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Enhance your credentials when you achieve the only certification developed and endorsed by The Joint Commission international represents the highest level of accreditation knowledge and achievement in related patient safety and quality issues.
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Joint Commission International
Standards and Survey Process
Mahboob Ali Khan MHA,CPHQ
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Objectives
Identify and describe the JCI Accreditation process
Describe and review tracer methodology
Discuss a hospital’s preparation for the JCI Accreditation process
Describe global standardization of healthcare services through the process of accreditation
Accreditation as part of a systems focus
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JCI Standards System framework
Checklist of all the important managerial and clinical functions or activities
Focus on patient perspective in context of their family
A balance of structure, process and outcomes standards
Optimal but achievable expectations
Measurable
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Accreditation Represents a Risk
Reduction Strategy
That an organization is doing the right
things and doing them well;
Thereby significantly reducing the risk of
harm in the delivery of care; and
Optimizing the likelihood of good
outcomes.
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External, objective evaluation
Uses consensus standards
Involves the health professions
Proactive not reactive
Organization wide
Focus on systems not individuals
Stimulates quality culture in the organization
Periodic re-evaluation against standards
Strengthens public’s confidence
Strengths of Accreditation
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Accreditation Can Help:
Enhance staff recruitment, retention and
satisfaction
Improve or expand sources of payment for
patient care
Increase chances to enter networks and new
provider arrangements
Provide greater independence from
government oversight
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Accreditation Can Help:
Build a quality measurement database
Provide comparison with self, others,
and best practices
Provide a framework to improve patient
safety
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Quality Improvement and Patient
Safety Programs
Are leadership driven
Seek to change the ethos of the organization
Proactively identify and reduce risk and variation
Use data to focus on priority issues
Seek to demonstrate sustainable improvement
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Accreditation as Part of
Continuous Quality Improvement
Accreditation is a milestone on the continuous journey of improvement
Accreditation Standards provide a common quality language and common set of expectations to point the way forward
Establishing a permanent organizational culture of safe, quality care is essential for sustaining improvement
The effort is for your patients, not the certificate
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Starting to Prepare
Available Resources:
JCI Accreditation Standards for Hospitals, 5TH
Edition
Survey Process Guide (electronic version)
Web-based training on introduction to the international accreditation process (ISAS)
Newsletters and publications
print and electronic (e.g. Getting Started)
JCI Practicum four times a year
(Annual JCI Executive Briefings – networking opportunity with accredited organizations)
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Begin with Education
Organizational leaders and managers
Introduction to accreditation philosophy and
approach
Accreditation as a 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
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Baseline Assessment
Conduct a detailed baseline assessment of
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
Consider using ISAS as guide
Include all areas of the organization in the assessment
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Baseline Assessmentcont.
Collect and analyze baseline quality data as
required by the quality monitoring standards
Examples: medication errors, hospital-associated
infection rates, antibiotic usage, surgical complications.
Establish an ongoing monitoring system for data
collection to identify problem areas and track
progress in improvement
Set frequency of data collection
Analyze data
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Action Planning
Using the findings of the baseline assessment,
develop a detailed project plan with assigned
responsibilities, deliverables, and time frames.
Start with priority areas established by leadership
Example: Revise informed consent policy, develop a new
informed consent statement, educate staff - to be completed
in two months (specify exact date)
If available, use a software program such as MS
Project or Excel to confirm project plan in writing
Hold leaders and staff accountable to the plan
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Team Approach
Assign oversight of each chapter of standards to
a respected champion/leader who will identify
team members from throughout the hospital
Also include those who may be skeptical of the
process
Look for good people skills, time management
skills, and consensus building skills
Be prepared to change as new champions
emerge, and some leaders drop out
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Policies and Procedures
Compile a list of all required policies and
procedures that will need development and
revision
Hint: look for list in Survey Guide 2008
These may take some time to get revise or develop,
undergo organizational review, and obtain final
approval
Be certain that your policy reflects your actual
practice, as this is one of the yardsticks the
surveyors will use to evaluate your performance
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Mid-Point Strategies
Continue to monitor your progress in meeting the
standards
Ex. Use a mini-evaluation of each chapter at regular
intervals (e.g quarterly)
Don’t be afraid to adjust your project plan to be
more realistic – change often takes longer than
one expects
Continue to involve as many staff as possible in
the process – make it an organizational quality
goal that you are striving to achieve together
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Strategies That Have Worked
Importance of physician commitment to the accreditation process cannot be overstated
They should see accreditation standards as framework by which hospital processes will be improve
Care will ultimately be of higher quality and safer for their patients
Reassure physicians that accreditation is not intended to tell them how to practice medicine!
