Joint Commission International

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1 Joint Commission International

2 Why JCI?

3 Accreditation A World Trend The U.S., Canada, and Australia have the oldest accreditation systems In Europe, Germany, France, Ireland and Spain have new accreditation systems In Japan, Korea, Malaysia, and Thailand there are new systems with government role The WHO, World Bank and development banks recognize and endorse the accreditation model

4 Since Since 2000

5 JCR WHO Collaborating Center for Patient Safety Solutions

6 Turkey 1. Istanbul Memorial Hospital Accredited: 29 March 2002 Re-accredited: 29 April Vehbi Koc Foundation American Hospital Accredited: 15 December 2002 Re-accredited: 16 December Metropolitan Florence Nightingale Hospital Accredited: 26 June Dnya Eye Hospital Accredited: 17 April Medline Alarm Salk Hizmetleri A.. Accredited: 28 April CardioCheck Grntleme Merkezi Accredited: 10 December Private Vehbi Koc Foundation Italian Oncology and Rehabilitation Hospital Accredited: 16 December Acibadem Healthcare Group Accredited: 3 June Kent Hastanesi Accredited: 10 June Mesa Hastanesi Accredited: 1 July Bayindir Hospital Accredited: 15 July 2006

7 Singapore 1. National University Hospital Accredited: 1 August Johns Hopkins Singapore International Medical Centre Accredited: 4 August Changi General Hospital Accredited: 11 June Singapore General Hospital Accredited: 16 July Alexandra Hospital Accredited: 22 July Institute of Mental Health/Woodbridge Hospital Accredited: 29 July Tan Tock Seng Hospital Accredited: 6 August National Heart Centre of Singapore Accredited: 27 October KK Women's and Children's Hospital Accredited: 9 December Gleneagles Hospital Accredited: 27 May Mount Elizabeth Hospital Accredited: 3 June 2006

8 India 1. Indraprastha Apollo Hospital Accredited: 18 June Wockhardt Hospital, Mumbai Accredited: 26 August Apollo Hospital, Chennai Accredited: 29 January Shroff Eye Hospital Accredited: 18 February Apollo Hospital, Hyderabad Accredited: 28 April Asian Heart Institute Mumbai Accredited: 20 October 2006

9 Republics of China Clifford Hospital Accredited: 20 December 2003 Beijing United Family Hospital and Clinics Accredited: 1 September 2005 Hong Kong Adventist Hospital Accredited: 25 February 2006 Tsuen Wan Adventist Hospital Accredited: 3 March 2006 DCSC for Acute Stroke: 29 April 2006 Taiwan Min-Sheng General Hospital Accredited: 15 July 2006 Taipei Medical University-Wan Fang Medical Center Accredited: 22 July 2006

10 Qatar 1. Hamad General Hospital Hamad Medical Corporation Doha, Accredited: 15 September Al Khor Hospital Hamad Corporation Doha, Accredited: 15 September Rumailah Hospital Hamad Medical Corporation Doha, Accredited: 22 September 2006

11 Philippines 1. St. Luke's Medical Center Accredited: 22 November 2003

12 Thailand 1. Bumrungrad International Hospital Accredited: 2 February 2002 Re-accredited: 8 April 2005 Focus survey: 10 December 2006

13 Malcolm Baldrige National Quality Award MBNQA World class UK Quality Award UKQA JQA Japan Quality Award Total Quality Management Leadership Strategy Deployment Singapore Quality Award SQA EQA European Quality Assurance Process Management Customer & Market Focus Information & Analysis HR Focus Joint commission International Accreditation JCIA Business/ Organization Results Thailand Quality Awards Public Sector Quality Awards

14 HA 2006 JCIA 2008 Clinical Tracer of Quality HA-Thailand PSGs Tracer Methodology/DSC 2007 IPSGs

15 HA and JCI QA PI/CQI Safety 3C- PDSA JCI Standard Pt care process HA Standard Innovation Mng KM

16 HA and JCI HA Standard JCI Standard

17 HA and JCI HA Standard JCI Standard Tool/KM Tool CQI PI QA QA (Process)

18 HA and JCI HA Standard JCI Standard Leader P&P Team Unit Training Education Daily JOB responsibility

19 HA and JCI HA Standard JCI Standard

20 Patient Tracer Follows the care and needs of the patient

21 An Overview of care as a System Macrosystem The Whole Mesosystem Clinics Microsystem Work Units

22 The System of Care CARE SYSTEM Teamness Lean Consumption User Friendly and Oriented Everyone Is Involved and Optimizes the Processes in the System Change Occurs at All Levels

23 IMPACT Theory Leadership and System Transformation Improvement on the front lines

24 Joint Commission International- Accreditation Philosophy Maximum achievable standards Patient-centered Process stimulates continuous improvement Culturally adaptable

25 Strengths of Accreditation External, objective evaluation : 1,032 ME Uses consensus standards : fields review Involves the health professions : microsystem Proactive not reactive eg. OpenMRR, process Organization wide : tracer methodology Focus on systems not individuals : P&P, Training Stimulates quality culture in the organization : discipline Periodic re-evaluation against standards : PI

