CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN,...
Transcript of CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN,...
![Page 1: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/1.jpg)
CSSD Vision on JCI Accreditation
Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel
![Page 2: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/2.jpg)
Haifa
![Page 3: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/3.jpg)
![Page 4: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/4.jpg)
Healthcare Accreditation
Hospital accreditation is an assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve
The accreditation process is becoming a common practice all over the world
![Page 5: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/5.jpg)
The Benefits of Accreditation
Comprehensive analysis of the hospital’s Strengths Weaknesses Opportunities Threats
Continuously improvement of safety and quality of care
Performance improvement Hospital prestige – a hallmark of quality
![Page 6: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/6.jpg)
Paradigm ShiftTraditional Contemporary
Information is a record Knowledge is shared and information flows freely
Decision making is based on training and experience
Decision making is based on evidence
“Do no harm” is an individual responsibility
Safety is a system property
Secrecy is necessary Transparency is necessary
The system reacts to needs Needs are anticipated
Cost reduction is sought Waste is continuously decreased
![Page 7: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/7.jpg)
Contemporary Paradigm
Comprehensive quality analysis health care is a series of systems and
subsystems Identifying “defects” within the system(s),
will reduce errors which may harm patient safety
![Page 8: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/8.jpg)
Our Experience
In November 2008 our hospital was surveyed by Joint Commission International (JCI) experts.
![Page 9: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/9.jpg)
The Survey
Documents review
Interviews with management
Patient tracer
System tracer
![Page 10: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/10.jpg)
TracersA methodology to assess an organization’s systems and processes by
Following the treatment path an individual patient has taken in the
hospital
Following a process in the hospital from a beginning to an
endpoint
Patient tracer System tracer
![Page 11: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/11.jpg)
System Analysis
Set of components that work together toward a common goal
Evaluation of how and how well the organization’s systems function
Examination of interrelationships of elements
Translates standards compliance issues into potential vulnerabilities related to patient quality and safety
![Page 12: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/12.jpg)
Survey Parameters Access to care (ACC) Patient and Family Rights (PFR) Assessment of Patient (AOP) Care of Patients (COP) Medication Management and Use (MMU) Patient and Family Education (PFE) Anesthesia and Surgical Care (ASC) Quality improvement and patient safety (QPS) Prevention and control of infections (PCI) Governance, leadership, and direction (GLD) Facility management and safety (FMS) Staff qualifications and education (SQE) Management of Communication and Information (MCI) International Patent Safety Goals (IPSG)
![Page 13: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/13.jpg)
Tracer Method
Walk around in the hospital facilities A multidimensional survey Observations, conversations Information cross checking
![Page 14: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/14.jpg)
Theoretical Background
Quality as a multi-dimensional concept More than one reason for assessing
quality The purpose of some quality surveys are
often not linked to the dimensions or parameters
![Page 15: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/15.jpg)
Tracers vs. Surveys Tracers Surveys &
inspectionsAssessment tool Non Structured
Bias or error Tracer’s judgment Subjects’ preparedness
Interpretative synthesis
Multi dimension explanatory claims
Strict results
Demonstration of employees’ knowledge
Possible if questions are asked
Possible If a knowledge test is carried out
![Page 16: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/16.jpg)
The Benefit of Tracers
Patient Staff Organization
Improves Safety and Quality of care
Improves patient flow
Encourages team building
Creates systems thinkers
Creates a better understanding of each other’s roles
Reduces risk to patients
Increases patient satisfaction
Fosters systems improvement
![Page 17: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/17.jpg)
CSSD in Focus
During the systems and patients tracers CSSD function and materials are being brought into focus
The survey creates a multidimensional matrix of parameters that provided us introspective insight of our department
![Page 19: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/19.jpg)
Information Cross-Checking
We have standards
We have an expected product quality level
