As you know, the mission of JCI is to improve the quality and safety of health care around the globe. We meet this mission in three ways: Individual organization accreditation Country-level efforts to assist Ministries of Health and Governmental Agencies to strengthen the role of quality oversight at the country level International level as a consensus builder and vehicle for sharing new knowledge on quality and safety in health care JCI includes international members on its Board and has representatives from Asia, Middle East and Europe.
Just as JCI requires its accredited organizations to demonstrate continuous quality improvement, we as an organization must hold itself to that same standard. We pride ourselves to be a learning organization – and our philosophical underpinning historically has been a focus on continuous quality improvement. Let me share with you a story about our origins, about a maverick and leader – who was a radiologist educated at Harvard University and who worked at the Massachusetts General Hospital in Boston. His name was Avery Ernest Codman and he was the original founder of accreditation. The time was the early 1900’s and Codman had a passion for a vision he believed fervently – in a simple construct – which he called the end result-theory. The essence of the end results theory was that physicians and hospitals should focus on their end results – track the treatments they provided to patients – analyze what worked and didn’t work – and then share those results publicly so patients could make informed decisions about which doctor to choose and which hospital to go to – (now remember – this was almost 100 years ago!!!). It turned out that the end result theory had many more complexities and was more radical than he had ever originally envisioned. But Codman was a man ahead of his time and he was fired from his position for his revolutionary yet courageous viewpoint.
The American College of Surgeons, however, embraced his philosophy of accreditation and determined to develop guidelines on best practices and standards. They saw accreditation as a way to standardize best practices. Encourage those who were doing well and stimulate those not doing well to do better. In 1919, the College developed what has become known as the minimum standard, encompassing a requirement for an organized medical staff, regular convening of the medical staff review, completion of patient records (precursor of a medical record) and the availability of hospital labs and x-rays. In a first review of compliance against this standard, 692 hospitals were surveyed and only 89 met the standard. Afraid of what the media might say about the quality of American hospitals – were the press to find out the results – they were burned in the furnace of the Waldorf Astoria Hotel in NYC during a meeting convened to determine next steps. It’s hard to believe that almost 100 years later, health care still struggles with transparency and public reporting. But thus was born the nucleus of accreditation – and today that nucleus has spread around the globe, facing no borders – as those working in health are – no matter where they live – are united in their commitment to delivering quality care.
An 18-member standards subcommittee was organized to guide the development of the standards with representatives from various countries.
JCI has offices all over the world, including one in Ferney-Voltaire, France.
JCI has established Regional Advisory Councils in Asia Pacific, Europe and the Middle East, composed of critical stakeholder groups to ensure we understand regional needs, the unique health care delivery systems within countries, and to receive direct input and feedback on standards, patient safety goals and performance measures.
We have vast representation from organizations across Europe on our Regional Advisory Council.
The 3rd edition of our hospital standards was published in 2008 and is available in 14 languages. We also offer accreditation for ambulatory care, care continuum, laboratories, medical transport, and primary care, as well as certification in disease- and condition-specific care. Some of these manuals have been translated into Czech.
There are 3 JCI-accredited hospitals in the Czech Republic, all in Prague.
This is a traditional definition of accreditation Voluntary – although come countries it is mandatory. Includes recognition given to health care organizations who meet the standards. Public recognition via certification/announcement, financial or requirement that one is accredited. In order to do something else, have a nursing or medical school, insurance discount. Philosophy commonly includes improvement – continuous improvement over time – not a one time effort. Not any one “right” definition. Accreditation must be relevant to unique characteristics of each county’s heath care system, financial reimbursement/payment scheme, culture, level of care provided.
Today, accreditation is recognized world wide by major influencers, such as the World Bank and WHO, as a major driver of Quality & Safety within a country and because of its positive impact on the quality of health care – it can also indirectly, but significantly, impact the economic status of countries. The International Society for Quality provides accreditation for those accrediting bodies. JCI is ISQua accredited – all of its standards and accreditation program – we are very proud – learned how to walk in shoes of clients.
