Tài liệu Getting started with jci accreditation dr. prahhu

© Copyright, Joint Commission International Getting started with JCI Accreditation  Evaluate the commitment of leadership (Board, CEO, and clinical leaders) to a never ending journey.  Assess the purity of purpose: to be a safe, high quality organization.  Set a clear understanding that the process will require significant leader time. Assigning accreditation only to the quality department will not work. Client name/ Presentation Name/ 12pt - 2 © Copyright, Joint Commission International The Accreditation Journey: The Basics  List all barriers and strengths to success and plan strategies for each  Understand implications for financial and human resources. These may include facility enhancement, training, recruitment of new staff, and redesign of systems.  Set a realistic timeframe for preparation. Average preparation time? Client name/ Presentation Name/ 12pt - 3 © Copyright, Joint Commission International The Accreditation Journey • JCI International Standards for Hospitals, 3nd Edition • Hospital Survey Process Guide • Web-based training on introduction to the international accreditation process • ISAS – International Self Assessment System • Newsletters and publications, both print and electronic • JCI Practicum – Several locations worldwide • JCI Executive Briefings Client name/ Presentation Name/ 12pt - 4 © Copyright, Joint Commission International The Accreditation Journey: JCI Resources Provide education for organizational leaders and managers and then progressively for all staff. Re-educate frequently. Include: Introduction to accreditation philosophy and approach Discussion of accreditation as a patient-focused 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 Client name/ Presentation Name/ 12pt - 5 © Copyright, Joint Commission International The Accreditation Journey: Continual Education The Accreditation Journey: Baseline Assessment Client name/ Presentation Name/ 12pt - 6 © Copyright, Joint Commission International Determine the organization’s 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. Score as Met, Partially Met, or Not Met and cite specific findings and recommendations. Include all areas of the organization in the assessment. Consider an assessment of organizational “culture” related to quality and patient safety. The Accreditation Journey: Baseline Assessment In addition to addressing standards adherence, analyze and collect available baseline quality data as required by the quality monitoring standards (QPS). Client name/ Presentation Name/ 12pt - 7 © Copyright, Joint Commission International More data and data sources may be available than you first realize. Begin to combine activities of riskmanagement, quality management, facility safety, etc. into one comprehensive data set. Examples: medication errors, hospitalassociated infection rates, antibiotic usage, falls, hazardous material spills, surgical complications, etc. Client name/ Presentation Name/ 12pt - 8 © Copyright, Joint Commission International The Accreditation Journey: Baseline Assessment Using the findings of the baseline assessment, develop a detailed project plan with assigned responsibilities, deliverables, and timeframes. Example: Revise informed consent policy, develop a new informed consent statement, educate staff by 30 August. Responsibility: One Person If available, use a software program such as MS Project or Excel to confirm project plan in writing. Hold leaders and staff accountable to plan. Client name/ Presentation Name/ 12pt - 9 © Copyright, Joint Commission International The Accreditation Journey: Action Planning  Think structure-process-outcome in the implementation sequence, in other words develop polices first. Expectation required actions result  Implement those requirements that will take the longest to make fully functional such as the quality monitoring system for the QPS indicators.  Do not forget the “track record” requirement = 4 months a first survey. Client name/ Presentation Name/ 12pt - 10 © Copyright, Joint Commission International The Accreditation Journey: Action Planning Tips Assign oversight of each chapter of standards to a respected champion or leader who will select team members from throughout the hospital. Tip: Involve those who may be skeptical of the process. Look for good people skills, time management skills, and consensus building skills. Be prepared to change assignments as new champions emerge and some leaders drop out. Client name/ Presentation Name/ 12pt - 11 © Copyright, Joint Commission International The Accreditation Journey: Team Approach In addition to an overall project plan, it is often helpful to compile a list of all required policies and procedures that will need development or revision.  It may take more time than you think to write, have organizational review, and get final approval on policies.  Be certain that your policy reflects your actual practice. This is how surveyors will evaluate your organization.  Plan time for education of new policies. Test understanding and compliance.  Create, refine and/or test your document management system. (Policy on Policies) Client name/ Presentation Name/ 12pt - 12 © Copyright, Joint Commission International The Accreditation Journey: Policies and Procedures The Accreditation Journey: Mid-Point Strategies  Continue to monitor your progress in meeting the standards; do a mini-evaluation of each chapter at regular intervals.  Continue to involve as many staff as possible in the process. Make accreditation an organizational quality goal that you are striving to achieve together.  Keep staff motivated. Client name/ Presentation Name/ 12pt - 13 © Copyright, Joint Commission International  It is not a setback to adjust your project plan if necessary. Changes in processes often take longer than expected. Physician commitment to the accreditation process is critical to success.  Physicians must see accreditation standards as a framework by which organizational processes will be improved in order to support good medical care.  Accreditation is not a peer review process as many physicians suspect.  Accreditation supports the use of good clinical science and best practices. Client name/ Presentation Name/ 12pt - 14 © Copyright, Joint Commission International Successful Strategies: Physician Perspective More Successful Strategies  Learn from what others have done well and adapt the experience to the needs of your organization.  Take advantage of resources such as the JCR Good Practices Database (e.g. download electronic example policies and plans and adapt to your organization). Client name/ Presentation Name/ 12pt - 15 © Copyright, Joint Commission International  Ask JCI for assistance and clarification with standards interpretation. Don’t waste time going down the wrong path. Pitfalls: Be Aware  Top leaders give “lip service” to the process, but are unrealistic in what it will take to achieve accreditation in terms of time and resources.  Over-eager managers make the entire accreditation process feel punitive and inspecting rather than motivating. Client name/ Presentation Name/ 12pt - 16 © Copyright, Joint Commission International  Staff end up feeling that accreditation is extra work for which they are not rewarded or recognized. Mock Survey  Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation. They will look at the organization with more objectivity. If using internal evaluators, mix disciplines and locations.  Plan revisions and corrections based on the findings of the mock survey. Educate. Client name/ Presentation Name/ 12pt - 17 © Copyright, Joint Commission International  Plan for a final “mock survey” at least 6 months in advance of the target date of your actual accreditation survey. Applying for Accreditation –Survey Application – Submit application in electronic or written format to JCI Office – Must inform JCI if changes to information in application after submission – determine length of survey & number of surveyors – prepare preliminary agenda & contract for survey –Survey Scheduled within 180 days Client name/ Presentation Name/ 12pt - 18 © Copyright, Joint Commission International –Application is used to The Accreditation Survey  Request an application from JCI at least 6 months or longer in advance of target dates for survey.  A survey team leader will be in contact to coordinate an agenda and plans for the survey.  Support staff in doing the work they routinely do so the survey does not cause undue anxiety and fear. Client name/ Presentation Name/ 12pt - 19 © Copyright, Joint Commission International  Once your application is completed, a surveyor team will be assigned and dates confirmed.  Celebrate your success!  If there are areas for improvement, you may need to submit documentation or a follow-up progress report to JCI.  Maintain the momentum from your preparation and survey. Establish a system and process for ongoing standards compliance and survey readiness.  Continue education. Client name/ Presentation Name/ 12pt - 20 © Copyright, Joint Commission International After the Survey