Getting Started How to pursue accreditation and how

Getting Started How to pursue accreditation and how JCI can help you Managing Director Asia Pacific Office © Copyright, Joint Commission International Dr. Prabhu Vinayagam

Accreditation Preparation Process al n tio t a niz men ent a g rr Or sess our cu ainst As uate y nce asgand rt a t S IA JC rvey Su Create New Processes Develop and implement new policies, plans, and procedures Client name/ Presentation Name/ 12 pt - 3 © Copyright, Joint Commission International a d d al Ev rform ndar s an ive pe sta plan o dr t the ate res nt e cr uctu eme str prov im

Organizational Assessment: Assess Current Compliance q Use knowledgeable and credible evaluators (either internal or external consultants) who will critically and objectively assess each area. q Cite specific findings and recommendations. q Include all areas of the organization in the assessment q Assess your organizational quality and patient safety “culture” Compile and analyze currently available baseline quality data as required by the quality monitoring standards (QPS). Client name/ Presentation Name/ 12 pt - 4 © Copyright, Joint Commission International Determine your current adherence to the standards and each measurable element.

– Use the findings of the organizational assessment to develop a detailed project plan. – Include: – Assigned responsibilities – Deliverables – Timeframes – Hold leaders and staff accountable to plan. Client name/ Presentation Name/ 12 pt - 5 © Copyright, Joint Commission International Organizational Assessment: Action Planning

Organizational Assessment: Action Planning Tips § Think structure-process-outcome § Implement those requirements that will take the longest to make fully functional § Do not forget the “track record” or “performance history” requirement § 4 months on the first survey. Client name/ Presentation Name/ 12 pt - 6 © Copyright, Joint Commission International § E. g. , the quality monitoring system for the QPS indicators.

Accreditation Preparation Process al n tio t & e a z y i n c n me ent oli dur nt a e g rr Or sess our cu ainst P roce opm P vel w As uate y nce asgand e p ne D al rma ard nd t v a E e o elo nd ha rt a t S a t v I De lices ures JC h po ced wit pro mply rds co nda sta IA JC rvey Su Create New Processes Develop and implement new policies, plans, and procedures 18 -24 Months Client name/ Presentation Name/ 12 pt - 7 © Copyright, Joint Commission International rf iv nd s pe sta plan o dr t the ate res nt e cr uctu eme str prov im

Policy and Procedure Development – Developing policies and procedures that meet the JCI standards is one of the most time consuming parts of the preparation process • • Make sure that all of these documents are in one place. Be certain that your existing policies reflects your actual practice. This is how surveyors will evaluate your organization. 2. Compile a list of all required policies and procedures that will need development or revision. Client name/ Presentation Name/ 12 pt - 8 © Copyright, Joint Commission International 1. Start by compiling all of your policies and procedures

Policy and Procedure Development 3. Revise your policies and procedures – It may take more time than you think to write, review, and approve policies – – Test understanding and compliance Make sure that policy = practice 5. Create, refine and/or test your document management system (Policy on Policies) Client name/ Presentation Name/ 12 pt - 9 © Copyright, Joint Commission International 4. Educate your staff on your new policies

Accreditation Preparation Process al n tio t & e a z y i n nt c n me ent oli dur nt e a e g rr um Or sess our cu ainst P roce opm c Do view ur P vel w As uate y nce asgand e s yo ies, e p ne R D al rma ard nd t d v lic res a E e ha o es elo n rt a t S a t v I De lices ures JC h po ced wit pro mply rds co nda sta s po u As ns, ced nce rds pla d pro plia nda an com I sta for h JC t wi IA JC rvey Su Create New Processes Develop and implement new policies, plans, and procedures 18 -24 Months Client name/ Presentation Name/ 12 pt - 10 © Copyright, Joint Commission International rf iv nd s pe sta plan o dr t the ate res nt e cr uctu eme str prov im

Document Review – Have an objective pair of “fresh-eyes” review your new policies and procedures to make sure: – The survey will assess if your policies and procedures meet the standards and if your staff is actually following them. Client name/ Presentation Name/ 12 pt - 11 © Copyright, Joint Commission International 1. They meet the JCI standards 2. They can be clearly understood by your staff 3. They can be followed by your staff