But it does compel them to look collectively at their own practices and evaluate their own results
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Strategies That Have WorkedCont.
Learn from what others have done well and
adapt the experience to the needs of your
organization
Ask JCI for clarification with standards
interpretation – don’t waste time going down
the wrong path
Take advantage of resources (e.g.
download electronic example policies and
plans and adapt to your organization)
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Pitfalls to Avoid
Top leaders “support” the process, but are totally unrealistic in what it will take to achieve it in terms of time and resources
Staff end up feeling that accreditation is extra work for which they are not rewarded or recognized
Over-eager managers using the standards as a threat rather than as a goal – can make entire accreditation process feel punitive and inspecting rather than motivating
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Final Mock Survey
Plan for a final “mock” or practice survey about 6-8 months in advance of the target date of the actual accreditation survey
Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organization with a fresh and objective eye
Plan final actions and corrections based on the
findings of the final mock survey
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Standards in two sections:
Patient-Centered Standards
Healthcare Organization Management Standards
JCI Hospital Standards 3rd Ed.
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JCI Hospital Standards 3rd Ed.
Cont.
Patient-Centered Standards
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
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Anesthesia and Surgical Care
1. Organization and Management
2. Sedation Care
3. Anesthesia Care
4. Surgical Care
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Medication Management and Use
1. Organization and Management
2. Selection and Procurement
3. Storage
4. Ordering and Transcribing
5. Preparing and Dispensing
6. Administration
7. Monitoring
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JCI Hospital Standards 3rd Ed.Cont.
Healthcare Organization Management Standards
Quality Improvement and Patient Safety
Prevention and Control of Infections
Governance, Leadership, and Direction
Facility Management and Safety
Staff qualifications and Education
Management of Communications and Information
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Staff Qualifications and Education
1. Planning
2. Orientation and Education
3. Medical Staff
4. Nursing Staff
5. Other Health Professional Staff
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Management of Communication
and Information
1. Communication with the Community
2. Communication with Patients and Families
3. Communication Between Providers Within and Outside the Organization
4. Leadership and Planning
5. Patient Clinical Record
6. Aggregate Data and Information
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Standards Content
Each JCI standard contains three
components:
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
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Standards Content (sample)
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International Patient Safety Goals
Identify patients correctly at risk points
Improve effective communication of critical information
Improve safety of high-alert medications
Ensure correct-site, correct-patient, correct-procedure surgery
Reduce the risk of healthcare-associated infection
Reduce the risk of patient harm from falls
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Approach and Philosophy
to the On Site Survey
A Survey is not intended to be punitive, a “got you” exercise, or an inspection
Tracer Methodology is a process of identifying imperfections, flaws, or broken systems
Surveyors will “drill down” or focus on areas where a potential risk area is identified Based on common problem areas in many hospitals
High risk or high volume services
They have identified a vulnerable area
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On-Site Evaluation Process
Opening conference
Orientation
Document review
Leadership session
Assessment activities Tracer activities – patient
Tracer activities – systems
Facility tour
Special interview / issue resolution
Feedback sessions Daily briefings
Leadership exit conference
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Tracer Methodology
Is an effective evaluation method that
is used to assess a healthcare
organization’s performance of care
and the services provided as
viewed or experienced by the
patient
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Objectives of Tracer Activity
