 20
© Copyright, Joint Commission International
Exercise
126
Medical Unit Exercise Step 7: Surveyor talks to the staff •In your and infection control practitioner organization,
C. How are staff educated in the management of infectious patients? D. How does the organization’s orientation program include infection control? E. Who attend this orientation? (PCI.8 ME 5; SQE.7 ME 1-3)
what is the best answer you can construct ? •What would you change in your organization to have a better 29 answer?
© Copyright, Joint Commission International
A. What hand hygiene guidelines do you follow? B. What hand hygiene products do you use? (IPSG Goal 5)
62
© Copyright, Joint Commission International
QUESTIONS?
127
Notes
128
Notes
129
130
131
© Copyright, Joint Commission International
Root Cause Analysis (RCA)
What is a Root Cause
– Most errors, failures, or accidents have multiple causes, but fewer (often one) root cause.
2
Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
– Root Cause: The underlying source of an error, failure, or accident
What is a Root Cause Analysis?
3
Client name/ Presentation Name/ 12pt - 3
© Copyright, Joint Commission International
– A Root Cause Analysis seeks to determine the root cause of an error, failure, or accident.
132
Why Conduct an RCA? – Some portion of our system just broke/failed – E.g. Sentinel event
4
Client name/ Presentation Name/ 12pt - 4
© Copyright, Joint Commission International
– We want to determine what broke in our system
What does Root Cause Analysis (RCA) do? Multiple tools, including 5 Whys and Ishikawa
Types of causes: Apparent and Underlying
Performance Expectation: What we want to happen (e.g. 0 Sentinel events)
Types of Variation: Common Cause and Special Cause
In other words—what is causing us to miss our performance goals? 5
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
– Identify the causes that lead to variation from our performance expectation.
Performance Expectations – A standard that we want to meet – Room service delivered within 30 minutes – Zero Sentinel Events – Lab work completed within 24 hours – Measurable – Specific – Within our control
– RCAs are most effective when they analyze a failure of a clear performance expectation 6
Client name/ Presentation Name/ 12pt - 6
© Copyright, Joint Commission International
– Good performance expectations are
133
Types of Causes Apparent Causes Underlying Causes –The causes that lead to our apparent cause –What factor(s): – Allowed the “error” to happen – Failed to prevent the “error” – Started a chain of events that led to the “error”
–May be a Root Cause –Usually, harder to see 7
Client name/ Presentation Name/ 12pt - 7
© Copyright, Joint Commission International
–“Proximate Causes” –What factor(s) led directly to the “error”? –Usually, easy to see
Types of Causes in a Car Accident
Client name/ Presentation Name/ 12pt - 8
© Copyright, Joint Commission International
Apparent Causes Underlying Causes –Driver did not hit the brakes –Driver reaction time slow fast enough to avoid hitting because of lack of sleep the Why? previous night the car in front of them –Driver did not get enough Why? sleep because they were stuck in the ED until 3 AM, but still needed to report for their 7 AM shift –Driver needed to report at 7 Why? AM because the hospital was short-staffed on this holiday weekend. –The hospital was short Why? staffed because they do not have a staffing plan that assures adequate staff on holidays. 8
The Five Whys
11
Client name/ Presentation Name/ 12pt - 11
© Copyright, Joint Commission International
– We have just performed a simplified version of the first RCA technique: the Five Whys.
134
How to Use the Five Whys – First, ask “Why did this error occur?” – The driver didn’t hit the brakes fast enough.
– Then, ask “Why did that occur?” – Then, ask “Why did that occur?” – They were stuck in the ED until 3 AM
– Then, ask “Why did that occur?” 12
Client name/ Presentation Name/ 12pt - 12
© Copyright, Joint Commission International
– They were tired
– Asking “Why” five times is generally sufficient to identify a root cause. – If you have not discovered a satisfying root cause after asking “why” five times, keep going until you do.
13
Client name/ Presentation Name/ 12pt - 13
© Copyright, Joint Commission International
Why not the Six Whys?
– Arrange yourself in groups of 4-7. – Select a single error, accident, or failure. – For the purposes of this exercise, you may use a fictional failure. – Perform the Five Whys as a group, to discover the root cause. 14
Client name/ Presentation Name/ 12pt - 14
© Copyright, Joint Commission International
Exercise: The Five Whys
135
– What were your Root Causes? – If this were a real RCA, who would be helpful to have on the team? – What kind of mindset is it important that the team have in order to complete an effective RCA?
15
Client name/ Presentation Name/ 12pt - 15
© Copyright, Joint Commission International
What did you Learn?
RCA Team Makeup – People involved (directly or indirectly) in the failure – Team Leader – Objective – Not part of the process – Experience conducing RCAs – Not always the most senior member of the team
– 5-8 members 16
Client name/ Presentation Name/ 12pt - 16
© Copyright, Joint Commission International
– Good RCA Teams often include the following:
Problems with the Five Whys
– Root cause depends on the group’s knowledge – Different groups = different root causes – It can be difficult to know when you have discovered the real root cause – There may be several answers that answer a single “why?” By selecting one, we choose simplicity over complexity, and may miss important causes that are not the main cause It may be helpful to consider a tool that attempts to collect allClient of name/ the Presentation potential causes 17 of Name/ 12pt - 17 an error.
© Copyright, Joint Commission International
– Although it is a useful tool, the “Five Whys” does have faults.
136
– If you are concerned about capturing and assessing multiple root causes, consider using the Fishbone Tool. – Like “5 Whys,” this tool requires a team to brainstorm causes. – Also known as a “Fishbone Diagram”
18
Client name/ Presentation Name/ 12pt - 18
© Copyright, Joint Commission International
Tool 2: Ishikawa Diagram
The Ishikawa Tool
The basic explanation of the problem.
y d m isse ight I m fl
19
Client name/ Presentation Name/ 12pt - 19
© Copyright, Joint Commission International
Start with an explanation of the “problem”
The Ishikawa Tool
– Seek 3 to 6 categories – The “Four-M” categories are a good place to start: –Materials –Machines –Manpower –Methods 20
Client name/ Presentation Name/ 12pt - 20
© Copyright, Joint Commission International
– What are the categories of causes that are leading to your problem?
137
The Ishikawa Tool Draw “bones” for each category of causes Materials
I missed my flight
Manpower
Methods
21
Client name/ Presentation Name/ 12pt - 21
© Copyright, Joint Commission International
Machines
The Ishikawa Tool Drill down on each category Machines
Materials
I missed my flight
Manpower
Methods
22
Client name/ Presentation Name/ 12pt - 22
© Copyright, Joint Commission International
Materials Cause 1
The Ishikawa Tool Sub-divide each cause into sensible divisions Materials
The further you subdivide, the more specific the cause.
Materials Cause 1 se au bc Su use a bc Su use a bc Su
Sub-subcause
Sub-subcause
Sub-subcause
Materials Cause 2
23
Client name/ Presentation Name/ 12pt - 23
© Copyright, Joint Commission International
Sub-subcause
Sub-subcause
138
The Ishikawa Tool Sub-divide each cause into sensible divisions The further you subdivide, the more specific the cause.
Materials
Ink smudged on my ticket
C in r A/ m e No sum e th
ice ff wo r Ne nage o ma nts t osts wa er c low
Office too warm New office manager wants to lower costs
Passport doesn’t match ticket
24
Client name/ Presentation Name/ 12pt - 24
© Copyright, Joint Commission International
e
h ug
nc d Ba perie ex
no te No ep sle
s nd ha ty ea Sw n pe
Nervous about flight
p ea Ch
Budget crisis
New pen supplier
The Ishikawa Tool Materials Materials Cause 1
Machines Cause 1
Materials Cause 2 Sub-subcause Sub-subcause
Sub-subcause
The basic explanation of the problem.
Sub-subcause
Sub-subcause
Machines Cause 3
Su bc a
e
e
Su bc au se Su bc au se Su bc au se
e
us
us
us
l ca
l ca
l ca
leve
leve
leve 4 th
Manpower Cause 1 Sub-subcause
4 th
Sub-subcause
Sub-subcause
4 th
us e
us e
Su bc a
Su bc a
Manpower Cause 2
Sub-subcause Sub-subcause
Sub-subcause
leve
l ca leve
4 th
l ca
us
us
e
e
Sub-subcause
Methods
Manpower
4 th
Sub-subcause
Sub-subcause Sub-subcause
us e
Methods Cause 1 Sub-subcause
Methods Cause 2 Sub-subcause
25
Client name/ Presentation Name/ 12pt - 25
How far down do we drill? – Keep separating causes into sensible subdivisions. – You subdivided enough when the “branches” are: – Specific – Measurable – Controllable
27
Client name/ Presentation Name/ 12pt - 27
© Copyright, Joint Commission International
Sub-subcause
se au bc Su use a bc Su
Sub-subcause
Sub-subcause
Sub-subcause
se au bc Su se au bc Su se au bc Su
se au bc Su se au bc Su
Sub-subcause
Machines Cause 2
© Copyright, Joint Commission International
Machines
139
Exercise: Ishikawa Diagram – In small groups, create your own Ishikawa diagram. Machines
Materials Materials Cause 1
Machines Cause 1 Sub-subcause
Materials Cause 2 Sub-subcause
us ca
us ca
e
e
Sub-subcause
Sub-subcause
se au bc Su se au bc Su se au bc
Su
Sub-subcause
se au bc e us ca
Sub-subcause
Sub-subcause
Sub-subcause
Machines Cause 3
The basic explanation of the problem.
Su bc au se
Methods Cause 1 Sub-subcause Sub-subcause Sub-subcause us e
us e
us e
ca
ca
ca
lev el
lev el
lev el
4 th
4 th
Manpower Cause 1 Sub-subcause
4 th
Sub-subcause
Sub-subcause
Su bc au se Su bc au se Su bc au se
Su bc au se Su bc au se
Methods Cause 2 Sub-subcause
Sub-subcause
Manpower Cause 2
Sub-subcause Sub-subcause
Sub-subcause
se 4 th
lev el
ca
cau lev el 4 th
Manpower
use
Sub-subcause
Methods
28
Client name/ Presentation Name/ 12pt - 28
© Copyright, Joint Commission International
b Su
Sub-subcause
Su
Sub-subcause
b Su
b Su
Machines Cause 2
What did you Learn?
