JCIA PRESENTATION

Joint Commission International:
An Overview

Karen H. Timmons
President and Chief Executive Officer
Joint Commission International

© Copyright, Joint Commission International
Association of Companies Health Insurance Funds
13 March 2009
Prague, Czech Republic

Mission of

– To improve the safety and quality
of care in the international
community through the provision of
education, publications,

consultation, evaluation, and
accreditation services

2

Ernest A. Codman:
End Result Theory
– “So I am called eccentric for saying in
public that hospitals, if they want to be
sure of improvement,
– Must find out what their results are.
– Must analyze their results, to find their
strong and weak points.
– Must compare their results with those of

other hospitals.
– Must welcome publicity not only for their
successes, but for their errors.”[1]

3

The American College of Surgeons
described the need for
standardization of hospitals through
accreditation as the need to:
– “Encourage those which are
doing the best work, and to

stimulate those of inferior
standard to do better.”

4

The Joint Commission

– An independent, non-profit, non-
governmental agency
– Accredits over 15,000 health care
organizations in the United States

5

Why International Standards?
The Joint Commission standards:
– Are filled with U.S. and state laws and regulations
– Include many “political” considerations such as
requirements for an organized medical staff
– Use American jargon such as “advanced directives”
– Rely on National Fire Protection Association
requirements for facility review–no international version
of these requirements

– Have a U.S. cultural overlay for patient rights

6

Standards Subcommittee:
How We Get Stakeholder Input
– Brazil
– Czech Republic
– Germany
– Italy
– Poland
– Portugal
– P.R. of China

– Republic of South Africa
– Saudi Arabia
– U.S.A.

7

JCI Hospital Standards
Translations
–Brazilian Portuguese –German
–Chinese –Greek/Cyprus
–Arabic –Italian
–Czech –Korean
–Danish –Japanese

–European –Spanish
Portuguese –Turkish

8

International Structure
– International Board of Directors
– International Accreditation Committee
– International Standards Committee
– Regional Advisory Councils
– Four International Offices
– International translations of many products

9

Offices
– Headquarters
– Oak Brook, IL, USA
– International
– Europe
– Ferney-Voltaire, France (edge of Geneva)
– Milan, Italy (Project Office)
– Middle East

– Dubai Health Care City
– Asia Pacific
– Singapore

10

Regional Advisory Councils
– Asia-Pacific
– Europe
– Middle East
– Provide advice and counsel to JCI
management about standards and patient
safety initiatives
– Guidance on regional or cultural

adaptations

11

European Regional Advisory
Council
– BQS – Health Care Quality Indicator
– Danish Institute for Patient Safety Project
– Danish Institute for Quality and – HOPE (European Hospital
Accreditation in Healthcare Federation)
(IKAS) – International Hospital Federation
– European Parliament – International Pharmaceutical
– European Society for Quality in Federation (FIP)
Healthcare (ESQH) – The Karolinska Institute
– Fundación Acreditación – Ministry of Health, State of Israel
Desarrollo Asistencial – Ministry of Health, Turkey

– Georgian Alliance for Patient – National Patient Safety Agency
Safety – Socialstyrelsen
– Haute Autorité de Santé (HAS) – Swedish Medical Injury Insurance
– WHO

12

JCI Today

– Global knowledge disseminator of quality
improvement and patient safety
– Non-profit affiliate of the Joint Commission
– 236 accredited organizations in 35 countries
– Commitment to partnering with NGOs, HCOs,
etc.

– ISQua-accredited
– WHO Collaborating Centre for Patient Safety
Solutions

13

Programs
International Accreditation

14


Accredited Hospitals in Czech
Republic
• Central Military Hospital
• Institute of Hematology and Blood
Transfusion
• Na Homolce Hospital

15

Accreditation – A Definition

• A government or non-government
agency grants recognition to health
care institutions which meet certain
standards that require continuous
improvement in structures, processes,

and outcomes
• Usually a voluntary process

16

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 Asia, China, Thailand, and Malaysia are
developing national accreditation programs
– The WHO, World Bank, and development banks
recognize and endorse the accreditation model

– The International Society for Quality in Health Care
(ISQua) accredits accrediting bodies

17

Common Core of Health Care
Accreditation Around the World
 Administered by a recognized body
• Establishes and publishes standards
• Conducts objective on-site evaluations
• Publishes accreditation decision
 Professional involvement

• Consensus on standards of quality and safety
• Professionals serve as the external evaluators
 Focus is on continuous improvement

18

What is Accreditation
Intended to Accomplish?
• 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

