Joint Commission International
Why JCI?
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
Since 1910 1917 1951 Since 2000
JCR WHO Collaborating Center for Patient Safety Solutions
Turkey 1. Istanbul Memorial Hospital Accredited: 29 March 2002 Re-accredited: 29 April 2005 2. Vehbi Koc Foundation American Hospital Accredited: 15 December 2002 Re-accredited: 16 December 2005 3. Metropolitan Florence Nightingale Hospital Accredited: 26 June 2003 4. Dnya Eye Hospital Accredited: 17 April 2004 5. Medline Alarm Salk Hizmetleri A.. Accredited: 28 April 2005 6. CardioCheck Grntleme Merkezi Accredited: 10 December 2005 7. Private Vehbi Koc Foundation Italian Oncology and Rehabilitation Hospital Accredited: 16 December 2005 8. Acibadem Healthcare Group Accredited: 3 June 2006 9. Kent Hastanesi Accredited: 10 June 2006 10.Mesa Hastanesi Accredited: 1 July 2006 11.Bayindir Hospital Accredited: 15 July 2006
Singapore 1. National University Hospital Accredited: 1 August 2004 2. Johns Hopkins Singapore International Medical Centre Accredited: 4 August 2004 3. Changi General Hospital Accredited: 11 June 2005 4. Singapore General Hospital Accredited: 16 July 2005 5. Alexandra Hospital Accredited: 22 July 2005 6. Institute of Mental Health/Woodbridge Hospital Accredited: 29 July 2005 7. Tan Tock Seng Hospital Accredited: 6 August 2005 8. National Heart Centre of Singapore Accredited: 27 October 2005 9. KK Women's and Children's Hospital Accredited: 9 December 2005 10. Gleneagles Hospital Accredited: 27 May 2006 11. Mount Elizabeth Hospital Accredited: 3 June 2006
India 1. Indraprastha Apollo Hospital Accredited: 18 June 2005 2. Wockhardt Hospital, Mumbai Accredited: 26 August 2005 3. Apollo Hospital, Chennai Accredited: 29 January 2006 4. Shroff Eye Hospital Accredited: 18 February 2006 5. Apollo Hospital, Hyderabad Accredited: 28 April 2006 6. Asian Heart Institute Mumbai Accredited: 20 October 2006
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
Qatar 1. Hamad General Hospital Hamad Medical Corporation Doha, Accredited: 15 September 2006 2. Al Khor Hospital Hamad Corporation Doha, Accredited: 15 September 2006 3. Rumailah Hospital Hamad Medical Corporation Doha, Accredited: 22 September 2006
Philippines 1. St. Luke's Medical Center Accredited: 22 November 2003
Thailand 1. Bumrungrad International Hospital Accredited: 2 February 2002 Re-accredited: 8 April 2005 Focus survey: 10 December 2006
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
HA 2006 JCIA 2008 Clinical Tracer of Quality HA-Thailand PSGs Tracer Methodology/DSC 2007 IPSGs
HA and JCI QA PI/CQI Safety 3C- PDSA JCI Standard Pt care process HA Standard Innovation Mng KM
HA and JCI HA Standard JCI Standard
HA and JCI HA Standard JCI Standard Tool/KM Tool CQI PI QA QA (Process)
HA and JCI HA Standard JCI Standard Leader P&P Team Unit Training Education Daily JOB responsibility
HA and JCI HA Standard JCI Standard
Patient Tracer Follows the care and needs of the patient
An Overview of care as a System Macrosystem The Whole Mesosystem Clinics Microsystem Work Units
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
IMPACT Theory Leadership and System Transformation Improvement on the front lines
Joint Commission International- Accreditation Philosophy Maximum achievable standards Patient-centered Process stimulates continuous improvement Culturally adaptable
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
Components of Standards Development Multiple Information Sources Scientific literature Survey compliance data Research Findings Individual input from field experts and key stakeholders
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
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
JAMA, 111 (4) July 23, 1938, Page 327 1938 or 2005?
What do you mean: Don t expect miracles? Why shouldn t I expect miracles?
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
Teamwork
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
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
University Hospital < 1,000 Beds 1. Clínica Universitaria de Navarra Navarra, Spain Accredited: 29 May 2004 2. National University Hospital, Singapore Accredited: 1 August 2004 928 Beds 3. Aga Khan University Hospital Karachi, Pakistan Accredited: 8 July 2006 4. Taipei Medical University-Wan Fang Medical Center, Taiwan Accredited: 22 July 2006 800 Beds
Key Success Factor Leader Buy in Doctor Engagement Nurse Smart & Professionalism
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
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 27-30 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 2007 23-26 Jan 2007
สร ปผล IQA ตาม JCI Standard-2 nd Editions
ผล IQA ของ Samitivej Sukumvit 29% Partially met Not met 71%
ผล IQA ของ Samitivej Sukumvit 350 319 300 ACC 250 PFR AOP 200 155 165 COP PFE QPS 150 110 GLD FMS 100 50 49 73 0 76 66 3 87 62 54 37 38 26 6 0 9 3 0 5 SQE MOI PCI 0 Partially met Not met
JCI No. Fully Met Partially Met Not Met Chapter 11 3 7 None Standards 368 360 8 None ME 1,032 1,011 21 None Core 95 86 9 None Non Core 273 259 12 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,... www.gooch-inc.com/-10k - หน าท ถ กเก บไว - หน าท คล ายก น
ด งน น
Support different situations by specific tools
Quality Management (Excellent) Center
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
รพ. HA JCIA ReAcc HA JCIA HA JCIA
We care
Healing Environment NHS Estates: Improvement Patient Experience
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
ส งคมตะว นออก ทางพ ทธศาสนา ไม ได พ ดถ งความส ขโดยตรง แต พ ดถ งความท กข ถ าม ความท กข น อยคนจะม ความส ข
ทางจ ตว ทยา (POSITIVE PSYCHOLOGY) Martin Seligman พ ดถ ง Happiness ว าประกอบด วย Positive emotion และ Positive activities.
GNH Gross National Happiness เร มโดยกษ ตร ย Jigme Singhe Wangchuk ข นครองราชในป พ.ศ. 2515 ม แนวค ดในการย ดน า ศาสนา ว ฒนธรรมและว ถ ช ว ต ความเป นอย มาเป นหล กในการพ ฒนาประเทศมากกว า มองเร องต วเลขทางเศรษฐก จ
"เจ าชายว งช ก" พระราชอาค นต กะ ผ ท าให ''ภ ฏาน'' เด นช ดบนแผนท โลก
(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
Labor of Love Humanized Birth
Question?
somporn@samitivej.co.th somporn@ha.or.th skumphong@gmail.com