29
Client name/ Presentation Name/ 12pt - 29
© Copyright, Joint Commission International
– What were your root causes? – What were the most important differences between Ishikawa and “five-whys”?
Problems with Ishikawa Diagrams
30
Client name/ Presentation Name/ 12pt - 30
© Copyright, Joint Commission International
– The complexity of the tool can be difficult to know which is the “key” root cause – Requires more time
140
Other RCA Tools
31
Client name/ Presentation Name/ 12pt - 31
© Copyright, Joint Commission International
– Five Whys and Ishikawa Diagrams are two easy ways to conduct RCAs on understandable processes – For some problems, a statisticallybased RCAs may be more useful
Why Did Our Root Cause Happen?
– Do not have a process – Have a bad process – Something causes variation within our process
33
Client name/ Presentation Name/ 12pt - 33
© Copyright, Joint Commission International
– Most Root Causes happen because we either:
Variation from a process
– Common Cause: The variation occurs regularly as a result of the way the process operates – Special Cause: The variation is rare, and is not a result of the process 35
Client name/ Presentation Name/ 12pt - 35
© Copyright, Joint Commission International
– Variation from an existing process is one of the most difficult root causes to address. – Two types of variation
141
Common Cause Variation –A result of the process. –The process allows this amount of variation. 30 20
Wait Times for26Room Service 28 25
24
23
20
19
17
22
22
19
17
9
10
25
26
14
15
19
© Copyright, Joint Commission International
10 0 1
2
3
4
5
6
7
8
11
12
13
–We would not expect that it is always delivered in 22 minutes. –Normal variation is often expected and 36 Client name/ Presentation Name/ 12pt - 36 allowed.
Common Cause Variation – Room Service sources of common cause variation include: – Imprecise burner temperatures – Staff availability – Slow elevators © Copyright, Joint Commission International
– Sources of common cause variation work together to deliver our food a little bit earlier or a little bit later than average. 37
Client name/ Presentation Name/ 12pt - 37
When is Common Cause Variation a Problem? – When it fails to meet our “customer’s” needs. Wait Times for Room Service 100
80
76
68
80
100
96
92
60
88
112
104 76
88 68
100 104
76
Our promise/customer requirement
40 20 0 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
38
Client name/ Presentation Name/ 12pt - 38
© Copyright, Joint Commission International
120
142
– Common Cause Variation suggests that your outcomes are a result of the process – If the process does not meet customer needs, you must change the process
39
Client name/ Presentation Name/ 12pt - 39
© Copyright, Joint Commission International
How do we Fix Common Cause Variation?
Special Cause Variation – Special Cause Variation happens outside of the normal process. Wait Times for Room Service 400
327
300
20
23
17
24
19
25
22
26
19
17
1
2
3
4
5
6
7
8
9
10
19
28
25
26
12
13
14
15
0 11
– The process is functioning normally, until some event happens 40
Client name/ Presentation Name/ 12pt - 40
Special Cause Variation – Room Service sources of special cause variation include: – A fire in the kitchen – Broken elevator – Crashing computer system
– A single sources of special cause variation causes us to miss our performance standard. 41
Client name/ Presentation Name/ 12pt - 41
© Copyright, Joint Commission International
100
© Copyright, Joint Commission International
200
143
How do we fix Special Cause Variation?
42
Client name/ Presentation Name/ 12pt - 42
© Copyright, Joint Commission International
– Sources of special cause variation must be identified and eliminated – Eliminating a single special cause does not always mean that the error cannot reoccur.
Common vs. Special Cause Variation
–Cause of at least 85% of the problem –Systems based –Improvement usually requires intense analysis of the system and changes to the system
Special Cause Variation –Attributed to less than 15% of the cause of the problem –Improvement requires change by an individual or avoidance of an isolated event
43
Client name/ Presentation Name/ 12pt - 43
© Copyright, Joint Commission International
Common Cause Variation
58
Client name/ Presentation Name/ 12pt - 58
© Copyright, Joint Commission International
RCA Summary
144
What does Root Cause Analysis (RCA) do? Multiple tools, including 5 Whys and Ishikawa
Types of causes: Apparent and Underlying
Performance Expectation: What we want to happen (e.g. 0 Sentinel events)
Types of Variation: Common Cause and Special Cause
This analysis helps us understand why we have missed our performance goals 59
Client name/ Presentation Name/ 12pt - 59
© Copyright, Joint Commission International
– Identify the causes that lead to variation from our performance expectation.
• Start with special causes in the clinical process and move to common causes in the organization process • Repeatedly peel away the layers of the incident until no additional logical answers can be found • Identify changes that could be made to systems and processes that would reduce the risk of such an event occurring in the future 60
Client name/ Presentation Name/ 12pt - 60
© Copyright, Joint Commission International
RCA Tips
RCA Tips
61
Client name/ Presentation Name/ 12pt - 61
© Copyright, Joint Commission International
• Eliminate culture of blame • Continue to study the process and compare it over time to assure ongoing change and improvement
145
62
© Copyright, Joint Commission International
Next Presentation Client name/ Presentation Name/ 12pt - 62
146
Day 3: The Survey and Continual Improvement
147
Advanced Quality Strategies
© Copyright, Joint Commission International
Failure Mode and Effects Analysis (FMEA)
Failure Modes and Effects Analysis (FMEA)
– Failure Mode: What one observes when a failure occurs. – Effect: The consequences of a failure 2
Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
– FMEA is a tool which helps identify and prioritize potential failures in a process. – FMEA does not fix failures
3
Client name/ Presentation Name/ 12pt - 3
© Copyright, Joint Commission International
A Failure?
148
A Failure in Pisa –Failure Mode: •The tower was built on ground that could not support it.
•The tower leans to one side.
–Effects: •The building is unsafe. •The building must be reinforced. •More staff must be hired to accommodate additional 4 Client name/ Presentation Name/ 12pt - 4 visitors.
© Copyright, Joint Commission International
•Visitors must be careful when climbing the stairs.
Root Cause Analysis v. FMEA FMEA can also be used to improve an existing system
5
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
RCA examines why a specific failure happened
R oo A t Ca na u ly s R sis e ed es ig n FM E Im A pr ov e
FM EA B ui ld in g
JCI Hospital Std QPS.10 – An ongoing program of identifying and reducing unanticipated adverse events and safety risks to patients and staff is defined and implemented. – Identify high risk processes – Prioritize risks annually – Proactive risk reduction annually – Redesign process, based on activity 6
Client name/ Presentation Name/ 12pt - 6
© Copyright, Joint Commission International
D
es ig n
FMEA is an early part of process improvement
149
What will an FMEA give us?
– What we will see when a failure occurs – How that failure impacts our “customers” – What is the likely cause of the failure
– Best for analysis of a system not an incident 7
Client name/ Presentation Name/ 12pt - 7
© Copyright, Joint Commission International
– A prioritized list of potential failures/risks that include:
What will we do with a completed FMEA?
– Predict possible failures – Eliminate the possibility of intolerable errors – Minimize the consequences of unavoidable errors 8
Client name/ Presentation Name/ 12pt - 8
© Copyright, Joint Commission International
– Use the prioritized failures/risks to focus our improvement efforts on the most pressing problems
© Copyright, Joint Commission International
The FMEA Process
150
1. 2. 3. 4. 5. 6. 7. 8.
Select a process Assemble a team Diagram the process Brainstorm Complete the FMEA form Redesign the process/design controls Analyze and test the new process Implement & monitor redesigned process 10
Client name/ Presentation Name/ 12pt - 10
© Copyright, Joint Commission International
FMEA Process Steps
Step 1: Select a Process – High-risk process
Healthcare •Humans •Many processes •Many lack standards •High degree of human interaction •Very hierarchical
11
Client name/ Presentation Name/ 12pt - 11
© Copyright, Joint Commission International
High Risk Process •Variable input •Complex •Non-standardized •Heavily dependent on human interaction •Hierarchical (not team) orientation
Step 2: Form a Team – 4 to 8 members – Experts on the process examined: – – – –
FMEA Expert (act as facilitator) Hospital Leader with decision-making power Team Leader (can be same as one of above) At least one person unfamiliar with the process to be examined
12
Client name/ Presentation Name/ 12pt - 12
© Copyright, Joint Commission International
– If clinical at least one nurse and one doctor – Preferably individuals who command respect
151
A Successful FMEA Needs
13
Client name/ Presentation Name/ 12pt - 13
© Copyright, Joint Commission International
– Leadership support – Trained and qualified personnel – Honesty – Creativity
Step 3: Diagram the Process – Multiple ways to diagram any process – Value Stream Mapping – Flow Charting
– Allocate plenty of time for this step – Be as detailed and complete as possible – Learn the flow chart process and symbols 14
Client name/ Presentation Name/ 12pt - 14
© Copyright, Joint Commission International
– Involve representation for everyone involved in the process
Value Stream Map Example
Cola unloaded at Conference Center
Cola carried to storage room
Value Added 120 mins Non-Value
Cola refrigerated
Carried to conference room
Wait for Cola order
Cola put on ice
30 mins
30 mins 30 mins
Wait for program to start
17,280 mins
120 mins
60 mins 15
Client name/ Presentation Name/ 12pt - 15
© Copyright, Joint Commission International
Customer
Cola Factory
152
Cola unloaded at Conference Center
Cola carried to storage room
Cola refrigerated
Carried to conference room
Wait for Cola order
Wait for program to start
Cola put on ice
16
Client name/ Presentation Name/ 12pt - 16
© Copyright, Joint Commission International
Customer
Cola Factory
Flow Charting Medication order
Order transcribed into medication administration record (MAR)
Order pulled from chart
Copy of order sent to Pharmacy
Order transcribed into Pharmacy system 17
Client name/ Presentation Name/ 12pt - 17
© Copyright, Joint Commission International
Physician writes order
Exercise 1: Flow Charting Examples –Ordering medication –Cleaning dishes –Making travel arrangement
Physician writes order
Medication order
Order pulled from chart
Order transcribed into medication administration record (MAR)
Copy of order sent to Pharmacy
Order transcribed into Pharmacy system
18
Client name/ Presentation Name/ 12pt - 18
© Copyright, Joint Commission International
Instructions –Minimum of 4 steps –Maximum of 8 steps –Pick something everyone in the group can understand
153
Value Stream Map Legend Electronic Info Flow
Transporting Someone moved something
Rework Something done again
Shipment Something is mailed/shipped externally
Blood drawn by technician
Hard Copy Info Flow
Wait Something is “sitting”
Customer
Cola Factory
Process Step We are actually doing something
External Customer/Supplier Cola unloaded at Conference Center
Cola carried to storage room
Cola refrigerated
Wait for Cola order
Carried to conference room
Wait for program to start
Cola put on ice
19
Client name/ Presentation Name/ 12pt - 19
FMEA Brainstorming
Soda
nation
bo decar ks rin rd me a sto Soda bonation Cu t sod car ds de la oi f av omer Cust emains -r soda ed ty open thirs Soda bonation Soda ft out decar le leaves Customer and r ed gerato to find unopen Refri n soda broke out left us t Soda g m er too lon om t s e ble Cu d ic availa No ice fin avoids omer Cust emains -r ed soda serv time ty enough Soda thirs Not after cool leaves to warm er ry Custom delive ed to find unopen t to forgo Staff r soda
da No so ed serv
© Copyright, Joint Commission International
Push Supply regardless if consumed
© Copyright, Joint Commission International
Pull Supply only when consumed
did delive butor Distri iver soda not del t to sen Soda room g wron nk t dri nno ns Ca op tio other t to forgo Staff r did delive butor Distri iver soda not del t to Customer leaves sen Soda room to find soda g wron
us t rm me er sto at Cu k w in dr omer irsty st Cu ns th remai
Step 4: FMEA Brainstorming
21
Client name/ Presentation Name/ 12pt - 21
© Copyright, Joint Commission International
– This FMEA looks for potential failure points in the process we are implementing – Essentially, FMEAs are very large brain-storming projects
154
Exercise 2: Brainstorm Failure Modes – Failure Mode: What you observe when a failure happens. – Do not list causes, effects, or reasons at this point.