Follow entire course of care and
services provided to the patient
Assess relationships among disciplines
and important functions
Evaluate performance of processes
provided to the patient
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Types of Tracers
Patient Tracer – Follows the patient
System Tracer – Follows the system
Data use
Medication management
Infection Control
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Conducting Tracers
Selection of patients
Diagnoses
High volume
Procedures
High volume
High risk
Low volume
Selection of units
Diagnoses/procedures
Special care
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Sample Patient Tracer
Hospital Setting
Patient – Mr. Ramponi
Cardiac-surgery related diagnosis (cardiac bypass
surgery)
Pulmonary complications (pneumonia)
Surveyor
Reviews patient record
Notes what services and transfers occurred
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72-year old man presented to ER with chest pain
An electrocardiogram showed signs of sinus tachycardia
Staff administered aspirin and drew blood
Mr. Ramponi
Treated for diabetes and hypertension
Recently quit smoking after 33 years
Sent to cardiac catheterization lab for an angiogram, which revealed
5 blockages
Put on IV heparin, nitroglycerin and beta-blocker
Transferred to ICU
Hypertension was an issue. So medications were adjusted to lower his blood pressure
Surgery for a coronary artery bypass graft was scheduled for the
next morning
Surveyor Reviews Medical Record
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Communication, assessment, performance improvement, and
medication management issues.
Surveyor speaks with ED Staff
At Emergency Department
“You’ve said that like many
heart attack victims, Mr.
Ramponi delayed seeking
help after experiencing the
first symptoms. Has your ED
conducted any performance
improvement projects to
decrease the time to begin
treatment?”
Step 1
“I see that a cardiac catheterization was
necessary; how was informed consent obtained
from Mr. Ramponi?”
“A little over 2 weeks ago, Mr. Ramponi came
into the ED with chest pains and a history of
hypertension and diabetes. What processes
were followed for triaging and treating him?”
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Surveyor reviews Medical Record
Antibiotics were begun at the time of surgery
Sent to ICU with ventilator which was removed 5 hours later
Developed pneumonia within 2 days
IV antibiotic was changed, but history of smoking has weakened his lungs
Placed on ventilator
Wean from ventilator within 6 days
Received pulmonary treatment regimen of nebulizer treatments, incentive spirometry, and assisted cough
Transferred to a general medical unit with telemetry after 3 days
Scheduled to be discharged for continued outpatient rehabilitation
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Emergency Department
points of discussion
Triage process
Patient assessment
Communication prior to patient transfer
Medication process, including for high risk concentrated medications and IV solutions
Communication needs for elderly patients
Competency of medical and nursing staff in emergency care
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Verbal orders, assessment and emergency care issues
Surveyor talks with Staff Nurse and CardiologistStep 2
At Cardiac Catheterization Lab
“What communication took place between
the catheterization lab and the ED before
Mr. Ramponi arrived for his procedure?”“How did you make certain Mr. Ramponi
had no allergies to the contrast medium
being used for the procedure?”
“What process was used for ensuring
medical equipment safety?”
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Catheterization Lab
points of discussion Pre-procedural patient assessment
Patient identification process
Informed consent
Patient privacy and confidentiality
Infection control
Patient monitoring during and after procedure
Use and maintenance of equipment
Sedation and anesthesia use and safety
Frequency of cancellation of procedures and
reasons (Quality Improvement project)
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Medication use, anesthesia care, informed consent, site verification,
emergency care issues and infection control.
Step 3
Surveyor also requests credentialling files for the
anesthesiologist and cardiac surgeon.
Surveyor talks to the
Staff, Circulating Nurse,
Anesthesiologist
At Operating Room
“What assessments had been
performed and what
information did you receive
before Mr. Ramponi arrived in
the OR?”
“Can you explain the process to
obtain informed consent for Mr.
Ramponi for this surgery?”
“What processes do you
follow to verify that you had
the correct patient and
procedure before you
started Mr. Ramponi’s
surgery?”
