Joint Commission International
Oak Brook, Illinois, USA
The process of external quality evaluation against consensus healthcare standards, commonly referred to as “Accreditation”, is one of the most effective means for standardising care processes in healthcare organisations. The accreditation process focusses on the functions and processes that support quality, safe care, and thus facilitates the use of the best science and professional knowledge and skills. There are few settings in the contemporary acute care hospital that can benefit more by this process standardisation than in fast paced critical care and intensive care medicine units. Standardisation through accreditation is a powerful risk reduction strategy proven effective around the world.
Joint Commission International (JCI), one of the oldest and largest accreditation bodies in the world has recently updated its’ accreditation standards to focus even more on patient safety. These updated international standards incorporate lessons learned since 2003 from the 140 hospitals in 26 countries accredited by JCI. There are currently 323 standards that hospitals must meet to receive accreditation. These standards allow for cultural differences while still requiring hospitals to standardise and provide patient care that promotes safety and quality. The accreditation is for a period of three years and therefore the implementation of standards must result in sustainable good practices.
Unlike some high reliability industries, such as air traffic control, healthcare has lacked standardisation across the globe. It is important to change that by helping hospitals around the world learn a common healthcare language, which promotes safety and consistency in the delivery of care.
Examples of changes to current standards that will reduce risk and improve quality in all units of a hospital include:
• More stringent requirements for how hospitals verify credentials of healthcare providers. It is no longer sufficient for a hospital to simply gather diplomas and certificates, they must be validated with the granting institution, including the validation of credentials from critical care medicine programs;
• New medication use standards for reporting and learning from errors and near misses to address the significant rise in medication errors in all units of hospitals, in particular emergency departments, where 70% or more of patients are given a medication;
• Enhanced protection of patient’s rights to ensure that every patient and their family are educated about their care in a language which they understand and thus can appropriately participate in their care decisions including the granting of informed consent through a process effective in emergency and critical situations; and
• Emphasis on ensuring healthcare organisations provide uniform care 7 days a week, 24 hours a day. Care provided on weekends and in the middle of the night must meet the standards as well.
In addition, there are standards changes that even more directly impact the standardisation of care, and thus the safety of care, in critical care units and in emergency services. For example, the clear and timely “hand-off” of critical information is one of the most important factors in safe care. This hand-off can be from the emergency department to the operating theatre, from the operating theatre to the critical care unit, and also from physician to physician, from nurse to nurse and many more combinations.
A 2006 survey by the Joint Commission showed that the most important information to hand-off correctly is the current condition of the patient (Joint Commission 2007). However, in most organisations, transfers use unclear language, are not standardised, are frequently done in noisy, busy environments and may be a mix of verbal, electronic and written information. Similarly, poor communication is cited 65% of the time as the root cause of treatment delays (Joint Commission 2007), as many of those treatment delays begin in overcrowded emergency departments.
As communication is complex, standards address effective communication through a variety of means, such as by focussing on the elimination or reduction of risk in processes known to frequently fail. For example, standards propose the following actions:
• Eliminating confusing abbreviations and stan dardisation of the format for indicating drug dosages,
• Writing down and reading back of verbally given drug orders,
• Reporting of critical test results, and
• Standardising information that is transferred with the patient from unit to unit in the hospital.
JCI standards describe the important “functions” and “processes” in an organisation that support safe, quality care. These include patient rights, patient assessment and care, patient education, infection control, quality management, and others. Thus, there is no chapter devoted to an emergency services department or critical care unit as all these functions apply. To evaluate the standards, we conduct an on-site survey with a team of three professionals, typically a doctor, nurse, and administrator. Although visits are currently announced, unannounced surveys are foreseen in the near future.
To begin the on-site evaluation process, surveyors (evaluators) use a “tracer” methodology where they select eight or more patients and examine their healthcare services from the time they enter the hospital until they are discharged. It is vitally important to examine how hospital departments work together to create positive outcomes for patients rather than survey each department separately as discrete units within the organisation. This process takes between three and five days. Before leaving the hospital, the survey team has a conference with hospital administrators and provides a preliminary report on how the organisation fared in the survey. As many of the patients “traced” are complex cases, they frequently enter the hospital through the emergency services department and involve a stay in a critical care unit. Thus, these units are integral to the evaluation process.
The mission of JCI is to improve the safety and quality of patient care in the international community. As not all organisations in a country will seek JCI accreditation, it is also important for JCI to be actively involved in helping countries around the world develop their own quality and safety evaluation programs. Through partnerships with ministries of health, many countries are adapting or adopting the standards while others have used our accreditation format and evaluation methodology as template for their own accreditation programs.
Although our reports are all confidential, we list hospitals receiving accreditation on our website. For more information on JCI, its new standards and other publications, and our accredited hospitals, please visit our website at www.jointcommissioninternational. com.