– Brainstorm at least 3 potential failure modes within your process.
Soda opened and left out
Soda served warm
No soda served
– In a “real” FMEA, brainstorm until you run out of ideas. – Leave plenty of room on your page!
24
Client name/ Presentation Name/ 12pt - 24
© Copyright, Joint Commission International
– Brainstorm potential Failure Modes in your process
Exercise 3: Brainstorm Effects
– Effect: How the failure impacts the customer. – Do not list causes or reasons at this point.
– Brainstorm at least 3 effects for each failure mode. – In a “real” FMEA, brainstorm until you run out of ideas. – Leave plenty of room on your page!
Soda opened and left out
inks er dr Custom da so flat Customer avoids soda-remains thirsty
Custome to fin r leaves d unopen soda ed
Soda served warm
st er mu Custom ice find Customer avoids soda-remains thirsty
Custome to fin r leaves d unopen soda ed
No soda served
st er mu Custom ter wa drink Customer remains thirsty
Custome to fin r leaves d soda
25
Client name/ Presentation Name/ 12pt - 25
© Copyright, Joint Commission International
– Brainstorm the potential effects for each failure mode
Exercise 4: Brainstorm Causes
– Cause: Whatever made the effect or failure mode occur.
– Brainstorm at least 1 cause for each failure mode. – In a “real” FMEA, brainstorm until you run out of ideas. – Leave plenty of room on your page!
Soda opened and left out
inks er dr Custom da so flat Customer avoids soda-remains thirsty
Custome to fin r leaves d unopen soda ed
Soda served warm
st er mu Custom ice find Customer avoids soda-remains thirsty
Custome to fin r leaves d unopen soda ed
No soda served
st er mu Custom ter wa drink
Customer remains thirsty Custome to fin r leaves d soda
Soda decarbonation
Soda decarbonation
Soda decarbonation Refrigerator broken Soda left out too long No ice available
Not enough time to cool after delivery Staff forgot to deliver Distributor did not deliver soda Soda sent to wrong room Cannot drink other options Staff forgot to deliver Distributor did not deliver soda Soda sent to wrong room
26
Client name/ Presentation Name/ 12pt - 26
© Copyright, Joint Commission International
– Brainstorm the likely cause(s) for each effect
155
© Copyright, Joint Commission International
Complete the FMEA Form
28
Client name/ Presentation Name/ 12pt - 28
© Copyright, Joint Commission International
Filling Out the FMEA
What Does the FMEA Form Help us Do? – The FMEA form guides us through two questions:
– 2. Which potential failures should we start working on first? 29
Client name/ Presentation Name/ 12pt - 29
© Copyright, Joint Commission International
– 1. What are the important elements of a potential failure?
156
1
– What will we observe when something fails?
2
– How will the failure impact our “customers”?
3
– What do we think might cause this failure? 30
Client name/ Presentation Name/ 12pt - 30
© Copyright, Joint Commission International
Elements of a Potential Failure
What is your first Failure
1 Mode?
– Failure Mode: What you observe when a failure occurs 1
Failure Mode
Soda opened and left out
32
Client name/ Presentation Name/ 12pt - 32
© Copyright, Joint Commission International
What you observe when a failure occurs
What is the first effect of your
2 first Failure Mode?
– Determine the effect on the customer 2
Effect
How the failure impacts the ultimate “customer”
Soda opened and left out
Customer drinks “flat” soda
33
Client name/ Presentation Name/ 12pt - 33
© Copyright, Joint Commission International
Failure Mode What you observe when a failure occurs
157
4 Severity – Determine the severity of the effect on the customer – This is step 4, so skip it for now.
left out
Effect
4
Severity
How the failure impacts the ultimate “customer”
10
5
1
Customer drinks “flat” soda
34
Client name/ Presentation Name/ 12pt - 34
© Copyright, Joint Commission International
Mode e when a failure
4 Severity – Determine the severity of the effect on the customer – This is step 4, so skip it for now.
left out
Effect
Severity
How the failure impacts the ultimate “customer”
10
5
1
Customer drinks “flat” soda
ame ordered orm X g ordered 35
Client name/ Presentation Name/ 12pt - 35
© Copyright, Joint Commission International
Mode e when a failure
3 Potential Cause – Determine the most likely cause of each Failure Mode/Effect – List as many as apply Failure Mode Severity
3
Potential Cause
What you observe when a failure occurs10 5 1
The most likely cause of the failure
s “flat” soda
Soda opened and left out
Soda opened too early Soda decarbonation Busy staff Incorrect meeting times 36
Client name/ Presentation Name/ 12pt - 36
© Copyright, Joint Commission International
ffect impacts the mer”
158
Repeat Steps 1 , 2 , 3
© Copyright, Joint Commission International
– Do you have all of the Potential Causes of an Effect? – Now, go back and brainstorm another Effect of the Failure Mode you are examining. – What are the Potential Causes of that Effect? – Exhaust all causes before moving on to a new effect. Exhaust all effects before moving on to a new failure mode. 37
Client name/ Presentation Name/ 12pt - 37
2
5
What’s the next most likely cause of that effect?
What’s the first effect of that failure mode?
What’s the first failure mode?
Soda served warm
3
4
Customer avoids soda, still thirsty
7
6
8
Are there more likely causes of the effect?
Yes
No © Copyright, Joint Commission International
1
Refrigerator broken Cold soda left out too long
Customer leaves venue to find soda Soda served warm
Yes No
Yes Are there No
more failure modes?
1
Soda served warm
2
Are there more likely effects of the failure mode? 38
Client name/ Presentation Name/ 12pt - 38
4
Customer avoids soda-remains thirsty
3
5
6
7
8
Refrigerator broken Not enough time to cool soda post delivery Cold soda left out too long No ice available
Customer leaves venue to find cold soda
Refrigerator broken Not enough time to cool soda post delivery Cold soda left out too long
Customer drinks “flat” soda
Soda decarbonation
Customer avoids soda-remains thirsty
Soda decarbonation
Customer bumps table and spills open soda
Soda decarbonation Shaky table
Customer thinks open sodas belong to others
No soda served
Soda decarbonation
Customer leaves venue to find unopened soda
Soda decarbonation
Customer leaves venue to find unopened soda
Distributor did not deliver soda Soda not ordered from distributor Soda sent to the wrong room Soda too warm to serve
39
Client name/ Presentation Name/ 12pt - 39
Staff forgot to deliver soda
© Copyright, Joint Commission International
No ice available
Soda opened and left out
159
2
1
4
Customer avoids soda-remains thirsty
Soda served warm
3
5
7
6
8
Refrigerator broken Not enough time to cool soda post delivery Cold soda left out too long
Some effects have the same set of causes
No ice available Customer leaves venue to find cold soda
Refrigerator broken
Not enough time to cool soda post delivery
Customer drinks “flat” soda
Soda decarbonation
Customer avoids soda-remains thirsty
Soda decarbonation
Effects may have multiple or single causes
Customer bumps table and spills open soda
Soda decarbonation Shaky table
Customer thinks open sodas belong to others
No soda served
Soda decarbonation
Customer leaves venue to find unopened soda
Soda decarbonation
Customer leaves venue to find unopened soda
Distributor did not deliver soda
© Copyright, Joint Commission International
Cold soda left out too long No ice available
Soda opened and left out
Different failure modes may have the same effects
Soda not ordered from distributor Soda sent to the wrong room
40
Soda too warm to serve
Client name/ Presentation Name/ 12pt - 40
Staff forgot to deliver soda
– Fill in 1 , 2 & 3 only – In a real FMEA, brainstorm until you are out of ideas. – Use the brainstorming you completed earlier to fill in this form. – For this exercise, please limit yourself to three causes, three effects, and two failure modes. – Remember: – Many lines will remain blank – No idea is a bad idea 41
Client name/ Presentation Name/ 12pt - 41
Soda served warm
2
4
Customer avoids soda-remains thirsty
3
5
Refrigerator broken Not enough time to cool soda post delivery Cold soda left out too long
Soda opened and left out
No ice available Customer leaves venue to find cold soda
Refrigerator broken
Not enough time to cool soda post delivery Cold soda left out too long No ice available
Soda served warm
inks er dr Custom da so flat Customer avoids soda-remains thirsty
Custome to fin r leaves d unopen soda ed st er mu Custom ice find Customer avoids soda-remains thirsty
Custome to fin r leaves d unopen soda ed
No soda served
Client name/
er mu Custom ter wa drink
st
Customer remains thirsty
Soda decarbonation
Soda decarbonation
Soda decarbonation Refrigerator broken Soda left out too long
© Copyright, Joint Commission International
1
© Copyright, Joint Commission International
Exercise: Brainstorming the FMEA
No ice available
Not enough time to cool after delivery Staff forgot to deliver Distributor did not deliver soda Soda sent to wrong room Cannot drink other options
Staff forgot to Custome deliver to fin r leaves d soda did Presentation Name/ 12ptDistributor - 42 not deliver soda
42
Soda sent to wrong room
160
What Does the FMEA Form Help us Do? – An FMEA helps us answer two questions:
© Copyright, Joint Commission International
– 1. What are the important elements of a potential failure? – What will we observe when something fails? – How will the failure impact our “customers”? – What do we think might cause this failure? – 2. Which potential failures should we start working on first? – Which failures are most severe? – Which failures occur most often – Which failures are hard to detect before they impact our customers?