Maximize quality/minimize safety risk Improve patient care processes and outcomes Enhance patient safety Strengthen the confidence of patients, professionals, and payors about the organization Improve the management of health services Enhance staff recruitment, retention, and satisfaction Provide education on better/best practices
1. Accreditation: IMTA issues position paper. International Medical Travel Journal . Sept. 2008. 2. AMA provides first ever guidance on medical tourism (press release). June 12, 2008. 3. International Herald Tribune (Sept. 25, 2008), US News & World Report (May 1, 2008). 4. Keckley P.H., Underwood H.R.: Medical tourism: Consumers in search of value. Deloitte Center for Health Solutions, 2008.
Using pre-established criteria (standards)—sets 15 expectations Evaluation/assessment considers full range of functions/systems—those supporting the patient—such as patient assessment, patient/family education-- and those supporting the organization (leadership, infection control) Recognizes that capacity to have good results is dependent on competency of staff (peer evaluation)
JCI’s entire philosophical framework is based on CQI. First, standards are optimally achievable, setting the bar high, but are professionally driven and developed through a consensus process that strives to assure they are also achievable and realistic. Our process focuses on the patient and we have noted already the commitment that the standards be culturally sensitive and stimulate continuous improvement. Hospitals being surveyed for the first time must demonstrate a track record of at least 4 months to show trends of improvement. After its first accreditation, an organization’s onsite survey is conducted every three years and the trend data from that period is reviewed. Thus, hospitals seeking JCI accreditation are demonstrating to the international community their commitment to quality improvement and safety as they voluntarily seek an objective, independent review of how well they comply with professionally driven standards that contribute and foster good outcomes.
Most accrediting bodies have distinct tools and methodologies designed to help organizations improve that complement each other. I’ll highlight 5 that JCI uses: Standards Evaluation Methodology Patient Safety Goals Data on Performance and Benchmarks Education
Standards are the heart of any accreditation program and the critical organ the other components rely upon. They must be designed well and be professionally driven. The art and science of developing standards needs to be based on what is known to work, based on evidence, scientific literature and our past experience. With the proper development of standards, accreditation can help facilitate the appropriate design of systems and processes within an organization. With the proper development of standards, accreditation can help facilitate the appropriate design of systems and processes within an organization. In developing standards, we look at health care organizations as a system and examine the inputs and outputs and the interdependencies of the various processes. We ensure significant management and clinical activities are reviewed.
First, standards are the heart of any accreditation program and the critical organ the other components rely upon. They must be designed well and be professionally driven. The art and science of developing standards needs to be based on what is known to work, based on evidence, scientific literature and our past experience. JCI made a significant decision to develop a set of international standards – that could be applied to various health care delivery systems as well as being sensitive to unique cultural or regional issues. To ensure that JCI’s standards would be applicable to multiple countries an expert task force was established – composed of 18 international experts representing all of the 5 major regions of the world. The task force determined to use the framework of accreditation espoused by TJC and its philosophy of continuous quality improvement, emphasis on systems as it developed the first set of international standards and these were further tested in 5 countries to ensure their appropriateness and applicability. In developing standards, we look at health care organizations as a system and examine the inputs and outputs and the interdependencies of the various processes.
We also review how the standards will be evaluated and measured. Is it readily understood how compliance with the standard is achieved. As shown on the slide, a good standard will permit convergent validity or multiple ways for different surveyors to assess compliance. Inter-rater reliability between and amongst the surveyors is critical and depends on careful selection, training, support and management of the surveyors. Surveyors are the soul of the accreditation program. This process also promotes transparency because organizations will understand what evidence of compliance is necessary for them to achieve accreditation. There should be no black box in accreditation.