Accreditation Preparation Process al n tio t & e a z y i n nt c n me ent oli dur nt e a e g rr um Or sess our cu ainst P roce opm c Do view ur P vel w As uate y nce asgand e s yo ies, e p ne R D al rma ard nd t d v lic res a E e ha o es elo n rt a t S a t v I De lices ures JC h po ced wit pro mply rds co nda sta s po u As ns, ced nce rds pla d pro plia nda an com I sta for h JC t wi IA JC rvey Su Create New Processes Monitor Progress and Adjust Develop and implement new policies, plans, and procedures Evaluate effectiveness of processes and refine as necessary Client name/ Presentation Name/ 12 pt - 12 © Copyright, Joint Commission International rf iv nd s pe sta plan o dr t the ate res nt e cr uctu eme str prov im

Monitoring Progress – Continue to monitor your progress in meeting the standards – Keep staff motivated. – Use the evaluation methods your JCI surveyor will use – Use the results of these evaluations to show progress or focus efforts Client name/ Presentation Name/ 12 pt - 13 © Copyright, Joint Commission International – Involve as many staff as possible – Make accreditation a goal that you are striving to achieve together.

Accreditation Preparation Process al n tio t & e a z y i n nt c al n me ent oli dur nt e c a i e g rr n nce um h Or sess our cu ainst P roce opm c c Do view ur Te sista s to P vel w As uate y nce asgand e s yo ies, s pert e p ne R A D al rma ard nd t c s d v li a ex E e ha o re es elo n rt a t S a t v I De lices ures JC h po ced wit pro mply rds co nda sta r s e s po u As ns, ced nce rds Us dres ent o pla d pro plia nda ad rsist t a an com I st pe ficul s r fo h JC dif blem t wi pro Create New Processes Monitor Progress and Adjust Develop and implement new policies, plans, and procedures Evaluate effectiveness of processes and refine as necessary IA JC rvey Su Client name/ Presentation Name/ 12 pt - 14 © Copyright, Joint Commission International rf iv nd s pe sta plan o dr t the ate res nt e cr uctu eme str prov im

Technical Assistance – Every accreditation preparation effort reveals persistent problems. – JCI is available to help: – Standards Interpretation & Clarification (free) – Compliance Assistance (for fee) – Let JCI help you develop solutions to your persistent problems, based upon our experience helping other organizations address similar problems Client name/ Presentation Name/ 12 pt - 15 © Copyright, Joint Commission International – Make sure that the standard really requires the element that is causing you difficulty.

Accreditation Preparation Process al n y tio t e & a v r nt al niz men ent olicy dure nt e Su rent c a i e r e g k m r c s cur 6 hn anc Or sess our cu ainst P roce opm o cu w c o D vie ur Te sist s to M asses ance r to you e P vel w As uate y nce asgand o e s yo ies, s pert e p ne Re rform pri llow mak R A D al rma ard nd t c s s d v a to li a ex E e ha o re es pe th elo n rt a t S a t v I De lices ures JC h po ced wit pro mply rds co nda sta r s e s po u As ns, ced nce rds Us dres ent o pla d pro plia nda ad rsist t a an com I st pe ficul s r fo h JC dif blem t wi pro n to e mo rvey tim su ough nute s en t mi ent las justm ad Create New Processes Monitor Progress and Adjust Develop and implement new policies, plans, and procedures Evaluate effectiveness of processes and refine as necessary IA JC rvey Su Client name/ Presentation Name/ 12 pt - 16 © Copyright, Joint Commission International rf iv nd s pe sta plan o dr t the ate res nt e cr uctu eme str prov im

Mock Survey – Conduct at least 6 months before your survey – Use objective evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation. – Plan revisions and corrections based on the findings of the mock survey. Client name/ Presentation Name/ 12 pt - 17 © Copyright, Joint Commission International – The “Mock Survey” helps you see what standards still need improvement before your survey.

Scheduling Your Accreditation Survey – At about the same time as your mock survey, you should schedule your “real” survey. – Once your application is completed, a surveyor team will be assigned and dates confirmed. – A survey team leader will be in contact to coordinate an agenda and plans for the survey. Client name/ Presentation Name/ 12 pt - 18 © Copyright, Joint Commission International – Request an application from JCI at least 6 months or longer in advance of target dates for survey.