43
Client name/ Presentation Name/ 12pt - 43
Scoring the FMEA
© Copyright, Joint Commission International
– In steps 4 , 5 & 6 , you will assign a set of numerical scores to your effects and causes.
44
Client name/ Presentation Name/ 12pt - 44
1
2
4
4 Severity Severity Soda served warm 10
5
Customer avoids soda-remains thirsty
4
Customer leaves venue to find cold soda
7
Customer drinks “flat” soda
2
Customer avoids soda-remains thirsty
4 8
1
– Determine the severity of the effect on the customer – 10=Extreme (death) Soda opened and left out – 1=Customer doesn’t care (not customer is happy)
No soda served
Customer bumps table and spills open soda
© Copyright, Joint Commission International
4
Customer thinks open sodas belong to others
2
Customer leaves venue to find unopened soda 45 Client name/ Presentation Name/ 12pt - 45 Customer leaves venue to find unopened soda
7 7
161
3
5
6
5 Occurrence Common
2
Refrigerator broken
Rare 5
Not enough time to cool soda post delivery 1
Cold soda left out too long
– How often does the cause occur? – 10=Very often – 1= Very rare
No ice available Refrigerator broken Not enough time to cool soda post delivery Cold soda left out too long
7 8 3 2 7 8 3 4 4
No ice available Soda decarbonation Soda decarbonation
© Copyright, Joint Commission International
Occurrence 10
4 2 4
Soda decarbonation Shaky table Soda decarbonation
Soda decarbonation 446 Client name/ Presentation Name/ 12pt - 46 Distributor did not deliver soda 1
3
5
6
6 Detectability Refrigerator broken
5
2
Not enough time to cool soda3post delivery
Likely
Unlikely
1
– How likely are we to detect problem before it effects the customer? – 10=Unlikely – 1= Certain
No ice available
7 5
Refrigerator broken
2
Cold soda left out too long
7
2 7 8
5 3 3
3 4 4
3 9 3
4 2 4
Not enough time to cool soda3post delivery Cold soda left out too long No ice available Soda decarbonation Soda decarbonation Soda decarbonation Shaky table Soda decarbonation
2 7 8 3
Soda decarbonation 3 447 Client name/ Presentation Name/ 12pt - 47 Distributor did not deliver soda 9 1
© Copyright, Joint Commission International
Detectability 10
Scoring Hints – Big number = worse outcome – Precision is not important.
– Keep the rest of the FMEA in mind as you score. – The first item may seem like a 10, but is it a 10 compared to the other items on the list?
48
Client name/ Presentation Name/ 12pt - 48
© Copyright, Joint Commission International
– Don’t waste time discussing if something should be scored a three or four.
162
Exercise: Scoring The FMEA columns.
– Score in relation to every item on your list. – Precision is not important—there is very little difference between a score of 2, 3, or 4. – Big number = worse outcome 49
Client name/ Presentation Name/ 12pt - 49
Customer leaves venue to find cold soda
Customer drinks “flat” soda
Soda opened and left out
Customer avoids soda-remains thirsty Customer bumps table and spills open soda
Customer thinks open sodas belong to others Customer leaves venue to find unopened soda Customer leaves venue to find unopened soda
No soda served
1
9
5
Not enough time to cool soda post delivery
4
8
5
Cold soda left out too long
6
3
5
No ice available
3
8
7 7
Refrigerator broken
1 4
9 8
5
Customer avoids soda-remains thirsty
Soda served warm
Refrigerator broken
Not enough time to cool soda post delivery
7
Cold soda left out too long
6
3
7 4 5
No ice available
3 8 8
8 9 9
Soda decarbonation Soda decarbonation
8
Soda decarbonation
8
9
8
Shaky table
3
3
4 7
Soda decarbonation Soda decarbonation
8 8
9 9
7
Distributor did not deliver soda
1
10
7
Soda not ordered from distributor
3
1
7 7
Soda sent to the wrong room
7
Staff forgot to deliver soda
7 2 50 2 7 Client name/ Presentation Name/ 12pt - 50
Soda too warm to serve
9
4
© Copyright, Joint Commission International
6
© Copyright, Joint Commission International
– Score the 4 , 5 & – Remember:
Risk Priority Number – The Risk Priority Number determines where our greatest danger lies – Severity X Occurrence X Detectability Occurrence Common 5
1
10
Detectability 1
10
RPN
Likely
Unlikely
Rare 5
5
1
3
8
7
168
9
8
5
360
9
1
6
54
6
5
51
Client name/ - 51 7 Presentation Name/ 12pt210
© Copyright, Joint Commission International
Severity 10
163
Risk Priority Number – The Risk Priority Number determines where our greatest danger lies – Severity X Occurrence X Detectability Occurrence Common 5
1
10
5
1
10
RPN
Likely
Unlikely 5
1
3
8
7
168
9
8
5
360
9
1
6
54
6
5
52
Client name/ - 52 7 Presentation Name/ 12pt210
Rank by RPN – Once you determine the RPN, determine the rank. – Higher numbers mean greater risk. Failure Mode
Soda opened and left out
168
Look alike drug name ordered
360
Used felt pen on form X
54 53
Non-formulary drug ordered
Client name/ Presentation Name/ 12pt210 - 53
© Copyright, Joint Commission International
RPN
What you observe when a failure occurs
Rank by RPN – Use the RPN to determine where to focus your limited resources – We are looking for failures that are most severe, occur often, and are hard to detect. Failure Mode
RPN
Rank
Soda opened and left out
168
3
Look alike drug name ordered
360
1
Used felt pen on form X
54
What you observe when a failure occurs
Non-formulary drug ordered
210
4 54
Client 2 name/ Presentation Name/ 12pt - 54
© Copyright, Joint Commission International
10
Detectability
Rare
© Copyright, Joint Commission International
Severity
164
Exercise: RPNs and Rankings
© Copyright, Joint Commission International
– Use the scores you created to determine Risk Priority Numbers (RPNs). – Use the RPNs to determine rank RPN= Severity x Occurrence x Detectability 55
Client name/ Presentation Name/ 12pt - 55
Customer leaves venue to find cold soda
Soda opened and left out
Customer drinks “flat” soda Customer avoids soda-remains thirsty Customer bumps table and spills open soda
Customer thinks open sodas belong to others Customer leaves venue to find unopened soda
No soda served
Customer leaves venue to find unopened soda
1
9
45
5
Not enough time to cool soda post delivery
4
8
160
5
Cold soda left out too long
6
3
90
14
5
No ice available
3
8
120
11
7 7
Refrigerator broken Not enough time to cool soda post delivery
5
Refrigerator broken
18 9
1 4
9 8
63 224
17 7
7
Cold soda left out too long
6
3
126
10
7 4 5
No ice available
3 8 8
8 9 9
168 288 360
8 4 3
Soda decarbonation Soda decarbonation
© Copyright, Joint Commission International
Customer avoids soda-remains thirsty
Soda served warm
8
Soda decarbonation
8
9
576
1
8
Shaky table
3
3
72
15
4 7
Soda decarbonation Soda decarbonation
8 8
9 9
288 504
4 2
7
Distributor did not deliver soda
1
10
70
16
7
Soda not ordered from distributor
3
1
7 7
Soda sent to the wrong room
7
Staff forgot to deliver soda
21
19
98 7 2 56 98 2 7 Client name/ Presentation Name/ 12pt - 56
12 12
9
6
Soda too warm to serve
4
252
Step 6: Redesign the process/design controls
– Eliminate risk if possible – Minimize/mitigate risk if it cannot be eliminated – Look for opportunities to “failure proof”
57
Client name/ Presentation Name/ 12pt - 57
© Copyright, Joint Commission International
– Brainstorm actions that could address the failure modes with the highest Risk Priority Number (RPN)
165
Prioritized Potential Failure Modes 600
400 300 200 100 0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Failure Modes 58 Client name/ Presentation Name/ 12pt - 58
© Copyright, Joint Commission International
– All failure modes are important – Some Failure Modes will be clear targets
500
How can we Reduce Risk? – One way to reduce risk is to reduce the Risk Priority Number
59
Client name/ Presentation Name/ 12pt - 59
© Copyright, Joint Commission International
– Can I make this failure less severe? – Can I make this failure occur less often? – Can I make this failure easier to detect?
7. Analyze and Test the New Process – One the new process has been developed, conduct another FMEA, examining the potential risks. – For failure modes with high RPNs, look for additional ways to eliminate or mitigate risk
60
Client name/ Presentation Name/ 12pt - 60
© Copyright, Joint Commission International
Risk Priority Number
700
166
8. Implement and Monitor New Process
61
Client name/ Presentation Name/ 12pt - 61
© Copyright, Joint Commission International
– Repeat several times, after elimination of each Failure Mode
Summary
– requires a well functioning team – requires resources in time and talent – results in reducing patient harm and improving patient outcomes 62
Client name/ Presentation Name/ 12pt - 62
© Copyright, Joint Commission International
– Failure Mode Effects Analysis (FMEA) is an effective proactive risk reduction technique – Doing it right
Filling out an FMEA: Words first
2
3 What is the first effect of that Failure Mode?
What is the first Failure Mode?