How well an accrediting body evaluates compliance against its standards is obviously an integral indicator of its quality and value. TJC introduced Tracer Methodology to sharpen its onsite evaluation in 2004. It also has had the enormous benefit of engaging clinicians during the process and significantly enhancing their satisfaction with the process. The tracer methodology is aptly labeled. It traces the journey of patients during their hospitalization and engages staff along the way to assess compliance with the standards. Patients are selected for this journey based on present criteria / demographics obtained pre-survey such as high volume diagnosis, high volume procedure, high risk procedure, low volume procedure. Once we have determined these – we ask for a patient chart matching the criteria and trace their journey. For a patient diagnosed with heart failure requiring cardiac catheterization, the following areas were visited--Staff queried regarding how standards were complied with—able to review medication management, assessment of patient, information, management, ethics, leadership – to name just a few. Again, different members of survey team reviewing different aspects. Able to reach convergent validity.
About half of TJC and JCI standards today focus on patient safety and ways to anticipate and prevent error. The standards encourage a culture of safety. They support open communication, reporting and learning and encourage patients to become active members of the health care team. But in 1995 that wasn’t the case. We also realized that standards alone weren’t sufficient drivers for safety. In a series of highly publicized events within a very short time frame, two hospitals that were recently accredited – having had their onsite survey within the past year had major adverse occurrences – one an overdose of chemotherapy resulted in death, one amputation of wrong leg. We asked ourselves – how could this have happened in accredited organizations? What could we as an accrediting body do differently to mitigate the risk of similar events happening in other hospitals (Remember – chronologically this was prior to The Err is Human Report). This period of scrutiny and examination led to the creation of our reporting and learning system, the SE database, the conduct of root cause analysis, the sharing of lessons learned through SE Alerts and the development of new standards focused on SE reporting and analysis, Failure Mode and Effectiveness Analysis, Transparency, infection control, medication management, a taxonomy. The establishment of national and international patient safety goals was also a significant outcome as part of this endeavor and focus on safety as practices organizations should comply with. These goals are requirements for accreditation and raised the bar for accreditation.
Where some of the practices seem obvious and very evident – washing hands, ensuring patient identification – we have learned that developing, implementing and sustaining systems that support their compliance 100% is challenging and health care industry has a long way to go towards becoming a high reliability industry. I will highlight 6 goals briefly: Goal 1: Basically requires that patients are identified by 2 identifiers for almost any care. Goal 2: Thru the conduct of thousands of RCAs – communication is a leading contributing cause of error – whether it be clinician to clinician, clinician to patient, verbal, written, elect effective communication strategies are needed – designed to mitigate risk of error due to communication. Goal 3: This goal has shown demonstrable impact on a number of sentinel events in USA, by removing high alert medications – the number of deaths have decreased. Goal 4: While major attention focused on WSS – clear that understanding how to implement this protocol requires further clarity. One good sign may be that the number of WSS events reported to TJC SE database has improved since this goal was implemented--perhaps due to more awareness. But clear that health care organizations’ understanding of how to design a fool-proof system as significant as operating on right patient or performing the right procedures on right side. Still learning opportunities – much to do. Goal 5: Similarly while hand hygiene known to reduce infections – small compliance rate – still a challenge. Goal 6 requires organizations to assess patients for risk of falling and to take steps to reduce fall risk. We have learned that being an accrediting body – humbling experience. Still many challenges with implementation / sustainability of safe practices.
Standards alone are not a sufficient underpinning for accreditation. A robust and reliable system of evaluation designed to foster public trust, continuous improvement and to be compatible with innovative ways to reward good performance – must be designed to integrate a standards based evaluation with ongoing indicator-based measurement. JCI developing a strategy that: Makes accreditation continuous and less dependent on survey as source of information. Lead eventually to public disclosure Complements existing measure requirements on organizations. Draws from common data sources but provides international comparisons. Meets needs of stakeholders—payers, patients, etc. Has rigor and data validation JCI currently has 20 performance measurement requirements that accredited organizations must comply with
This graph shows improvement in treatment for acute myocardial infarction. And with respect to AMI, a report in the New England Journal of Medicine noted consistent improvement in measures reflecting process of care for AMI, based on Joint Commission-accredited hospitals’ use of performance measures. Source: Williams S.C., et al.: Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004. N Engl J Med 353:255-264, July 21, 2005. In addition, a study of Joint Commission-accredited hospitals’ use of rate-based performance measures related to AMI concluded that many of these hospitals provided care that was consistent with practice guidelines at least 83% of the time. Source: Williams S.C., Koss R.G., Morton D.J., Loeb J.M.: Performance of Top-ranked Heart Care Hospitals on Evidence-Based Process Measures. Circulation: Journal of the American Heart Association . 2006.