26 Components of Standards Development Multiple Information Sources Scientific literature Survey compliance data Research Findings Individual input from field experts and key stakeholders

27 Benefits for the Hospital Improves care and enhances public confidence Stimulates continuous improvement Demonstrates commitment to quality care Raises community confidence Comparison with self and other similar organizations

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31 Benefits for the Medical Staff and Nursing Staff Improves professional staff development Provides education on consensus standards Provides leadership for quality improvement within medicine and nursing Increases satisfaction with working conditions, leadership and accountability

32 JAMA, 111 (4) July 23, 1938, Page or 2005?

33 What do you mean: Don t expect miracles? Why shouldn t I expect miracles?

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36 Benefits for Hospital Employees Values employee opinions Measures employee satisfaction Involvement in quality activities Improved employee safety and security Clearer lines of authority and accountability Promotes teamwork

37 Teamwork

38 Benefits for Patients Access to a quality focused organization Rights are respected and protected Understandable education and communication Satisfaction is evaluated Involvement in care decisions and care process Focus on patient safety

39 Characteristics of Excellent Hospitals Patient centered with good customer service Coordinated and efficient care processes Safe, low risk facility and environment Staff with good skills and knowledge Quality culture supported by leaders and managers Use standards and guidelines to continually improve safety and quality of care and the environment

40 University Hospital < 1,000 Beds 1. Clínica Universitaria de Navarra Navarra, Spain Accredited: 29 May National University Hospital, Singapore Accredited: 1 August Beds 3. Aga Khan University Hospital Karachi, Pakistan Accredited: 8 July Taipei Medical University-Wan Fang Medical Center, Taiwan Accredited: 22 July Beds

41 Key Success Factor Leader Buy in Doctor Engagement Nurse Smart & Professionalism

42 Human as well as technical factors and processes The sociology and organisation of improvement The science and technology of improvement Organisation, culture, language & cognition, identity, leadership, structure, strategy, citizenship etc Scorecards, metrics, measurement systems and technology, clinical pathways, EBM

43 Review status Action Plan Timeframe F/U Progression Focus on Core Standard Compliance meet to Mock Surveys Recommendations Detailed Project Plan / Policies and Procedures redesign Education Team Staff 10 IQA Mid-Point Strategies/Dec 15,06 Continuous Performance review Preparation along with Survey Process Guide Nov 2006 Conclusion 15 Dec 2006 Jan Jan 2007

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47 สร ปผล IQA ตาม JCI Standard-2 nd Editions

48 ผล IQA ของ Samitivej Sukumvit 29% Partially met Not met 71%

49 ผล IQA ของ Samitivej Sukumvit ACC 250 PFR AOP COP PFE QPS GLD FMS SQE MOI PCI 0 Partially met Not met

50

51 JCI No. Fully Met Partially Met Not Met Chapter None Standards None ME 1,032 1, None Core None Non Core None Average =98.99% Core =9.5 Non-core=9.7 Healthcare Consultants - Gooch & Associates provides JCAHO... Please visit our International Section. A client in Turkey achieved an unofficial score of 99.5% compliance on their initial JCI accreditation survey, หน าท ถ กเก บไว - หน าท คล ายก น

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55 ด งน น

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60 Support different situations by specific tools

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63 Quality Management (Excellent) Center

64 Quality Control System INPUT PROCESS OUTPUT Manpower Material Infrastructure Mgt. system MIS Quality Mgt. System Hospital Accreditation JCI Accreditation Referral & Network Development Hospital outcome Quality Indicators Quality Audit Satisfaction

65 รพ. HA JCIA ReAcc HA JCIA HA JCIA

66 We care

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73 Healing Environment NHS Estates: Improvement Patient Experience

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83 ส งคมตะว นตก ความส ขเก ดจากการม ช ว ตท ประสบความส าเร จ ส ขภาพด,ม ฐานะ ทางเศรษฐก จ และครอบคร วท ม นคง American dream.. ท าท กอย างเพ อให ได เง นม ฐานะ, ม ช อเส ยง

84 ส งคมตะว นออก ทางพ ทธศาสนา ไม ได พ ดถ งความส ขโดยตรง แต พ ดถ งความท กข ถ าม ความท กข น อยคนจะม ความส ข

85 ทางจ ตว ทยา (POSITIVE PSYCHOLOGY) Martin Seligman พ ดถ ง Happiness ว าประกอบด วย Positive emotion และ Positive activities.

86 GNH Gross National Happiness เร มโดยกษ ตร ย Jigme Singhe Wangchuk ข นครองราชในป พ.ศ ม แนวค ดในการย ดน า ศาสนา ว ฒนธรรมและว ถ ช ว ต ความเป นอย มาเป นหล กในการพ ฒนาประเทศมากกว า มองเร องต วเลขทางเศรษฐก จ

87 "เจ าชายว งช ก" พระราชอาค นต กะ ผ ท าให ''ภ ฏาน'' เด นช ดบนแผนท โลก

88 (six H plus) ของ Edward de Bono Human + Happiness + Humour + Help + Hope + Health + เป นหล ก 6 ประการ ในการด ารงช ว ตอย างม ความส ข

89 Labor of Love Humanized Birth

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92 Question?

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