What is the most likely cause of the failure that produces this effect?
4 What is the next most likely cause of the failure? Enter causes until you run out.
5 When you run out of causes for the effect your working on, move on to another effect.
7 When you run out of effects, move on to another Failure Mode.
6 Enter causes for this effect until you run out.
63
Client name/ Presentation Name/ 12pt - 63
© Copyright, Joint Commission International
1
167
8 Fill in all of the severity ratings
9
Then, fill in all of the occurrence ratings
12
16
13
17 Then, fill in all of the detectability ratings
10
14
18
11
15
19 64
Client name/ Presentation Name/ 12pt - 64
© Copyright, Joint Commission International
Filling out an FMEA: Numbers last
Tips for Filling out an FMEA
65
Client name/ Presentation Name/ 12pt - 65
Next Presentation 66
Client name/ Presentation Name/ 12pt - 66
© Copyright, Joint Commission International
– The numbers are relative values—they only mean something ranked against each other
© Copyright, Joint Commission International
– Words first (Failure Mode, Effect, Cause) – Number second (Severity, Occurrence, Detectability)
168
Failure Mode Effects Analysis Worksheet
1
2 Failure Mode
What you observed when a failure occurs
3
4 Effect
5 Potential Cause
Severity
How the failure impacts the How severe is the effect to the customer? The most likely causes of the customer failure--this line must always be filled in 10
5
1
6 Occurrence
Detectability
How often does the cause or Failure Mode occur? Common 10
8
RPN
Rank
How likely are we to be able to detect the failure or cause? Likely
Unlikely
Rare 5
7
1
10
5
1
169
Failure Mode Effects Analysis Worksheet
1
2 Failure Mode
What you observed when a failure occurs
3
4 Effect
5 Potential Cause
Severity
How the failure impacts the How severe is the effect to the customer? The most likely causes of the customer failure--this line must always be filled in 10
5
1
6 Occurrence
Detectability
How often does the cause or Failure Mode occur? Common 10
8
RPN
Rank
How likely are we to be able to detect the failure or cause? Likely
Unlikely
Rare 5
7
1
10
5
1
170
Failure Mode Effects Analysis Worksheet
1
2 Failure Mode
What you observed when a failure occurs
3
4 Effect
5 Potential Cause
Severity
How the failure impacts the How severe is the effect to the customer? The most likely causes of the customer failure--this line must always be filled in 10
5
1
6 Occurrence
Detectability
How often does the cause or Failure Mode occur? Common 10
8
RPN
Rank
How likely are we to be able to detect the failure or cause? Likely
Unlikely
Rare 5
7
1
10
5
1
171
Failure Mode Effects Analysis Worksheet
1
2 Failure Mode
What you observed when a failure occurs
3
4 Effect
5 Potential Cause
Severity
How the failure impacts the How severe is the effect to the customer? The most likely causes of the customer failure--this line must always be filled in 10
5
1
6 Occurrence
Detectability
How often does the cause or Failure Mode occur? Common 10
8
RPN
Rank
How likely are we to be able to detect the failure or cause? Likely
Unlikely
Rare 5
7
1
10
5
1
172
Failure Mode Effects Analysis Worksheet
1
2 Failure Mode
What you observed when a failure occurs
3
4 Effect
5 Potential Cause
Severity
How the failure impacts the How severe is the effect to the customer? The most likely causes of the customer failure--this line must always be filled in 10
5
1
6 Occurrence
Detectability
How often does the cause or Failure Mode occur? Common 10
8
RPN
Rank
How likely are we to be able to detect the failure or cause? Likely
Unlikely
Rare 5
7
1
10
5
1
173
Failure Mode Effects Analysis Worksheet
1
2 Failure Mode
What you observed when a failure occurs
3
4 Effect
5 Potential Cause
Severity
How the failure impacts the How severe is the effect to the customer? The most likely causes of the customer failure--this line must always be filled in 10
5
1
6 Occurrence
Detectability
How often does the cause or Failure Mode occur? Common 10
8
RPN
Rank
How likely are we to be able to detect the failure or cause? Likely
Unlikely
Rare 5
7
1
10
5
1
174
Failure Mode Effects Analysis Worksheet
1
2 Failure Mode
What you observed when a failure occurs
3
4 Effect
5 Potential Cause
Severity
How the failure impacts the How severe is the effect to the customer? The most likely causes of the customer failure--this line must always be filled in 10
5
1
6 Occurrence
Detectability
How often does the cause or Failure Mode occur? Common 10
8
RPN
Rank
How likely are we to be able to detect the failure or cause? Likely
Unlikely
Rare 5
7
1
10
5
1
175
Day 4: The Survey and International Patient Safety Goals
176
© Copyright, Joint Commission International
Last Survey Simulation Discussion and Reflective Learning
– What differences did you notice between the approaches that your two surveyors used? – What do these differences mean for how you will prepare for your survey?
Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
Discussion Questions
Discussion Questions
Client name/ Presentation Name/ 12pt - 3
© Copyright, Joint Commission International
– What surprised you the most about the tracer process?
177
Discussion Questions
Client name/ Presentation Name/ 12pt - 4
© Copyright, Joint Commission International
– What are three most important things that you have learned about the tracer process?
Discussion Questions
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
– What are the three most important pieces of advice that you would give to a staff members who must conduct their first tracer?
178
Notes
179
Notes
180
181
182
Four Steps for Continual Improvement
© Copyright, Joint Commission International
It’s not where you’ve been—it’s where you’re going.
The Mindset Accreditation is a milestone on the continuous journey of improvement
Three years fly by quickly, staying ready is easier than getting ready 2
Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
The effort is for your patients, not the certificate
The Tools Accreditation Standards provide a common quality language and common set of expectations to point the way forward
Credible Data guide individual decisions and overall strategic direction
3
Client name/ Presentation Name/ 12pt - 3
© Copyright, Joint Commission International
Motivational Goals bring collective energy and ideas to priority topics
183
The Challenge Sustaining improvement requires establishing an organizational culture of safe, quality care Individual behaviors must change one person at a time.
4
Client name/ Presentation Name/ 12pt - 4
© Copyright, Joint Commission International
Organizational cultures can change at a moments notice Sentinel events or leadership changes can alter culture immediately. Frequently measure the direction and rate of progress
Four Steps To Success 1. Keep things simple and clear 2. Consider data your best friend
4. Practice the process
5
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
3. Presume change and manage it
Success Step #1: Keep Things Simple and Clear
A strong quality culture in an organization is sustained by leadership not policies Individual behaviors are shaped best by mentors and role models not policies 6
Client name/ Presentation Name/ 12pt - 6
© Copyright, Joint Commission International
Policies and Procedures: As few as practical Short Simple language Readily accessible for those who need them Kept up-to-date
184
Success Step #1: Keep Things Simple and Clear Find simple and effective ways to communicate essential quality and safety information to all parties – governance, leaders, staff, patients
better than a big document once a month
7
Client name/ Presentation Name/ 12pt - 7
© Copyright, Joint Commission International
A brief communication about quality once a week is
Success Step #2: Consider Data Your Best Friend Consider how key points can be made more effective with data - a graph is worth a thousand words
Post infection rates all over the hospital Post average length of stay for procedures on the door of the staff lounge 8
Client name/ Presentation Name/ 12pt - 8
© Copyright, Joint Commission International
Motivate governance, management, professional staff and patients with data
Success Step #2: Consider Data Your Best Friend
Data owners must also own the actions for improvement and claim success for sustained improvements
9
Client name/ Presentation Name/ 12pt - 9
© Copyright, Joint Commission International
Do not try to interpret all the data--let the data owners do so Let the orthopedic surgeons explain why the complication rate for hip replacements is drifting upward for the last 2 quarters
185
Success Step #2: Consider Data Your Best Friend Continue to refine and mature your data systems
Strengthen the data analysis process so that it becomes more rapid and comprehensive Demonstrate data use and how it contributes to understanding all aspects of your organization 10
Client name/ Presentation Name/ 12pt - 10
© Copyright, Joint Commission International
Create data collection tools that people want to use Create event reporting processes that everyone uses
Success Step #3: Presume Change and Manage It Catalogue the changes occurring in your organization: Leadership changes Clinical services New staff (including contract workers) Changes in the patient population Clinical and management activities
Consider how they should be managed 11
Client name/ Presentation Name/ 12pt - 11
© Copyright, Joint Commission International
New/renovated buildings, facilities
Success Step #3: Presume Change and Manage It Ensure that standards are met as changes occur
Fire safety in new facilities and during renovations Build quality into all contracts for services 12
Client name/ Presentation Name/ 12pt - 12
© Copyright, Joint Commission International
Training for staff as they are hired
186
Success Step #4: Practice the Process Do patient and system tracers
Continually evaluate patient records to ensure they tell the entire “story” of the patient Do exercises that “break” high-risk processes to see if adverse events can sneak though 13
Client name/ Presentation Name/ 12pt - 13
© Copyright, Joint Commission International
complete at least one a month to be ready for survey or resurvey
Success Step #4: Practice the Process Practice the group interviews of leaders
Check the track record for all documentation 4 months for an initial survey 12 months for a triennial survey 14
Client name/ Presentation Name/ 12pt - 14
© Copyright, Joint Commission International
Practice using interpreters to ensure the comfort level of staff
Some Final Tips
As you prepare for an accreditation survey or maintain continued readiness for survey, your quality and patient safety capabilities should and will grow Keep quality and safety as an integrated activity 15
Client name/ Presentation Name/ 12pt - 15
© Copyright, Joint Commission International
The accreditation survey is also a learning process—there is something new to learn every time you go through it.
187
Some Final Tips Quality and safety everyone’s job. The quality department/unit is primarily for coordination and facilitation of quality with leaders monitoring and improving quality and safety. Avoid the “it’s the quality department’s job” syndrome.