“During open-heart surgery, concentrated
potassium was used. How is access to
this undiluted concentrated electrolyte
controlled?”
“Patients undergoing bypass
surgery are at increased risk
of developing a surgical site
infection. What preventive
measures did you take to help
reduce that risk for the
patient?”“How was the placement
of Mr. Ramponi’s
pulmonary artery catheter
confirmed?”
“How do you maintain this
equipment? How were you
trained to use it?”
“What do you do in the event of fire?”
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At OR Recovery Area
Verbal orders, clinical practice guidelines and equipment management
Step 4
At Recovery Room
“Following Mr. Ramponi’s surgery,
he started on an IV infusion pump
for pain management. What
checks did you perform on the
equipment before starting him on
the pump?”
“Who made the decision to discharge Mr.
Ramponi from the Recovery, OT?”
“What guidelines did you follow for post-
anesthesia monitoring of Mr. Ramponi?”
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Communication, assessment, clinical practice guidelines,
credentialling, infection control, equipment management and
medication management
Surveyor talks with attending Physician, ICU Nurse,
Respiratory Therapist, Infection Control PractitionerStep 5
At Cardiac ICU
“Was Mr. Ramponi restrained while on
ventilator? How was the decision made to
remove Mr. Ramponi from the ventilator?”“How did the OR communicate what
procedures took place when Mr.
Ramponi was transferred to the ICU?
“Mr. Ramponi was receiving IV pain medication
following surgery. Can you show me where you
documented Mr. Ramponi’s pain assessment,
treatment and reassessment?”
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Cardiac ICU
points of discussion
Communications received from Recovery Room
Patient assessment and monitoring
Patient privacy and confidentiality
Infection control
Use and maintenance of equipment, especially clinical alarm systems
Staff competency based on patient populations cared for in ICU
End-of-life issues
Medication management
Handling of verbal orders
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Equipment management, patient education, rights & ethics,
discharge planning, continuum of care.
Step 6 Surveyor talks to Staff Nurse, Cardiac Rehab Nurse,
Respiratory Therapist, Nutritionist, Patient Educator
At Medical - Surgical Unit
“I see that Mr. Ramponi was on telemetry. How would
you know if the equipment is working? Can you explain how the
patient is monitored on this
system?”
“What process was followed for ordering
respiratory therapy for Mr. Ramponi?”
“Can you describe Mr. Ramponi’s medication protocols?”
“How was nutrition and weight management
education provided to the patient?”
“What is your plan for Mr.
Ramponi’s discharge?”
Surveyor reviews patient education materials.
Speaks with Mr. Ramponi and his wife about ongoing
education, informed consent process and the care
provided.
“What written information will Mr. Ramponi receive about his medications
when he is discharged this afternoon? Does the patient know about his
medications? When did you educate him? How?”
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Patient Tracer
Summary
Surveyor visits areas within the organization where the tracer patient was physically treated.
Wherever the surveyor is, he/she is assessing numerous standards.
Surveyor might also tour other areas, e.g., laboratory and pharmacy to explore issues such as diagnostics and medication management.
Surveyor could theoretically visit any location in the organization if it related to the care provided to the patient, including registration, dietary dept, physical therapy, outpatient pharmacy, etc.
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Infection Control Assessment
Assess processes to identify, prevent & manage healthcare acquired infections throughout organization
Uses information obtained from other assessment activities
Facility tour
Tracer activities to inpatient / outpatient care areas
Tracer activities to diagnostic services
Document review
Open & closed record review activities
System tracers activities, e.g. Pharmacy
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Infection Control System Tracer
Group discussion
Goals
Surveillance data
Analysis
Prevention & control strategies
Areas of concern & action
Outbreaks
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Infection Control System TracerCont.
Focused tracer
Tracing infection control processes across the
organization
Example 1: a TB patient admitted through
Emergency to Medical Unit to Radiology to
Medical Unit to Rehab
Example 2: an immuno-compromised patient
admitted through Emergency to Oncology to
Intensive Care Unit to Medical Unit to End-of -
Life care unit.
