JCI ORIENTATION

2018
 An Introduction To JCI
JCI ORGANIZATIONAL BASE
- Joint Commission International (JCI) is the
international arm of The Joint Commission
(USA)
- Both organizations are independent, non-
profit, non governmental agencies
MISSION OF JOINT COMMISSION
INTERNATIONAL
- To improve the safety and quality of care in
the international community
- Mission chiefly accomplished through:
1.Accreditation services
2.Education
3.Publications
4.Consultation
ACCREDITATION: DOES IT MAKE A
DIFFERENCE?
- Descriptive research with a sample of accredited hospitals
revealed significant improvements in:
1.Leadership
2.Medical records management
3.Infection control
4.Reduction in medication errors
5.Staff training and professional credentialing
6.Improved quality monitoring
 THE JCI ACCREDITATION
PHILOSOPHY

- Maximum achievable standards

- Patient-centered
- Culturally adaptable
- Leave the organization with sustainable
practices and the capacity to continually
improve.
JCI ACCREDITED ORGANIZATIONS IN
ASIA PACIFIC REGION
1.China (2 Hospitals)
2.Hong Kong ( 2 Hospitals)
3.India (10 Hospitals)
4.Korea (1 Hospital)
5.Pakistan (1 Hospital)
6.Philippines (5 Hospitals) – The Medical City
7.Indonesia (1 Hospital)
8.Singapore (13 Hospitals)
9.Malaysia (1 Hospital)
10.Taiwan (3 Hospitals)
11.Thailand (4 Hospitals)
 Introduction to the JCI
Standards
THE TRANSPARENT JCI PROCESS

Accreditation
Certificate
Accreditation
Decision Rules

On-site
Evaluation of
Standards

International
Standards
 REVIEW AND APPROVAL PROCESS
1. Consensus of the Standards Subcommittee (12
members)
- Singapore (2) – Chair - Denmark
- Czech Republic - P.R. China
- United States (3) - South Africa
- Brazil - A JCI Surveyor
- Saudi Arabia
2. Review by individual experts or expert panels
3. Focus groups on select areas
4. Internet review by as many international users as
possible
5. Final approval by Accreditation Committee and the
Board of JCI
STANDARDS REVIEW
How are the standards organized?
• Patient-Centered Standards

• Healthcare Organization and Management

Standards

• Academic Medical Center Hospital

Standards
 JCI standards define the performance
expectations, structures, or functions that
must be in place for a hospital
to be accredited by JCI.
JCI’s standards are evaluated during the on-
site survey.
 JCIA STANDARDS (14)
1. International Patient Safety Goals (IPSG)
2. Access to Care and Continuity of Care (ACC)
3. Patient and Family Rights (PFR)
4. Assessment of Patients (AOP)
5. Care of Patients (COP)
6. Anesthesia and Surgical Care (ASC)
7. Medication Management and Use (MMU)
8. Patient and Family Education (PFE)
9. Quality Improvement and Patient Safety (QPS)
10. Prevention and Control of Infection (PCI)
11. Governance, Leadership and Direction (GLD)
12. Facility Management and Safety (FMS)
13. Staff Qualification and Education (SQE)
14. Management of Information (MOI)
 PATIENT – CENTERED STANDARDS