16
Client name/ Presentation Name/ 12pt - 16
© Copyright, Joint Commission International
setting priorities and all staff participating in
Some Final Tips Continue to celebrate your successes as you continue to improve.
have a profound impact on patient safety.
17
Client name/ Presentation Name/ 12pt - 17
© Copyright, Joint Commission International
Constant, incremental improvement can
Step 5?
18
Client name/ Presentation Name/ 12pt - 18
© Copyright, Joint Commission International
– For those that are preparing for reaccreditation, what practices have helped you?
188
Questions-Discussion
Next Presentation 19
Client name/ Presentation Name/ 12pt - 19
© Copyright, Joint Commission International
www.jointcommissioninternational.org
189
Day 5: Tools and Techniques
190
Client name/ Presentation Name/ 12pt - 1
© Copyright, Joint Commission International
Communication Between Hospital Staff and Patients and Families: Skills to Improve Patient Safety and Build Trust and Confidence
Mission of Joint Commission International
through the provision of education, publications, consultation, evaluation, and accreditation services 2
Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
To improve the safety and quality of care in the international community
The Importance of Communication to Medical Errors
– Poor communication with patients and families destroys trust and confidence in providers and the health care system
3
Client name/ Presentation Name/ 12pt - 3
© Copyright, Joint Commission International
– Poor communication among health care providers places patients at risk
191
Sentinel Event Experience to Date Provides the Evidence 531 events of wrong site surgery 520 inpatient suicides 488 operative/post op complications 385 events relating to medication errors 302 deaths related to delay in treatment 224 patient falls 153 deaths of patients in restraints 138 assault/rape/homicide
125 perinatal death/injury 94 transfusion-related events 85 infection-related events 72 deaths following elopement 66 fires 67 anesthesia-related events 51 retained foreign objects 763 “other”
= 4064 RCAs
4
Client name/ Presentation Name/ 12pt - 4
© Copyright, Joint Commission International
Of 4064 sentinel events reviewed by the Joint Commission, January 1995 through December 2006:
Root Causes of Sentinel Events (All categories; 1995-2004) Communication Orientation/training Patient assessment Staffing Availability of info
Procedural compliance Environ. safety / security
Percent of 2966 events
Leadership Continuum of care Care planning Organization culture
0
10
20
30
40
50
60
70
80
90 100 5
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
Average number of root causes cited per RCA = 3.1
Competency/credentialing
Root Causes of Sentinel Events (All categories; 2005) Communication Orientation/training Patient assessment Staffing
Average number of root causes cited per RCA = 3.8
Availability of info Competency/credentialing
Percent of 582 events
Leadership Continuum of care Care planning Organization culture
0
10
20
30
40
50
60
70
80
90 100 6
Client name/ Presentation Name/ 12pt - 6
© Copyright, Joint Commission International
Procedural compliance Environ. safety / security
192
Root Causes of Sentinel Events (All categories; 2006) Communication Orientation/training Patient assessment Staffing
Competency/credentialing
Average number of root causes cited per RCA = 5.3
Procedural compliance Environ. safety / security Leadership Continuum of care
Percent of 516 events
Care planning Organization culture
0
10
20
30
40
50
60
70
80
90 100 7
Client name/ Presentation Name/ 12pt - 7
© Copyright, Joint Commission International
Availability of info
Why Communication Breaks Down
– Example: patients are asked questions by health care providers and not permitted to tell their story on an initial assessment. Average patient is interrupted by the provider within 20 seconds when explaining why they are seeking care. 8
Client name/ Presentation Name/ 12pt - 8
© Copyright, Joint Commission International
– Organizations and health care providers do not have the two way “conversations” with patients to build a trusting relationship.
Why Communication Breaks Down – Professional jargon used by all groups of health care providers – Abbreviations and short hand notes seem to be a personal preference not an organization policy – Information is a mixture of electronic, verbal and paper in most organizations thus no single source captures everything 9
Client name/ Presentation Name/ 12pt - 9
© Copyright, Joint Commission International
– Communication is not standardized
193
Why Communication Breaks Down
– The hand off of information from shift to shift and from setting to setting is poor and even critical information can fall between the cracks for example, medications the patient is or should be taking 10
Client name/ Presentation Name/ 12pt - 10
© Copyright, Joint Commission International
– Health care is complex and delivered across a continuum of acute care and community settings
Why Communication Breaks Down
– Nurses hesitate to challenge physicians even when they sense an error is about to be made – Admitting errors is not viewed as an opportunity to learn rather, they are covered up to save face
11
Client name/ Presentation Name/ 12pt - 11
© Copyright, Joint Commission International
– The “culture” within and between professional groups is often a barrier
– “By focusing on the human consequences of medical errors, they (advocacy groups) force care givers to confront our inadequacies in communicating with patients and families when things go wrong” – Lucian L. Leape, M.D. – Adjunct Professor of Health Policy – Harvard School of Public Health
12
Client name/ Presentation Name/ 12pt - 12
© Copyright, Joint Commission International
The Human Side of Errors
194
organization – Patient and family rights are respected and protected – Education and communication is understandable – Satisfaction is seriously evaluated – Involvement in care decisions and care process is welcomed – Kept informed of care process and when unexpected errors and complications occur
13
Client name/ Presentation Name/ 12pt - 13
© Copyright, Joint Commission International
–
JCI Standards and Accreditation Support Good Communication Patients have access to a quality focused
JCI Standards and Accreditation Support Good Communication
14
Client name/ Presentation Name/ 12pt - 14
© Copyright, Joint Commission International
– Family valued in the care process and part of all communication – End of life care and pain management respect personal preferences and maintain dignity – There are clear processes to resolve care issues or address complaints
– Approach patients’ and their families’ need for communication and information with an attitude of understanding and respect. – Tell patients and their families what went wrong as soon as it is known. – Sincerely apologize. – Tell patients and their families how such errors will be prevented in the future. 15
Client name/ Presentation Name/ 12pt - 15
© Copyright, Joint Commission International
Disclosing Medical Errors
195
– Identify the individuals or departments who should be notified of an incident. – Specify how the incident should be reported. – Define who is responsible for reporting. – Define the process for the events that follow reporting the incident. – Report errors promptly to supervisors, risk managers, and others. 16
Client name/ Presentation Name/ 12pt - 16
© Copyright, Joint Commission International
Internal Processes Related to Medical Errors
Apology and Litigation – A new policy on handling medical malpractice claims was based on three principles: – a) When we hurt someone through unreasonable medical care we ought to make it right – b) We ask the staff to do hard work. When the care they provide is reasonable, we need to support them even when something goes awry. – c) We need to learn something from medical errors and patients’ experiences. 17
Client name/ Presentation Name/ 12pt - 17
© Copyright, Joint Commission International
– University of Michigan Health System
Apology and Litigation – Results of an open disclosure policy
– Before the policy - $48,000 average claim – Since policy - $21,000 average claim
18
Client name/ Presentation Name/ 12pt - 18
© Copyright, Joint Commission International
– August 2001 – 262 claims and suits – May 2006 – 93 claims and suits
196
19
Client name/ Presentation Name/ 12pt - 19
© Copyright, Joint Commission International
Patients as Partners: Involving Patients and Families
FACT
– Feel free to ask questions until they understand the answers – Feel empowered to challenge a physician or nurse about some aspect of treatment – Feel support from the entire organization – Are more likely to comply with 20 Client name/ Presentation Name/ 12pt - 20 treatment
© Copyright, Joint Commission International
– Patients as respected partners in health care
FACT
21
Client name/ Presentation Name/ 12pt - 21
© Copyright, Joint Commission International
– Have better outcomes – Are less likely to bring legal action if things go wrong – Often identify potential medical errors that hospital staff are overlooking
197
Reality – They are only seriously listened too when a bad event occurs – Making patients into partners takes change that most organizations are reluctant to make – Creating a new culture takes leadership that is often missing – Changing philosophy, attitudes and behaviors is not easy
22
Client name/ Presentation Name/ 12pt - 22
© Copyright, Joint Commission International
– In most organizations patients are not serious partners
23
Client name/ Presentation Name/ 12pt - 23
24
Client name/ Presentation Name/ 12pt - 24
© Copyright, Joint Commission International
Brochures can be ordered that have a blank panel to allow for information about the organization, its commitment to patient safety, and the organization logo.
© Copyright, Joint Commission International
Organizations can order campaign buttons that can be worn by staff.
198
SpeakUP Initiatives – Speak Up: Help Prevent Errors In Your Care
– Three Things You Can Do To Prevent Infection – Tips To Prevent Medication Mistakes 25
Client name/ Presentation Name/ 12pt - 25
© Copyright, Joint Commission International
– Universal Protocol: Wrong Site Surgery
26
Client name/ Presentation Name/ 12pt - 26
© Copyright, Joint Commission International
Communication is Critical
– Have a conversation with a patient not just talk at them – Make sure they understand all portions of a consent form – Involve the patient and their family in care decisions to the extent they want to be involved – Make sure patient rights are known by patients and staff – Say you are “sorry” if something unexpected and adverse happens – Communicate in a language and style the patient understands
Some Tips – Post signs urging patients and families to ask questions
– Create a patient and family advisory council – Find ways to ensure that patients understand the education you provide to them and their families 27
Client name/ Presentation Name/ 12pt - 27
© Copyright, Joint Commission International
– Develop a fact sheet with advice and questions that make patient and family participation easier
199
– “Every child is different, every parent is different, every illness or behavior is somewhat different from any other……….Remember that you know a lot about your child and I don’t know anything” – Benjamin Spock, M.D. – Baby and Child Care 28
Client name/ Presentation Name/ 12pt - 28
© Copyright, Joint Commission International
Advice to a Parent
THANK YOU For more information www.JointCommissionInternational.org
29
Client name/ Presentation Name/ 12pt - 29
© Copyright, Joint Commission International
please visit our website:
200
Notes
201
Notes
202
203
204
© Copyright, Joint Commission International
International Patient Safety Goals (IPSG)
Evolution of the International Patient Safety Goals 2005 Announcement of the JCI International Patient Safety Goals (IPSG)
2007 Implementation of IPSG as requirements for International accreditation of hospitals 2008 IPSG as part of published 3rd Edition of JCI Standards for hospitals, effective January 2008 Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
2006 Pilot testing of the JCI IPSG – Results did not impact accreditation decision
Represents proactive strategies to reduce risk of medical error and reflect good practices proposed by leading patient safety experts
Incorporating these new tools into our accreditation requirements is a significant step
Organizations taking responsibility for using the IPSG to foster an atmosphere of continuous improvement is even more important
Client name/ Presentation Name/ 12pt - 3
© Copyright, Joint Commission International
Implementation of IPSG….