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Data System Tracer
Group Discussion
20 Minute presentation – optional
Required measures and sustained improvements reviewed
Steps – selection, collection, analysis, dissemination/transmission, action, monitoring, sustained improvement
How data is used throughout the organization
Short surveys
Include medication management and infection control data issues
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Benefits of Tracers
For Patients
Improves Safety and Quality of care
Improves patient flow
For Staff
Encourages team building
Creates systems thinkers
Creates a better understanding of roles
For Organizations
Reduces risk to patients
Increases patient satisfaction
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Tracer Methodology
You can learn more
in 8 hours of tracing
than in 20 hours of
chart review
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Follow-up Process
Written report is required within 6 months for
standards that require a plan, policy or procedure,
or documentation
Focused survey is required within 6 months for
standards that require surveyor observation, staff
or patient interviews, or the inspection of the
physical facility
If both are required, written report is reviewed at
time of focused survey
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Accreditation Denied
A required follow-up focused survey has not
resulted in acceptable compliance with the
applicable standards and/or International Patient
Safety Goal requirements
JCI withdraws its accreditation for other reasons
Organization voluntarily withdraws from the
accreditation process
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After the Survey
Celebrate the success!
Let your patients know what
you have achieved
Take a week off and then start again
May need to work on areas for improvement and submit a follow-up progress report to JCI
Maintain the momentum from the survey –establish an ongoing system of standards compliance and survey readiness
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The Globalization of Healthcare
Color Palette
JCI
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Why International Standards?
JCAHO standards filled with U.S. and state laws and regulations
JCAHO standards contain many “political” considerations such as requirements for an organized medical staff
JCAHO standards use U.S. jargon such as “advanced directives”
JCAHO standards rely on NFPA requirements for facility review with no international version of those requirements
JCAHO standards have a U.S. cultural overlay for patient rights
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JCI’s Commitment to Globalization
International Board Members Mandated
International Standards Committee
Regional Offices Asia Pacific
Europe
Middle East
Regional Advisory Councils
WHO Collaborating Centre for Patient Safety Solutions
International Standards
International Patient Safety Goals
ISQua Accredited
International Surveyors
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Comparisons
International standards include all topics from Joint Commission standards including newer ones related to pain management, and care at the end of life
International standards contain many of the quality control and quality leadership ISO 9000 criteria
International standards include the criteria of the European (EFQM) and U.S. (Baldridge) quality award
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JCI Standards Address Key Issues
Relevant to Globalization
Truth in admission policies
Patients are admitted for care only if the organization can provide the necessary services and settings for care.
At admission patients and families are provided information on the proposed care, expected results of care, and expected costs.
There is an established framework for ethical management including marketing, admissions, transfer, and discharge, and disclosure of ownership and any professional conflicts that may not be in the patients’ best interests.
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JCI Standards Address Key Issues
Relevant to Globalization
Professional Competence
The organization has an effective process to authorize all medical staff members to admit and treat patients and provide other clinical services consistent with their qualifications.
The credentials of medical staff members are reevaluated at least every three years to determine their qualifications to continue to provide patient care services in the organization.
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Accreditation as Part of a
Systems Focus
Focusing on staff would mean reviewing
the mistakes of individuals
A focus on systems examines
conditions where staff work and targets
strategy development to ensure that
there are fewer errors and risk is
reduced
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Accreditation as Part of a
Systems Focus
Errors need to be seen as consequences, not as causes
The best professionals can make the worst mistakes
Errors tend to have recurrent patterns
Organizations should review high reliability systems and anticipate the worst possibilities
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Accreditation as Part of a
Systems Focus
If systems are designed with the full
understanding that we do mistakes,
and nobody is perfect, errors should
occur less frequently.
Furthermore, increasing the
consistency of care provision will
decrease the frequency of errors.