19

Increasing Requests for Ensuring
Quality and Safety for Medical Travel
• International Medical Travel Association issued position paper
advocating that international health care organizations be held
to high standards set by recognized accreditation authorities1
• American Medical Association adopted guiding principles on
medical tourism2
– Outline steps for care abroad for consideration by patients,
employers, insurers, and third parties
– Require patients to be made aware of their legal rights and have
access to physician licensing and facility accreditation
• Increasing exposure in international trade journals highlighting

the need to research quality when considering medical travel3
• Deloitte study mentions JCI in particular in reference to patients’
increasing concerns about quality in international hospitals4

20

Accreditation

– Assesses the capability of an
organization to provide good results

21

Accreditation
International Accreditation Philosophy
– Maximum achievable standards
– Patient-centered
– Culturally adaptable
– Process stimulates continuous improvement

22

The Accreditor’s Tools
 Standards
 Evaluation Methodology
 Patient Safety Goals and Tools
 Data on Performance and Benchmarks
 Education

23

Standards
– A system framework
– Address all the important managerial and
clinical functions of a health care organization
– Focus on patients in context of their family
– A balance of structure, process, and
outcomes standards

– Set optimal, achievable expectations
– Set measurable expectations

24

Standards are Continually a
“Work in Progress”
– The heart of any accreditation program is the
standards upon which all else is based – the
evaluation methodology, decision process,
evaluator training, and other operational
elements
– Thus, a standard must be “good”, not just on

the day the standard is written, but on a
continuing basis

25

Evidence of Performance is
Available
– Standards have multiple dimensions and thus have
multiple sources of evidence
– Policy – document review
– Knowledge – staff training logs, interviews with
staff
– Practice – clinical observation, patient interviews
– Documentation of practice – open and closed

record review
– A good standard permits a convergent validity scoring
process – all surveyors evaluating all types of
evidence and reaching one score

26

Standards
– Organized Around Important Functions
– 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

27

JCI Standards, continued
– Organized Around Important Functions
– 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 Communication and
Information

28

Patient Tracer: Systems Analysis

– Set of components that work together toward
common goal
– Evaluation of how - and how well - the
organization’s systems function
– Addresses interrelationships of elements
– Translates standards compliance issues into

potential vulnerabilities as far as patient
quality and safety

29

International Patient Safety Goals
and Tools
– Represent proactive strategies to reduce risk of
medical error and reflect good practices
proposed by leading patient safety experts
– Incorporating these new tools into our
accreditation requirements is a significant step
– Organizations taking responsibility for using the

IPSG to foster an atmosphere of continuous
improvement is even more important

30

JCI International Patient Safety Goals
1. Identify patients correctly
2. Improve effective communication
3. Improve the safety of high-alert medications
4. Ensure right-site, right-patient, right-procedure
surgery
5. Reduce the risk of health care-associated

infections
6. Reduce the risk of patient harm from falls

31

JCI’s Measurement Strategy
– Accreditation is continuous
– Accreditation status publicly disclosed
– Complements existing standards requirements
– International comparisons
– Meets needs of multiple stakeholders
– Develop and identify measures that address clinical
and managerial dimensions

– Need for and rigor of data validation
– Measurement system supported by IT platform
– JCI currently has 20 performance measurement
requirements

32

33


International Cardiac Surgery
Benchmarking (ICSB) Project
• Pilot program addressing international clinical cardiac
indicators
• 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

34

ICSB Project Objectives

• 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

35

Speak Up™

– Help Prevent Errors in Your Care
– Help Avoid Mistakes in Your Surgery
– Information for Living Organ Donors
– Five Things You Can Do to Prevent Infection
– Help Avoid Mistakes With Your Medicines
– What You Should Know About Research Studies
– Planning Your Follow-up Care
– Help Prevent Medical Test Mistakes

– Know Your Rights
– Understanding Your Doctors and Other Caregivers
– What You Should Know About Pain Management

36

Sentinel Event Database

– Sentinel Event database collects data from
accredited organizations on errors that have occurred
– Information in database led to the publication of
Sentinel Event Alert, published by The Joint
Commission
– Sentinel Event Alerts highlight significant risk areas in
care

– Offer suggestions and recommendations for
mitigating risk
– Latest Alert focuses on information technology

37

Sentinel Event Experience to Date
Of 5632 sentinel events reviewed by the Joint Commission,
January 1995 through December 2008:
741 Events of wrong site surgery
698 Inpatient suicides
631 Operative/post op complications
492 Events relating to medication errors
442 Deaths related to delay in treatment
341 Patient falls
218 Assault/rape/homicide
212 Retained foreign objects
189 Deaths of patients in restraints
175 Perinatal death/injury

132 Transfusion-related events
113 Infection-related events
86
85
Deaths following elopement
Anesthesia-related events
= 5632 RCAs
85 Fires
992 “Other”

38
Client name/ Presentation Name/ 12pt - 38

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.