JCI has a pilot program addressing international clinical cardiac indicators It enables hospitals to evaluate the current status of their coronary artery bypass graft (CABG) and valve-related surgery risk-adjusted mortality rates Encourages hospitals to implement and measure rates of improvement using the New York State Department of Health (NYSDOH) Cardiac Surgery Reporting System (CSRS) as a model
Participating hospitals will get information to help them improve quality of care and assess a patient’s risk factors before cardiac surgery Multi-site and multi-country use of the ICSB assessment and reporting tool to guide organized quality improvement and benchmarking efforts Long-term goal – to improve the outcomes of cardiac surgical procedures in participating organizations
There is much patient safety information on the Internet. But patients learn from friends and other patients that accredited hospitals involve patients in care decisions, respect their rights, seek their opinion on care and have processes to address issues for which patients are not satisfied. This type of subjective and informal information is often more powerful than clinical outcomes data. In addition, through its Speak Up™ campaign, the Joint Commission urges patients to take a role in preventing health care errors by becoming active, involved and informed participants on the health care team. The Speak Up brochures are available on the Joint Commission’s Web site.
A few years before the IOM report was released, the Joint Commission had begun collecting data from accredited organizations about reportable errors. This data, as part of the Sentinel Event Database, has shed light on just often errors—and specific types of errors--occur. From this data, the Joint Commission began publishing Sentinel Event Alerts , which highlight significant risk areas in health care and offer recommendations to help health care organizations mitigate the risks from the occurrence of these areas. The latest Sentinel Event Alert highlights how the use of technology to improve care also can carry risks.
Through the end of 2008, nearly 6000 errors have been reported to the Joint Commission, which continues to evaluate the data to identify root causes and develop recommendations to prevent these errors from recurring.
Accreditation is really a risk reduction activity – woven together, the various components of accreditation – standards, patient safety goals and performance measures work together so that if an organization is doing the right thing and doing them well, they are reducing the likelihood of harm and optimizing the likelihood of good outcomes. In addition, a recent study in the Journal of Healthcare Management showed that accreditation is a significant factor in whether facilities engaged in actions widely recognized to improve patient safety. Ernest Codman would be pleased and proud.
5. Longo D.R., Hewett J.E., Ge B., Schubert S.: Hospital Patient Safety: Characteristics of Best-Performing Hospitals. J Healthc Manag. 52(3):188-204, May-June 2007. 6. Devers K.J., Pham H.H., Liu G: What is driving hospitals’ patient-safety efforts? Health Affairs 23(2):103-115, 2004. 7. Hosford S.B.: Hospital progress in reducing error: The impact of external interventions. Hospital Topics 86(1):9-19, 2008.
I would now like to talk about JCI’s work as part of the WHO Collaborating Centre for Patient Safety Solutions. The World Alliance has a very powerful – and challenging mandate – to make health care as safe as possible – as soon as possible. Where global interest and certainly national interests in patient safety – in patient safety has increased in the last decade – no one country has come to grips with the problems posed by patient safety. Certainly we have seen that the case for action is urgent and compelling. It was within this context and faced with the similarities of unacceptable adverse events occurring throughout the world that the WHO established the World Alliance – the intent was to gain global commitment to glean the knowledge and better understand the contributing causes to safety problems and errors so that systems and solutions might be designed that detect risk and to design systems and standardized processes with safety in mind.