Accreditation Preparation Process al n y tio t e & a v r nt al niz men ent olicy dure nt e Su rent c a i e r e g k m r c s cur 6 hn anc Or sess our cu ainst P roce opm o cu w c o D vie ur Te sist s to M asses ance r to you e P vel w As uate y nce asgand o e s yo ies, s pert e p ne Re rform pri llow mak R A D al rma ard nd t c s s d v a to li a ex E e ha o re es pe th elo n rt a t S a t v I De lices ures JC h po ced wit pro mply rds co nda sta r s e s po u As ns, ced nce rds Us dres ent o pla d pro plia nda ad rsist t a an com I st pe ficul s r fo h JC dif blem t wi pro n to e mo rvey tim su ough nute s en t mi ent las justm ad Create New Processes Monitor Progress and Adjust Develop and implement new policies, plans, and procedures Evaluate effectiveness of processes and refine as necessary IA JC rvey Su 18 -24 Months Client name/ Presentation Name/ 12 pt - 19 © Copyright, Joint Commission International rf iv nd s pe sta plan o dr t the ate res nt e cr uctu eme str prov im

© Copyright, Joint Commission International Two Pieces of Advice from Accreditation Leaders

1. Honestly Address Resistors Client name/ Presentation Name/ 12 pt - 21 © Copyright, Joint Commission International – Many staff members may not see the value of JCI Accreditation.

Common Sources of Resistance Although JCI is expensive, the quality improvement activities and patient safety techniques that accreditation preparation requires can lead to significant cost savings for an organization. Client name/ Presentation Name/ 12 pt - 22 © Copyright, Joint Commission International “JCI is too expensive. ”

– Brandeis University examined this question in a forthcoming pilot study – Three study hospitals matched with three control hospitals – Designed to control for the changes within a country that may influence standards compliance Client name/ Presentation Name/ 12 pt - 23 © Copyright, Joint Commission International Brandeis Value and Impact Study

Value and Impact Study – Early analysis suggests significant findings: Metric Savings • Staff turnover • $53, 000 per year Client name/ Presentation Name/ 12 pt - 24 24 © Copyright, Joint Commission International • Reduced rate of return • $34, 000 per year to ICU within 24 hours

Common Sources of Resistance Achieving JCI’s gold seal can have a profound impact on a hospital’s business operations. Client name/ Presentation Name/ 12 pt - 25 © Copyright, Joint Commission International “JCI only helps staff members in clinical departments. There’s nothing in it for me. ”

– JCI is globally recognized as the preeminent international accrediting body. – JCI accreditation is increasingly seen as the mark of an organization’s commitment to quality and patient safety. Client name/ Presentation Name/ 12 pt - 26 © Copyright, Joint Commission International Marketing

© Copyright, Joint Commission International Client name/ Presentation Name/ 12 pt - 27

Common Sources of Resistance “We don’t want JCI telling us what to do. ” We believe that your organization and your healthcare professionals are best suited to make these decisions. We do not evaluate clinical decisions. Client name/ Presentation Name/ 12 pt - 31 © Copyright, Joint Commission International JCI asks you to decide which processes, practices, and policies will lead to the best outcomes for your patients.

– Vocal resistors who are willing to share their concerns will help you understand the concerns of those that are silently resistant. – Their input is critical in crafting a strategy that helps address the concerns of everyone in your organization. Client name/ Presentation Name/ 12 pt - 32 © Copyright, Joint Commission International A Final Note About Resistors

– There is no need to memorize all 287 standards and 1, 146 measurable elements. – Most people only need to know the few standards applicable to their job. – Everyone should be familiar with the organization of the standards manual, so they can find the standards that may apply to new situations. Client name/ Presentation Name/ 12 pt - 33 © Copyright, Joint Commission International 2. Don’t try to memorize the standards

JCI in Summary Our Mission and our Activities § To improve the safety and quality of care in the international community Our Activities § Create global accreditation standards that provide a roadmap for organizations seeking a rigorous approach to safety and quality. § Assist organizations to achieve their safety and quality goals through consulting, education, and publications. § Encourage organizations to meet our accreditation standard as a way of structuring their continuing improvement. Client name/ Presentation Name/ 12 pt - 36 © Copyright, Joint Commission International Our Mission

Client name/ Presentation Name/ 12 pt - 37 © Copyright, Joint Commission International Thank You