39

Accreditation
The Value and Impact of

40


Impact of Accreditation

– What is the evidence that
– Accreditation improves quality and safety
of care?
– High quality lowers cost of health care?
– The cost of implementing accreditation
standards is worth the achievable

benefit?

41

Impact of Accreditation (cont’d)

– The process of Joint Commission
International accreditation has set many of
the fundamental principles that guide health
care organizations today
– Many of these principles are routine in health
care today but were revolutionary in their time

42

Impact of Accreditation:
Some Examples
Medical Records
• First required in 1917, many considered
the medical record unnecessary
• Today the medical record is inarguably
the central point of information gathering
for treatment decisions, research, patient

monitoring, outcomes measurement, and
even billing

43

Some Examples
Infection Control Programs
– In the mid-1950s, patients, especially surgery
patients and newborns, acquired infections in
epidemic proportions
– In the 1950s, hospitals were required to appoint
infection control committees to direct activities
aimed at curbing epidemics of infections

– Infection control programs were created that
reduced the spread of devastating infectious
agents

44

Some Examples
Fire Safety
– Non-smoking standards for hospitals were developed due to the
adverse effects of passive non-smokers and significant fire
hazards
Advance Directives
– Protects patients from a life or death they would not have wished
– Requires organizations to establish Do-Not-Resuscitate (DNR)
standards and request an advance directive from each patient so

the individual’s wishes can be documented in the patient chart
– In the 1980s only 20% of hospitals addressed this issue; since the
implementation of the standard, nearly 100% of accredited
organizations are in compliance with the standard

45

Accreditation: The Value Equation
– JCI has conducted descriptive research with a sample
of accredited hospitals to determine the value of
accreditation
– Accredited hospitals report significant improvements in:
– Leadership
– Medical records management
– Infection control

– Reduction in medication errors
– Staff training and professional credentialing
– Improved quality monitoring

46

Recent Studies Support the Value of
Joint Commission Accreditation
– Longo study showed that accreditation is a significant
factor in whether facilities engaged in actions widely
recognized to improve patient safety; advocates
accreditation as a means for improving health care5
– Health Affairs report indicated that Joint Commission
accreditation requirements influenced hospitals’
efforts toward implementing patient safety initiatives6

– Study in Hospital Topics found accreditation to be
effective in driving efforts to reduce errors7

47

WHO
World Alliance
for Patient
Safety

to address the problem of
patient safety worldwide
48

World Alliance for Patient Safety:
Ten Action Areas
Global Patient Safety Challenges : Solutions to improve
1. Clean Care is Safer Care patient safety
2. Safe Surgery Saves Lives
High 5s

Patients for
Patient Safety

Catalyse Technology for
Patient Safety
Research for
Patient Safety countries’ action
to achieve Knowledge Management

International safety of care Special projects:
Classification for - Education
Patient Safety (ICPS) - Radiotherapy
- Rewarding excellence
Reporting & Learning - When things go wrong
- Vincristine sulphate

Solutions for Patient Safety

50


Clean Care is Safer Care

51

© Copyright, Joint Commission Resources

Patients for Patient Safety

• A patient engagement initiative
• Focus on individuals (“champions”), not
organizations
• Links to other World Alliance strands
• Creation of regional groups

52

Taxonomy for Patient Safety

53


International Patient Safety Events
Taxonomy

• Cornerstone of patient safety
communications

54

Reporting and Learning

y
s afet
a tient
. int/p

.who
n www
la ble o
Avai

55

Research for Patient Safety
Harvard Practice
Canadian Adverse
Medical Study
Event Study
2004 1984

Danish Adverse
Event Study
2001

Adverse events in French Adverse
Utah Colorado British Hospitals Event Study
1999-2001 2004
Study 1992

The Commonwealth
Fund Survey
2005 Australian Quality
in Healthcare
Study 1992

Adverse Events in
New Zealand 56
Study 2002

Technology for Patient Safety

– “To identify and clarify the role and
objectives of technology in improving
patient safety both in the developed and
developing world, and future directions
(research, education, implementation)
for the alliance regarding technology for

patient safety.”

57

High 5s Project Objective
– 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 community that
fosters the sharing of knowledge and
experience in implementing innovative
standardized operating protocols and

evaluating their impact.

