JCIA Update

(April May 2011)

 KFSH&RC Mission
KFSH&RC provides the highest
level of specialized healthcare in
an integrated education and
research setting.
It is important to have a culture of :
Quality
Patient safety
Continuous Improvement

JCIA accreditation is designed to create that culture.

 Objectives

2008 JCIA survey visit findings

Standards Changes

Medical Quality Directors Role

 2008 JCIA Survey visit findings

4
 2008 JCIA Survey visit findings
Documentation

H&P form (Admission Notes) use.

Procedural Sedation Assessment form

completion (Endoscopy).

Pain documentation.

D4 Chronic Patients Weekly Assessment.

 2008 JCIA Survey visit findings
Documentation

Authentication of telephone orders.

PRN order for Restraint.

Inconsistency in ASA score documented for

the same patient.

Renewed orders completion (e.g. cont

fentanyl)
 2008 JCIA Survey visit findings
Documentation

Consultants co-signature on Residents

entries as hospital policy states

Date documentation in the progress notes

Significant Medical Record Documentation

issues: Timeliness, Eligibility, Completeness
 2008 JCIA Survey visit findings

Practice & Documentation

ASA Score of III accepted for procedural

sedation in Outpatient w/o explanation

Inconsistency in the location of documenting

site marking (tooth) in dental clinic

Patient discharged from post anesthesia unit

w/o physician order
 Standards Changes

Quality Management is currently

working with concerned departments
and staff to implement the required
policies & processes for the standards
changes
 At least 5 Clinical
Measures
should be chosen from
(International Library of International
Measures) Library of Measures

Heart Failure (HF)

Stroke (STK)
Childrens Asthma Care (CAC)
Hospital-Based Inpatient Psychiatric Services (HBIPS)
Perinatal Care (PC)
Pneumonia (PN)
Surgical Care Improvement Project (SCIP)
Venous Thromboembolism (VTE)
Acute Myocardial infarction (AMI)
Nursing Sensitive care (NSC)
 Standards Changes
(International Patient Safety Goals (IPSG))

IPSG stay the same but more emphasis on monitoring

1. Identify Patients Correctly
2. Improve Effective Communication
3. Improve the Safety of High-Alert Medications (IPP list)
4. Ensure Correct Site , Correct- Procedure , Correct
Patient Surgery
5. Reduce the Risk of Health Care Associated Infections
6. Reduce the risk of patient harm resulting from falls
(High Alert Medication Policy)
(High Alert Medication Policy)
 Standards Changes
Standards Changes
(Patient and Family Rights PFR)
Patients right to seek a second opinion without fear

Consent is obtained in a language the patient can

understand

Process to respond to patients request for additional

information on the practitioner

The organization obtains informed consent from live

donors
 Standards Changes
Standards Changes
(Patient and Family Rights PFR)
Patients right to seek a second opinion without fear

Consent is obtained in a language the patient can

understand

Process to respond to patients request for

additional information on the practitioner

The organization obtains informed consent from

live donors
 Standards Changes
(Access to Care and Continuity of
Care ACC)

Patients with emergent, needs are given priority for

assessment and treatment.
The clinical records of outpatients receiving continuing
care contain a summary of all significant diagnoses,
drug allergiesetc
Follow-up process for patients who leave against
medical advice.
Planning to meet the patients transportation needs.
Medication reconciliation upon admission.
 Standards Changes
(Care Of Patient COP)

The planned care is documented in the record in

the form of measurable progress (goals) & updated
based on assessment

The care planned is reviewed and verified by the

responsible physician.
 Standards Changes
(Aesthesia & Surgical Care ASC)

The post-surgical plan is documented by the

responsible surgeon or verified by the responsible
surgeon

The plans of care are documented within 24 hours

of surgery.

The anesthesiologist are identified in the patients

anesthesia record.
 Standards Changes
(Staff Qualification and Education-SQE)

Each medical staff member provides only those

services that have been permitted by the
organization.

Have a uniform process (defined by organization

policy for ongoing professional practice evaluation &
(at least) annual review on quality & safety of
services
 Standards Changes
(Staff Qualification and Education-SQE)

Uses comparative data such as benchmarking to

literature-based medicine.

Use conclusions of in-depth analysis of known

complications as applicable.

Feedback to staff.
 Your role as a Quality Director

Reinforce the following to department members:

Patient Safety.
Safety reporting (SRS).
Applying Infection Control Measures.

Promote the Just culture.

 Your role as a Quality Director

Documentation :
(Not documented, Not completely done !!)
Identify documentation compliance issues in your
area (i.e. insufficient computers, training..etc ) and
work with Chairman for solutions.

Review tracer reports & Quarterly documentation

reports. Discuss results with the concerned staff.
 Your role as a Quality Director

Medical Staff files, Ensure that :

Staff privileges are up to date

Saudi Commission registration completed

Life Support certification is completed

Fire training completed

Reference: Joint Commission
International Accreditation Hospital
Evaluations Survey Process Guide
Page 67
 Your role as a Quality Director

Departmental education on :

New JCIA standards

Hospital policies related to physicians.

Quality Management Educational Role

Help directors to provide JCIA visit update in

departments meetings.

Provide Educational material for directors.

Prepare Readiness Tips.

Thank You