1. International Patient Safety Goals

2. Access to Care and Continuity of Care
3. Patient and Family Rights
4. Assessment of Patients
5. Care of Patients
6. Anesthesia and Surgical Care
7. Medication Management and Use
8. Patient and Family Education
HEALTH CARE ORGANIZATION AND
MANAGEMENT STANDARDS
1. Quality Improvement and Patient Safety
2. Prevention and Control of Infections
3. Governance, Leadership, and Direction
4. Facility Management and Safety
5. Staff Qualifications and Education
6. Management of Information
 JCI Standards: PATIENT -
CENTERED
** International Patient
Safety Goals (IPSG)
1. Access to Care and
Continuity of Care
2. Patient and Family Rights
3. Assessment of Patients
4. Care of Patients
5. Anesthesia and Surgical
Care
6. Medication Management
and Use
7. Patient and Family
Education
GOALS:
1.Identify Patients Correctly
2.Improve Effective
Communication
3.Improve the Safety of
High-Alert Medications
4.Ensure Safe Surgery
5.Reduce the Risk of Health
Care-Associated
Infections
6.Reduce the Risk of Patient
Harm Resulting from
Falls
 JCI Standards: PATIENT -
CENTERED
** International Patient Safety • Process of Admission (In
Goals (IPSG)
patient and out patient).
1. Access to Care and
Continuity of Care • Triaging and prioritization
2. Patient and Family Rights of patients.
3. Assessment of Patients • Information on the care.
4. Care of Patients
• Addressing
5. Anesthesia and Surgical
Care Communication barriers.
6. Medication Management • Transferring of Patient.
and Use
7. Patient and Family
Education
 JCI Standards: PATIENT -
CENTERED
** International Patient Safety • Hand over checklists.
Goals (IPSG)
• Health Care team who
1. Access to Care and
Continuity of Care
can access the chart.
2. Patient and Family Rights • Discharge processes,
3. Assessment of Patients instructions and
4. Care of Patients summary.
5. Anesthesia and Surgical • Referral to the
Care community.
6. Medication Management • Ambulance conduction
and Use
policy.
7. Patient and Family
Education
 JCI Standards: PATIENT -
CENTERED
** International Patient Safety • Respect of the patient’s
Goals (IPSG) personal values, beliefs and
1. Access to Care and privacy.
Continuity of Care • Confidentiality of patient’s
2. Patient and Family Rights information.
3. Assessment of Patients • Information on the medical
4. Care of Patients condition.
5. Anesthesia and Surgical • Patient and family
Care participation in care
6. Medication Management processes.
and Use • Advance Directives and
7. Patient and Family DNR.
Education
 JCI Standards: PATIENT -
CENTERED
** International Patient Safety • Organ donation.
Goals (IPSG)
• Clinical research,
1. Access to Care and
Continuity of Care
investigation, or clinical
2. Patient and Family Rights
trials involving human
3. Assessment of Patients
subjects.
4. Care of Patients • Process to receive and
5. Anesthesia and Surgical act on complaints,
Care conflicts, and differences
6. Medication Management of opinion about patient
and Use care.
7. Patient and Family • Informed consent.
Education
 JCI Standards: PATIENT -
CENTERED
** International Patient
Safety Goals (IPSG)
1. Access to Care and
Continuity of Care
2. Patient and Family Rights
3. Assessment of Patients
4. Care of Patients
5. Anesthesia and Surgical
Care
6. Medication Management
and Use
7. Patient and Family
Education
• Screening of patient’s
nutritional status and
functional needs.
• Initial assessment includes
an evaluation of physical,
psychological, social, and
economic factors,
including a physical
examination and health
history.
• Referral of patients who
need additional
specialized assessments.
• Availability of laboratory
services.
 JCI Standards: PATIENT -
CENTERED
** International Patient
Safety Goals (IPSG)
1. Access to Care and
Continuity of Care
2. Patient and Family Rights
3. Assessment of Patients
4. Care of Patients
5. Anesthesia and Surgical
Care
6. Medication Management
and Use
7. Patient and Family
Education
• The care and procedures are
documented within 24 hours
of admission.
• High-risk patients and
services.
• Use of resuscitation
services.
• Immune-suppressed patients
and communicable disease
patients receive care
according to the policies and
procedure.
 JCI Standards: PATIENT -
CENTERED
** International Patient • Addressing end-of-life
Safety Goals (IPSG) care.
1. Access to Care and
Continuity of Care
2. Patient and Family Rights • Assessments,
3. Assessment of Patients reassessments and care
4. Care of Patients of the dying patient.
5. Anesthesia and Surgical
Care • Patients and families
6. Medication Management survivor risk factors and
and Use
bereavement support.
7. Patient and Family
Education
 JCI Standards: PATIENT -
CENTERED
** International Patient Safety
Goals (IPSG)
1. Access to Care and
Continuity of Care
2. Patient and Family Rights
3. Assessment of Patients
4. Care of Patients
5. Anesthesia and Surgical
Care
6. Medication Management
and Use
7. Patient and Family
Education
• Anesthesia services are
available for emergencies
after normal hours of
operation.
• Knowledge of various
modes of sedation,
appropriate monitoring,
response to complications,
use of reversal agents and
basic life support.
• Pre-anesthesia assessment
and pre-induction
assessment.
• Risks, benefits and
alternatives are discussed
by the anesthesiologist.
 JCI Standards: PATIENT -
CENTERED
** International Patient Safety
Goals (IPSG)
1. Access to Care and
Continuity of Care
2. Patient and Family Rights
3. Assessment of Patients
4. Care of Patients
5. Anesthesia and Surgical
Care
6. Medication Management
and Use
7. Patient and Family
Education
• Anesthesia used and
anesthetic technique.
• Patient’s postanesthesia
status is monitored and
documented
• Monitoring findings,
recovery area arrival and
discharge times are
recorded.
• The patient’s
physiological status is
monitored continuously
during surgery and
immediate post surgery
period.
 JCI Standards: PATIENT -
CENTERED
** International Patient Safety
Goals (IPSG)
1. Access to Care and
Continuity of Care
2. Patient and Family Rights
3. Assessment of Patients
4. Care of Patients
5. Anesthesia and Surgical
Care
6. Medication Management
and Use
7. Patient and Family
Education
• Formulary book, to
purchase form, ADR
form.
• Medications are
properly and safely
stored.
• Medications and
chemicals are accurately
labeled with contents,
expiration dates, and
warnings.
• Periodically inspection
of medication storage
areas.
 JCI Standards: PATIENT -
CENTERED
** International Patient Safety
Goals (IPSG)
1. Access to Care and
Continuity of Care
2. Patient and Family Rights
3. Assessment of Patients
4. Care of Patients
5. Anesthesia and Surgical
Care
6. Medication Management
and Use
7. Patient and Family
Education
• Emergency medications
are monitored and
replaced after use or
when expired or
damaged.
• Prescribing, ordering
and transcribing of
medicines.
• Standing Order process.
• Administering of
medicine.
• Medication error and
near miss.
 JCI Standards: PATIENT -
CENTERED
** International Patient Safety • Learning about informed
Goals (IPSG) consent, participation in
1. Access to Care and care decisions and process.
Continuity of Care
2. Patient and Family Rights
3. Assessment of Patients
• Patient and Family
4. Care of Patients
Education Form.
5. Anesthesia and Surgical
Care • Education and training
6. Medication Management
and Use
7. Patient and Family
• Achieving health goals.
Education
 JCI Standards: PATIENT -
CENTERED
** International Patient Safety • Cooperating with available
Goals (IPSG) community resources to provide
1. Access to Care and health promotion and disease
Continuity of Care prevention education.
2. Patient and Family Rights
3. Assessment of Patients • Education methods consider the
patient’s and family’s values and
4. Care of Patients
preferences and allow sufficient
5. Anesthesia and Surgical interaction for learning to occur.
Care
6. Medication Management
• Collaboration of health
and Use
professionals.
7. Patient and Family
Education
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Clinical pathways.