58

High 5s Standardized Operating
Protocols
– Managing Concentrated Injectable Medicines
(U.K.)
– Assuring Medication Accuracy at Transitions in
Care (Canada)
– Performance of Correct Procedure at Correct
Body Sites (U.S.)
– Improved Hand Hygiene to Prevent Health Care-
Associated Infections (New Zealand) (deferred)

– Communication During Patient Care Handovers
(Australia) (deferred)

59

WHO Collaborating Centre
for Patient Safety Solutions

– Identify Current Regional Safety Problems and
Solutions Available
– Understand Regional Barriers to Solutions
– Assess Risk of Solutions
– Adapt Solutions to Local/Regional Needs

– Develop/Disseminate Solutions

60

Definition

A Patient Safety Solution is any
system design or intervention that has
demonstrated the ability to prevent or
mitigate patient harm stemming from
the processes of health care.

61

Topic Selection Process

– Sentinel Event Topic Areas
– Expert Panels
– National Agencies and Governments
– Professional societies and organizations
– Patient and family advocacy organizations
– Field reviews

– Open solicitations

62

Confusing drug names is one of the most common causes of
medication errors and is a worldwide concern. With tens of
thousands of drugs currently on the market, the potential for error
created by confusing brand or generic drug names and
packaging is significant. The recommendations focus on using
protocols to reduce risks and ensuring prescription legibility or the
use of preprinted orders or electronic prescribing. 63

The widespread and continuing failures to correctly identify patients

often leads to medication, transfusion and testing errors; wrong person
procedures; and the discharge of infants to the wrong families. The
recommendations place emphasis on methods for verifying patient
identity, including patient involvement in this process; standardization of
identification methods across hospitals in a health care system; and
patient participation in this confirmation; and use of protocols for
distinguishing the identity of patients with the same name. 64

Gaps in hand-over (or hand-off) communication between patient care

units, and between and among care teams, can cause serious
breakdowns in the continuity of care, inappropriate treatment, and
potential harm for the patient. The recommendations for improving
patient hand-overs include using protocols for communicating critical
information; providing opportunities for practitioners to ask and resolve
questions during the hand-over; and involving patients and families in the
hand-over process. 65

Considered totally preventable, cases of wrong procedure or wrong site
surgery are largely the result of miscommunication and unavailable, or

incorrect, information. A major contributing factor to these types of
errors is the lack of a standardized preoperative process. The
recommendations to prevent these types of errors rely on the conduct of
a preoperative verification process; marking of the operative site by the
practitioner who will do the procedure; and having the team involved in
the procedure take a “time out” immediately before starting the
procedure to confirm patient identity, procedure, and operative site. 66

While all drugs, biologics, vaccines and contrast media have a
defined risk profile, concentrated electrolyte solutions that are used
for injection are especially dangerous. The recommendations
address standardization of the dosing, units of measure and
terminology; and prevention of mix-ups of specific concentrated
electrolyte solutions. 67

Medication errors occur most commonly at transitions. Medication
reconciliation is a process designed to prevent medication errors at patient
transition points. The recommendations address creation of the most
complete and accurate list of all medications the patient is currently taking—
also called the “home” medication list; comparison of the list against the
admission, transfer and/or discharge orders when writing medication orders;
and communication of the list to the next provider of care whenever the
patient is transferred or discharged. 68

The design of tubing, catheters, and syringes currently in use is

such that it is possible to inadvertently cause patient harm through
connecting the wrong syringes and tubing and then delivering
medication or fluids through an unintended wrong route. The
recommendations address the need for meticulous attention to
detail when administering medications and feedings (i.e., the right
route of administration), and when connecting devices to patients
(i.e., using the right connection/tubing). 69

One of the biggest global concerns is the spread of Human

Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the
Hepatitis C Virus (HCV) because of the reuse of injection needles.
The recommendations address the need for prohibitions on the reuse
of needles at health care facilities; periodic training of practitioners and
other health care workers regarding infection control principles;
education of patients and families regarding transmission of blood
borne pathogens; and safe needle disposal practices. 70

One of the biggest global concerns is the spread of Human

Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the
Hepatitis C Virus (HCV) because of the reuse of injection needles.
The recommendations address the need for prohibitions on the reuse
of needles at health care facilities; periodic training of practitioners and
other health care workers regarding infection control principles;
education of patients and families regarding transmission of blood
borne pathogens; and safe needle disposal practices. 71

Next Set of Solutions

 Preventing Central Line Infections
 Communicating Critical Test Results
 Recognizing and Responding to
Deteriorating Patients
 Preventing Pressure Ulcers
 Preventing Harm from Patient Falls

72

Next Set of Solutions (cont’d)
Prototype will target four audiences:
– Government policy at ministry of health level
– Health care organization at the CEO level
– Clinician/provider levels
– Patient and family level

73

74


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