We have educated our staff
We have a storage policy (FIFO…)
Employees are not aware to some of the guidelines
Our customers are not aware about it
Our staff has no official qualification
Expired materials were found in the wards
Yes But
![Page 20: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/20.jpg)
Quality Matrix
IC
ASC COP
PFR
FMS
PFE
QPS
AOP
AAC
MMU
IPSG
GLD PCI SQE
Systems
Patient care
Patient safety goals
![Page 21: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/21.jpg)
The Matrix Enables
A logical multi-step process Its milestones are essentials for quality and
patient Safety
Each system may be examined with several (relevant) parameters of the matrix
A multidimensional view
![Page 22: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/22.jpg)
A Multidimensional ViewIC
ASCCOP
PFR
FMS
PFE
QPS
AOP
AAC
MMU
IPSG
GLD PCI SQE
SQE
ASC
QPS
PCI
FMS
GLD
CSSD
![Page 23: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/23.jpg)
A Multidimensional View
SQE
ASC
QPS
PCI
FMS
GLD
CSSD
Do we protect our employees
Do we follow
guidelines
Is our equipment
reliable
Is our staff qualified
Do we support surgery
well?Do we
maintain a quality system
![Page 24: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/24.jpg)
SWOT Analysis
Strengths Weaknesses Opportunities Threats
![Page 25: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/25.jpg)
GLD- Governance & Leadership
S
T
W
O
Good understanding of CSSD importance
A desire to increase number of surgeries
No allowance for extra work force
Suggestions to shorten turnaround time
![Page 26: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/26.jpg)
PCI – Prevention & Control of Infections
S
T
W
O
Awareness to emerging nosocomial diseases
Constant attempts to revive reuse of SUD’s
Complying to international standards
Not enough resources for renovations & materials
Still using fabrics as wrappers
![Page 27: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/27.jpg)
SQE – Staff Qualification & Education
S
T
W
O
A tendency to solve HR problems in CSSD
Experienced staff Aging staffOn the job trainingA long training time for new employees
Growing awareness to educational needs
![Page 28: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/28.jpg)
FMS - Facility Management & Safety
S
T
W
O
Proper CSSD design
Small space Poor steam qualityNo tracking system
Not enough resources for further improvements
Promote a safety environment
![Page 29: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/29.jpg)
QPS - Quality Improvement & Patient safety
S
T
W
O
Have a quality systemTransparency
No tracking of sets
Current quality processes may include CSSD
Missing items during surgery or timeout may inflict the department prestige
![Page 30: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/30.jpg)
Outcomes
![Page 31: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/31.jpg)
A Plan
Describes the structure of the department Details processes
Flowcharts Risk areas
Interventions: change
![Page 32: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/32.jpg)
Load Release
Cycle end
Inspect printout
Open door
Inspect load
Dry, external indicators pass
Inspect PCD
Validated system
Knowledge
Knowledge
Consistency
Failed cycle
Criteria?
Wet
False negativ
e
Process Tools Risk areas
![Page 33: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/33.jpg)
ExampleTask Guidelines Safety
guidelinesInfection control issues
Other issues
Autoclave operation
1. 2.. 3…4…..
a..b…c….
1.2,3,
I. 2II. 1III. 3
Load release 1. 2.. 3…4…..
a..b…c….
1.2,3,
I. 2II. 1III. 3
Job
Description
![Page 34: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/34.jpg)
From Job Description to Qualification
Task OrientationDate
Working under supervision
Performance evaluation
Qualification(able to work independently)
Autoclave operation
dd/mm//yy dd/mm/yy till dd/mm/yy
dd/mm/yy
Load release
dd/mm//yy dd/mm/yy till dd/mm/yy
dd/mm/yy
![Page 35: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/35.jpg)
From Qualification to EvaluationTask 1st month
evaluation6th month evaluation
12th month evaluation
Further evaluations
Autoclave operation
Load release
HR
Decisions
![Page 36: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/36.jpg)
Tracers Course
Recently some of our quality team have graduated tracers course
An opportunity to learn more
![Page 37: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/37.jpg)
Summary
The consultation and mock survey provide systematic input
A a multidimensional profile of our department A different point of view – a new perspective A chance for change and improvements
![Page 38: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/38.jpg)
Summary
The process has guided us to be ready for the next patient and not just for the next survey
![Page 39: CSSD Vision on JCI Accreditation - · PDF fileCSSD Vision on JCI Accreditation Yaffa Raz, RN, BA, CSSD Manager Lady Davis Carmel Medical Center, Haifa, Israel](https://reader034.fdocument.pub/reader034/viewer/2022050703/5a9673467f8b9a18628d0f6f/html5/thumbnails/39.jpg)
Thank you