205
IPSG 1 Identify Patients Correctly IPSG 2 Improve Effective Communication IPSG 3 Improve the Safety of High-Alert Medications IPSG 4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery IPSG 5 Reduce the Risk of Health Care Associated Infections IPSG 6 Reduce the Risk of Patient Harm Resulting from Falls Client name/ Presentation Name/ 12pt - 4
© Copyright, Joint Commission International
2008 International Patient Safety Goals
A collaborative process is used to develop policies and/or procedures that address the accuracy of patient identification
Use at least two (2) ways to identify a patient: • • • • •
giving medications giving blood and blood products taking blood samples taking other samples for clinical testing providing treatment or procedure
The patient’s Room Number cannot be used as an identifier
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
IPSG.1 Identify Patients Correctly
IPSG 2: Improve Effective Communication
• Verbal order • Telephone order • Reporting of critical test results Must use a verification “read back” of complete order or test result The order or test result is confirmed by the individual who gave the order or test result Client name/ Presentation Name/ 12pt - 6
© Copyright, Joint Commission International
A collaborative process is used to develop policies and/or procedures that address the accuracy of verbal and telephone communications Person receiving the following:
206
Critical Test Results – Ensure that there is collaborative process to determine what they are – Clinical Laboratories
Client name/ Presentation Name/ 12pt - 7
© Copyright, Joint Commission International
– Bedside testing
– Imaging Studies – Electrocardiogram – Pulmonary Function Testing – other
A collaborative process is used to develop policies and/or procedures that address the location, labeling and storage of concentrated electrolytes Concentrated electrolytes are not present in patient care units unless clinically necessary and actions are taken to prevent inadvertent administration in those areas where permitted by policy
Remove concentrated electrolytes from patient care units, including, but not limited to, the following: • Potassium Chloride • Potassium Phosphate • Sodium Chloride > 0.9% Client name/ Presentation Name/ 12pt - 8
© Copyright, Joint Commission International
IPSG 3: Improve Safety of High Alert Medications
– Has to be supported by evidence – Is the substance really needed very quickly? – If it is used to dilute, is the diluted solution not available?
Client name/ Presentation Name/ 12pt - 9
© Copyright, Joint Commission International
Clinical Necessity
207
Collaborative process used to develop PP
Mark the precise site in clearly understood way and involve patient in doing this
Develop process or checklist to verify correct documents and functioning equipment
Use a Checklist including “Time-Out” just before surgical procedure
Client name/ Presentation Name/ 12pt - 10
© Copyright, Joint Commission International
IPSG 4: Ensure Correct-site, Correct-procedure, Correctpatient Surgery
Universal Protocol DOCUMENTS
T REC PATIENT R O C
BODY PART PROCEDURE
Client name/ Presentation Name/ 12pt - 11
© Copyright, Joint Commission International
SURGERY SITE
EQUIPMENT
Client name/ Presentation Name/ 12pt - 12
© Copyright, Joint Commission International
Universal Protocol
208
A collaborative process is used to develop PP that address reducing the risk of health care– associated infections
The hospital has adopted or adapted currently published and generally accepted hand hygiene guidelines (can be national or international)
The hospital implements an effective hand hygiene program Need data to demonstrate effectiveness Client name/ Presentation Name/ 12pt - 13
© Copyright, Joint Commission International
IPSG 5: Reduce the Risk of Health Care-Associated Infections
Client name/ Presentation Name/ 12pt - 14
Client name/ Presentation Name/ 12pt - 15
© Copyright, Joint Commission International
Develop PP using collaborative process Assess and periodically Reassess each patient’s risk for falling, including the potential risk associated with the patient’s medication regime, Take action to decrease or eliminate any identified risks.
© Copyright, Joint Commission International
IPSG 6: Reduce the Risk of Patient Harm resulting from Falls
209
Notes
210
Notes
211
212
213
© Copyright, Joint Commission International
How to Get Started with JCI Accreditation
Evaluate the commitment of leadership (Board, CEO, and clinical leaders) to a never ending journey. Assess the purity of purpose: to be a 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. Client name/ Presentation Name/ 12pt - 2
© Copyright, Joint Commission International
The Accreditation Journey: The Basics
The Accreditation Journey
Understand implications for financial and human resources. These may include facility enhancement, training, recruitment of new staff, and redesign of systems. Set a realistic timeframe for preparation. Average preparation time? Client name/ Presentation Name/ 12pt - 3
© Copyright, Joint Commission International
List all barriers and strengths to success and plan strategies for each.
214
• JCI International Standards for Hospitals, 3nd Edition • Hospital Survey Process Guide • Web-based training on introduction to the international accreditation process • ISAS – International Self Assessment System • Newsletters and publications, both print and electronic • JCI Practicum – Several locations worldwide • JCI Executive Briefings Client name/ Presentation Name/ 12pt - 4
© Copyright, Joint Commission International
The Accreditation Journey: JCI Resources
Provide education for organizational leaders and managers and then progressively for all staff. Re-educate frequently. Include: Introduction to accreditation philosophy and approach Discussion of accreditation as a patient-focused quality improvement and risk reduction strategy Review of the standards and measurable elements Discussion of the survey process and what to expect Project planning and next steps
Client name/ Presentation Name/ 12pt - 5
© Copyright, Joint Commission International
The Accreditation Journey: Continual Education
Determine the organization’s current adherence to the standards and each measurable element. Use knowledgeable and credible evaluators (either internal or external consultants) who will critically and objectively assess each area. Score as Met, Partially Met, or Not Met and cite specific findings and recommendations. Include all areas of the organization in the assessment. Consider an assessment of organizational “culture” related to quality and patient safety.
Client name/ Presentation Name/ 12pt - 6
© Copyright, Joint Commission International
The Accreditation Journey: Baseline Assessment
215
The Accreditation Journey: Baseline Assessment In addition to addressing standards adherence, analyze and collect available baseline quality data as required by the quality monitoring standards (QPS).
Client name/ Presentation Name/ 12pt - 7
© Copyright, Joint Commission International
More data and data sources may be available than you first realize.
The Accreditation Journey: Baseline Assessment
Examples: medication errors, hospitalassociated infection rates, antibiotic usage, falls, hazardous material spills, surgical complications, etc.
Client name/ Presentation Name/ 12pt - 8
© Copyright, Joint Commission International
Begin to combine activities of riskmanagement, quality management, facility safety, etc. into one comprehensive data set.
Using the findings of the baseline assessment, develop a detailed project plan with assigned responsibilities, deliverables, and timeframes. Example: Revise informed consent policy, develop a new informed consent statement, educate staff by 30 August. Responsibility: One Person If available, use a software program such as MS Project or Excel to confirm project plan in writing. Hold leaders and staff accountable to plan.
Client name/ Presentation Name/ 12pt - 9
© Copyright, Joint Commission International
The Accreditation Journey: Action Planning
216
The Accreditation Journey: Action Planning Tips
Implement those requirements that will take the longest to make fully functional such as the quality monitoring system for the QPS indicators. Do not forget the “track record” requirement = 4 months a first survey.
Client name/ Presentation Name/ 12pt - 10
© Copyright, Joint Commission International
Think structure-process-outcome in the implementation sequence, in other words develop polices first. Expectation required actions result
Assign oversight of each chapter of standards to a respected champion or leader who will select team members from throughout the hospital. Tip: Involve those who may be skeptical of the process. Look for good people skills, time management skills, and consensus building skills. Be prepared to change assignments as new champions emerge and some leaders drop out. Client name/ Presentation Name/ 12pt - 11
© Copyright, Joint Commission International
The Accreditation Journey: Team Approach
The Accreditation Journey: Policies and Procedures
It may take more time than you think to write, have organizational review, and get final approval on policies. Be certain that your policy reflects your actual practice. This is how surveyors will evaluate your organization. Plan time for education of new policies. Test understanding and compliance. Create, refine and/or test your document management system. (Policy on Policies)
Client name/ Presentation Name/ 12pt - 12
© Copyright, Joint Commission International
In addition to an overall project plan, it is often helpful to compile a list of all required policies and procedures that will need development or revision.
217
The Accreditation Journey: Mid-Point Strategies Continue to monitor your progress in meeting the standards; do a mini-evaluation of each chapter at regular intervals.
Continue to involve as many staff as possible in the process. Make accreditation an organizational quality goal that you are striving to achieve together. Keep staff motivated. Client name/ Presentation Name/ 12pt - 13
© Copyright, Joint Commission International
It is not a setback to adjust your project plan if necessary. Changes in processes often take longer than expected.
Physician commitment to the accreditation process is critical to success. ¾ Physicians must see accreditation standards as a framework by which organizational processes will be improved in order to support good medical care. ¾ Accreditation is not a peer review process as many physicians suspect. ¾ Accreditation supports the use of good clinical science and best practices.
Client name/ Presentation Name/ 12pt - 14
© Copyright, Joint Commission International
Successful Strategies: Physician Perspective
Suggested Strategies
– Focus the tracer, educate on standards and develop interviewer skills – Practice questions in different ways with various ways for staff to show evidence of compliance – Practice tracers with staff – not management Client name/ Presentation Name/ 12pt - 15
© Copyright, Joint Commission International
– Educate, Educate, Educate – Develop/revise P/P and forms based upon the standards and MEs – Involve all staff including leaders on a regular basis – Conduct monthly patient tracers and system tracers
218
Suggested Strategies – Conduct open medical record reviews
– Train staff in care processes, P/P, and documentation expectations – Educate, re-educate, re-educate Client name/ Presentation Name/ 12pt - 16
© Copyright, Joint Commission International
– Have staff involved in medical record reviews – Use MR evidence while conducting the tracers – Use the internal audit data to show progress or areas of focus
Successful Strategies
¾Ask JCI for assistance and clarification with standards interpretation. Don’t waste time going down the wrong path.