and Patient Safety • Monitoring the
2. Prevention and Control organization’s clinical
of Infections and managerial
3. Governance, structures, processes,
Leadership, and and outcomes and the
Direction International Patient
4. Facility Management Safety Goals.
and Safety
• Managing sentinel
5. Staff Qualifications and events and conducting
Education of Root Cause Analysis.
6. Management of
Information
• Sentinel Events
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Identification and

and Patient Safety analysis of near-miss
2. Prevention and Control events.
of Infections
3. Governance, • Identifying high-risk
Leadership, and areas in terms of
Direction patient and staff
4. Facility Management safety.
and Safety
• Proactive risk-
5. Staff Qualifications and
Education
reduction tool.
6. Management of
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Reducing the risk of health

and Patient Safety care-associated infections in
2. Prevention and patients and health care
Control of Infections workers.
3. Governance, • Precautions and PPE Use
Leadership, and • Equipment cleaning and
Direction sterilization methods in a
4. Facility Management central sterilization service.
and Safety
5. Staff Qualifications and
Education
6. Management of
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Infection risk, infection

and Patient Safety rates, and trends in
2. Prevention and health care-associated
Control of Infections
infections.
3. Governance,
Leadership, and • Gloves, masks, eye
Direction protection, other
4. Facility Management protective equipment,
and Safety soap, and disinfectants.
5. Staff Qualifications and
Education
6. Management of
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Organization chart or

and Patient Safety document.
2. Prevention and Control • Those responsible for
of Infections governing are identified by
title.
3. Governance,
Leadership, and • Those responsible for
Direction
governance approve the
mission statement, policies
4. Facility Management and plans, and appoint the
and Safety senior managers or
5. Staff Qualifications and directors.
Education • Day-to-day operations.
6. Management of
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Providing direction for each