At present – no one player or country has the expertise – let alone funding and research capabilities to tackle the full range of patient safety issues. The Alliance aims to bring together the knowledge and resources that have been developed from patient safety work form around the world in the last decade. Alliance – big ideas, committed collaborative network of learners – expanding and progressing each year. Highlight main components of the Alliance. When it started just 3 yrs ago – there were six main planks – now 10. Solutions High 5s Technology Knowledge Management Special projects Reporting and Learning ICPS Research Patients for Patient Safety Global Patient Safety challenges
The Joint Commission and JCI were designated by WHO as a Collaborating Centre for Patient Safety in August 2005. Our chief objective is to develop solutions in cooperation with others that help mitigate the risk of adverse events from happening. The Solutions strand is a sharing, learning and support function for the World Alliance.
A key lesson learned is that those organizations that are most successful in improving patient safety involve patients.
The taxonomy will allow us: To communicate clearly To categorize and catalogue To analyze and learn To develop solutions The taxonomy will allow us to define, harmonize and catalogue patient safety events and will do so within a classification system that will elicit, capture and analyze factors in a way conducive to learning.
Obviously, reporting is dependent on a valid taxonomy. But safety can’t be improved without a system of valid reporting that identifies the sources and causes of risk. The reasons for reporting are not to punish, but for accountability and learning sake.
Next strand – Research Slide highlights regions of world conducting research.
The High 5’s initials aims: To achieve significant, sustained, and measurable reduction in the occurrence of patient safety problems over 5 years in at least 7 countries and build an international collaborative learning network that fosters the sharing of knowledge and experience in implementing innovative standardized operating protocols. The Commonwealth Fund countries that have participated in development phase are: Australia Canada Germany Netherlands New Zealand United Kingdom United States Expansion to additional countries is planned for implementation phase
The High 5’s subtitles are: Managing Concentrated Injectable Medicines Assuring Medication Accuracy at Transitions in Care Communication During Patient Care Handovers Improved Hand Hygiene to Prevent Health Care-Associated Infections Performance of Correct Procedure at Correct Body Sites
Our chief objective is to develop and disseminate solutions in cooperation with others that help mitigate the risk of adverse events from happening. However, the intent has been to do this in a collaborative way with sensitivity to regional and local issues.
An initial task of the Steering Committee was to develop and approve what is meant by a solution – defined as – any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care.
Where the first set of solutions represented “low hanging fruit” – struck by commonality I mentioned earlier - no matter region or country of world. The Steering Committee has developed a process – for prioritizing and selecting solutions – ranging from reported events, national agencies, literature, patient groups, open solicitation.
The inaugural nine solutions were released in May of last year. Are available on TJC/JCI/WHO websites. Briefly highlight them: Aims to mitigate the risk of confusing drug names. The recommendations focus on protocols, legibility and use of preprinted orders or electronic prescribing.
This solution mitigates the risk of failure to correctly identify patients – which often lead to medication and testing errors and sometimes to wrong person procedures.
Gaps in hand-over communications between care-givers can seriously disrupt continuity of care and result in patient harm. Solution focuses on protocols to mitigate these.
Considered totally preventable, these errors are commonly the result of miscommunication and lack of a standard preoperative process.
While all drugs have a defined risk profile, these are especially dangerous.
This solution seeks to ensure medication reconciliation and suggests a number of strategies to assure medication accuracy.
This solution seeks to reduce the potential of errors caused by current design of tubing, catheters and syringes thru misconnect.
This solution is designed to reduce the spread of serious contagious disease thru the reuse of injection devices.
This solution focuses mitigating risk of health care associated infections – due to care giver failure to wash their hands.
July 2008 ISC agreed to build prototype for one topic area to include overview of topic and additional resources, measures, case studies, etc. Central Line Infections chosen as topic area; will be disseminated in early 2009
Four target audiences for Solutions: Government policy at ministry of health level Health care organization at the CEO level Clinician/provider levels Patient and family level