Client name/ Presentation Name/ 12pt - 17
© Copyright, Joint Commission International
¾Learn from what others have done well and adapt the experience to the needs of your organization.
Pitfalls To Avoid: Be Aware ¾ Top leaders give “lip service” to the process, but are unrealistic in what it will take to achieve accreditation in terms of time and resources.
¾ Over-eager managers make the entire accreditation process feel punitive and inspecting rather than motivating.
Client name/ Presentation Name/ 12pt - 18
© Copyright, Joint Commission International
¾ Staff end up feeling that accreditation is extra work for which they are not rewarded or recognized.
219
Final Mock Survey
Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation. They will look at the organization with more objectivity. If using internal evaluators, mix disciplines and locations. Plan revisions and corrections based on the findings of the mock survey. Educate.
Client name/ Presentation Name/ 12pt - 19
© Copyright, Joint Commission International
Plan for a final “mock survey” at least 6 months in advance of the target date of your actual accreditation survey.
The Accreditation Survey ¾ Request an application from JCI at least 6 months or longer in advance of target dates for survey. ¾ Once your application is completed, a surveyor team will be assigned and dates confirmed.
¾ Support staff in doing the work they routinely do so the survey does not cause undue anxiety and fear.
Client name/ Presentation Name/ 12pt - 20
© Copyright, Joint Commission International
¾ A survey team leader will be in contact to coordinate an agenda and plans for the survey.
After the Survey Celebrate your success!
Maintain the momentum from your preparation and survey. Establish a system and process for ongoing standards compliance and survey readiness. Continue education.
Client name/ Presentation Name/ 12pt - 21
© Copyright, Joint Commission International
If there are areas for improvement, you may need to submit documentation or a follow-up progress report to JCI.
220
© Copyright, Joint Commission International
Questions?
221
Notes
222
Notes
223
224
225
Appendix
226
Tracer Activity Data Collection Tool Clinical Service:______________________________ Patient ID Number:____________ Focus Areas: Date of Tracer:________________ 1. _________________________________________ 3.___________________________________ 2. _________________________________________ 4.___________________________________ Unit / Department
©JCR, Inc. 2003
Individuals Providing Care
Issues
Standards
Focus Areas
227
Tracer Activity Data Collection Tool Clinical Service:______________________________ Patient ID Number:____________ Focus Areas: Date of Tracer:________________ 1. _________________________________________ 3.___________________________________ 2. _________________________________________ 4.___________________________________ Unit / Department
©JCR, Inc. 2003
Individuals Providing Care
Issues
Standards
Focus Areas
228
Tracer Activity Data Collection Tool Clinical Service:______________________________ Patient ID Number:____________ Focus Areas: Date of Tracer:________________ 1. _________________________________________ 3.___________________________________ 2. _________________________________________ 4.___________________________________ Unit / Department
©JCR, Inc. 2003
Individuals Providing Care
Issues
Standards
Focus Areas
229
Tracer Activity Data Collection Tool Clinical Service:______________________________ Patient ID Number:____________ Focus Areas: Date of Tracer:________________ 1. _________________________________________ 3.___________________________________ 2. _________________________________________ 4.___________________________________ Unit / Department
©JCR, Inc. 2003
Individuals Providing Care
Issues
Standards
Focus Areas
230
Tracer Activity Data Collection Tool Clinical Service:______________________________ Patient ID Number:____________ Focus Areas: Date of Tracer:________________ 1. _________________________________________ 3.___________________________________ 2. _________________________________________ 4.___________________________________ Unit / Department
©JCR, Inc. 2003
Individuals Providing Care
Issues
Standards
Focus Areas
231
Notes
232
Notes
233
Zakaria Zaki Alattal, MSN Consultant, Joint Commission International Zakaria Zaki Alattal has more than 15 years of experience in management and training health care providers in various areas. His expertise includes utilizing Joint Commission International (JCI) standards to build quality systems in hospitals and health care organizations. Through management of the unique challenges facing each organization, he is able to identify quality concepts and enhance the quality of health care services. Dr. Alattal serves as a professional trainer for health care providers and health administrators on quality and management competencies at the Wollongong University Dubai, as well as providing on-the-job training for health care staff in Saudi Arabia, Yemen, Jordan, Egypt and the United Arab Emirates. He consults for hospitals in the Middle East on subjects related to quality and patient safety, but is also knowledgeable of the United States health care standards. He also lectures on patient safety quality management, performance management, and health management. Dr. Alattal holds an honor’s master’s degree in quality management and a master’s degree in nursing. He received the Dubai Quality Group Award as the top graduate of Wollongong University in 2003. He is currently conducting his PhD research at the University of Salford – Manchester in the UK on factors affecting the implementation of the JCI standards in UAE hospitals. Dr. Alattal is a certified senior assessor for Dubai Quality and EFQM (European Quality Award) as well as an ISO certified assessor. He is also a Certified Professional in Healthcare Quality (CPHQ) and National Association for Healthcare Quality (NAHQ).
234
Ashraf Ismail, MD, MPH, CPHQ Managing Director, Middle East International Office Joint Commission International In March 2009, JCI appointed Dr. Ismail as the managing director of its Middle East office located in Dubai. Dr. Ismail is a physician with 20 years of international experience in hospital accreditation, healthcare quality management, performance improvement and development of human resources for health. His contributions in postgraduate quality education and training are well recognized. As an adjunct professor at George Mason University, School of Health and Human Services, he teaches a variety of quality courses for the certificate in quality and outcomes management. Dr. Ismail is a WHO consultant in accreditation and health care quality. In 2006, he was appointed as Strategic Planning Advisor to the Minister of Health in UAE to develop the new strategy of the health sector. As a quality consultant, he assists healthcare facilities through the accreditation process. His experience in these areas has extended from USA to the Middle East. For four years, he was as a quality consultant to Inova Health System, the largest health system in Northern Virginia. As a faculty at Johns Hopkins University and Director of JHPIEGO’s Asia/Near East/Europe Regional office. While he was employed with USAID in Cairo, Egypt, he implemented the first National Quality Improvement Program in the Family Planning Clinics in Egypt
235
Suhail Kady, MD, MPH, CPE, CPHQ Consultant, Joint Commission International Suhail Kady is a certified physician executive with over 15 years of experience in health care, including expertise in medical management, medical staff leadership, performance improvement, staff credentialing and education of staff in leadership and quality improvement areas. Dr. Kady’s broad background includes teaching in a residency program, serving as both an assistant medical director and a medical director domestically and internationally. His consulting expertise includes operational management of health care delivery systems, quality measurement and management, hospital/physician relations, patient and family education, patient safety, medication management systems and credentialing. Dr. Kady has provided educational programs and international consulting services to organizations in UAE, Saudi Arabia, Ireland, Qatar, Lebanon, Turkey, South Korea, Singapore, Belgium and Thailand. Some of Dr. Kady’s experience with health care and acute hospitals includes serving as an attending physician at Generations+ Northern Manhattan Health Network, in New York, an Assistant Professor of Clinical Medicine at New York Medical College, in Valhalla, New York and a Senior Consultant\ Medical Director at Al Rahba Hospital in Abu Dhabi, UAE. Dr. Kady’s professional affiliations include a Certified Physician Executive at the American College of Health Care Executives and a Diplomate of the American Board of Internal Medicine. He received his doctor of medicine degree from Jordan University, in Amman, Jordan, and Master in Public Health (MPH) from New York Medical College, where he also completed his internal medicine residency.
236
Sherry Kaufield, MA, FACHE, Executive Director, International Services Ms. Kaufield joined Joint Commission Resources in 2004 with over 30 years of experience in health care. Sherry oversees JCI international consulting and education services in over 80 countries, collaborating regularly with JCI Regional Managing Directors in Singapore, Dubai, Milan, and Ferney-Voltaire, France. Sherry has advised both domestic and international healthcare organizations in the areas of standards compliance, accreditation readiness and patient safety and quality improvement. She has traveled extensively and worked with multiple clients in Europe, the Middle East, Asia, and Latin America. Clients include individual organizations, healthcare systems, Ministries of Health, health authorities, third party payors and other government bodies. Sherry regularly serves as a faculty member at international practica and other educational events. She is a consulting editor and contributor for the publication, "Joint Commission International Accreditation: Getting Started" and many other publications. As a former Chief Operating Officer and Corporate Compliance Officer of a 400 bed tertiary Medical Center and Level I trauma center, Sherry has expertise in operations, business development, public relations and marketing, and in the development and implementation of multi-hospital performance improvement and strategic planning initiatives. Her background also includes consultation to non-profit healthcare and other organizations in the areas of board leadership and development.
237
Lynda E. Mikalauskas, BScN, MBA Consultant, Joint Commission International Lynda Mikalauskas has over 25 years of experience in health care and over 15 years of experience in international management and speaks fluent French, Turkish and English. Ms. Mikalauskas brings demonstrated expertise in nursing and administrative leadership to her role as a consultant for Joint Commission International, Inc. She specializes in organizational improvement and management and motivation of professional teams. She has adapted to multiple cultural diversities having worked in Saudi Arabia, Turkey, Canada and other parts of Europe and has consulted throughout Europe, Asia, and the Middle East. Ms. Mikalauskas’ consulting expertise includes operational assessment; patient safety assessment; medication management; infection prevention and control; environment of care; executive leadership and governing bodies; performance improvement; and incorporating tracer methodology and the periodic performance review as management tools. Ms. Mikalauskas’ experience with acute care hospitals and health care includes Associate Director, Joint Commission International, at the Europe Office, in Ferney-Voltaire, France; and Patient Care Services Group Manager and Director of Nursing, at V.K.V. American Hospital, in Istanbul, Turkey. Ms. Mikalauskas is professionally affiliated with the American College of Health Care Executives, the American Association of Nurse Executives and the International Society of Quality. She received her MBA from the University of Colorado in Boulder, Colorado and her BScN in Nursing from the University of Montreal in Montreal, Canada.
238
Notes
239
Notes
240