and Patient Safety department or service in the
2. Prevention and Control
organization.
of Infections
3. Governance, • Recommending space,
Leadership, and staffing and criteria for
Direction
staff.
4. Facility Management
and Safety • Providing orientation and
training for all staff and
5. Staff Qualifications and monitor the department’s
Education performance.
6. Management of
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Safety and Security,

and Patient Safety Hazardous materials,
2. Prevention and Control
Emergencies, Fire safety
and Medical Equipment.
of Infections
• Monitoring program that
3. Governance, provides data on incidents,
Leadership, and injuries, and other events
Direction that support planning and
4. Facility Management further risk reduction.
and Safety • Inspecting all patient care
5. Staff Qualifications and buildings, reducing evident
Education risks and providing a safe
6. Management of
physical facility.
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Inventory, handling,

and Patient Safety storage, and use of
2. Prevention and Control
hazardous materials and the
control and disposal of
of Infections
hazardous materials and
3. Governance, waste.
Leadership, and • Material Safety Data Sheet.
Direction
• The identification and
4. Facility Management assignment of staff roles
and Safety and responsibilities during
5. Staff Qualifications and an event.
Education
6. Management of
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Testing of emergency water

and Patient Safety and electrical systems on a
2. Prevention and Control
regular basis.
of Infections
3. Governance, • Inspection and
Leadership, and maintenance of electrical,
Direction
waste, ventilation, medical
gas, and other key systems
4. Facility Management
and Safety
5. Staff Qualifications and
Education
6. Management of
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Desired education, skills,

and Patient Safety knowledge, and other
2. Prevention and Control
requirements of all staff
members.
of Infections
• Job Description.
3. Governance,
Leadership, and • Processes for recruiting,
Direction
evaluating, and appointing
staff.
4. Facility Management
• Evaluation of each staff
and Safety member.
5. Staff Qualifications
and Education
6. Management of
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • 201 Files.

and Patient Safety
2. Prevention and Control • Staff members receive
of Infections ongoing in-service and
3. Governance, other education and training
Leadership, and to maintain or advance his
Direction
or her skills and knowledge.
4. Facility Management
and Safety
5. Staff Qualifications
and Education
6. Management of
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Annual performance review

and Patient Safety of the practitioner.
2. Prevention and Control
of Infections • Gathering, verifying, and
3. Governance, evaluating the nursing
Leadership, and staff’s credentials (license,
Direction
education, training, and
experience).
4. Facility Management
and Safety
5. Staff Qualifications
and Education
6. Management of
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Endorsements during each

and Patient Safety staffing shift, and between
2. Prevention and Control
shifts.
of Infections
3. Governance, • Patient’s records.
Leadership, and
Direction • Discharge Summary and
4. Facility Management Clinical Abstract.
and Safety
5. Staff Qualifications and • Information privacy and
Education confidentiality
6. Management of
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Policy on the retention time

and Patient Safety of records, data and
2. Prevention and Control
information.
of Infections
3. Governance, • Using standardized
Leadership, and diagnosis codes, procedure
Direction
codes, symbols,
abbreviations and
4. Facility Management definitions.
and Safety
5. Staff Qualifications and
Education
6. Management of
Information
 JCI Standards: HEALTH CARE ORGANIZATION &
MANAGEMENT

1. Quality Improvement • Records and information

and Patient Safety are protected from loss,
2. Prevention and Control
destruction, tampering, and
unauthorized access or use.
of Infections
3. Governance,
Leadership, and • Identifying those authorized
Direction
to make entries in the
patient clinical record
4. Facility Management
and Safety
5. Staff Qualifications and
Education
6. Management of
Information
 Patient - Centered Health Care Organization &
Management

1. International Patient Safety 1. Quality Improvement and

Goals (IPSG) Patient Safety
2. Access to Care and Continuity
2. Prevention and Control of
of Care
Infections
3. Patient and Family Rights
3. Governance, Leadership,
4. Assessment of Patients
and Direction
5. Care of Patients
4. Facility Management and
6. Anesthesia and Surgical Care
Safety
7. Medication Management and
Use 5. Staff Qualifications and
8. Patient and Family Education Education
6. Management of
Information