Joint Commission International - Siriraj · PDF fileJoint Commission. International. Why JCI?...
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Transcript of Joint Commission International - Siriraj · PDF fileJoint Commission. International. Why JCI?...
Joint CommissionInternational
Why JCI?Why JCI?
The U.S., Canada, and Australia have the oldest accreditation systemsIn Europe, Germany, France, Ireland and Spain have new accreditation systemsIn Japan, Korea, Malaysia, and Thailand there are new systems with government roleThe WHO, World Bank and development banks recognize and endorse the accreditation model
Accreditation A World Trend
Since 1910 1917 1951 Since 2000
JCR WHO Collaborating Center JCR WHO Collaborating Center forfor
Patient Safety SolutionsPatient Safety Solutions
TurkeyTurkey1. Istanbul Memorial Hospital
Accredited: 29 March 2002 Re-accredited: 29 April 2005 2. Vehbi Koc Foundation American Hospital
Accredited: 15 December 2002 Re-accredited: 16 December 2005 3. Metropolitan Florence Nightingale Hospital
Accredited: 26 June 2003 4. Dnya Eye Hospital
Accredited: 17 April 2004 5. Medline Alarm Salk Hizmetleri A..
Accredited: 28 April 20056. CardioCheck Grntleme Merkezi
Accredited: 10 December 20057. Private Vehbi Koc Foundation Italian Oncology and Rehabilitation Hospital
Accredited: 16 December 2005 8. Acibadem Healthcare Group Accredited: 3 June 20069. Kent Hastanesi Accredited: 10 June 200610.Mesa Hastanesi Accredited: 1 July 200611.Bayindir Hospital Accredited: 15 July 2006
SingaporeSingapore
1. National University Hospital Accredited: 1 August 20042. Johns Hopkins Singapore International Medical Centre
Accredited: 4 August 2004 3. Changi General Hospital Accredited: 11 June 20054. Singapore General Hospital Accredited: 16 July 20055. Alexandra Hospital Accredited: 22 July 20056. Institute of Mental Health/Woodbridge Hospital
Accredited: 29 July 20057. Tan Tock Seng Hospital Accredited: 6 August 20058. National Heart Centre of Singapore Accredited: 27 October 20059. KK Women's and Children's Hospital Accredited: 9 December 200510. Gleneagles Hospital Accredited: 27 May 200611. Mount Elizabeth Hospital Accredited: 3 June 2006
IndiaIndia
1. Indraprastha Apollo Hospital Accredited: 18 June 20052. Wockhardt Hospital, Mumbai Accredited: 26 August 20053. Apollo Hospital, Chennai Accredited: 29 January 20064. Shroff Eye Hospital Accredited: 18 February 20065. Apollo Hospital, Hyderabad Accredited: 28 April 20066. Asian Heart Institute Mumbai Accredited: 20 October 2006
Republics of ChinaRepublics of China• Clifford Hospital Accredited: 20 December 2003 • Beijing United Family Hospital and Clinics
Accredited: 1 September 2005• Hong Kong Adventist Hospital
Accredited: 25 February 2006• Tsuen Wan Adventist Hospital Accredited: 3 March 2006
DCSC for Acute Stroke: 29 April 2006
TaiwanTaiwan• Min-Sheng General Hospital Accredited: 15 July 2006• Taipei Medical University-Wan Fang Medical Center
Accredited: 22 July 2006
QatarQatar
1. Hamad General Hospital Hamad Medical Corporation Doha, Accredited: 15 September 2006
2. Al Khor Hospital Hamad Corporation Doha, Accredited: 15 September 2006
3. Rumailah Hospital Hamad Medical Corporation Doha, Accredited: 22 September 2006
PhilippinesPhilippines
1. St. Luke's Medical Center Accredited: 22 November 2003
ThailandThailand
1. Bumrungrad International Hospital Accredited: 2 February 2002 Re-accredited: 8 April 2005 Focus survey: 10 December 2006
Public Sector Quality Public Sector Quality AwardsAwards
Thailand Quality AwardsThailand Quality AwardsSQASQA
Strategy Deployment HR Focus
ProcessManagement
Customer &Market Focus
Business/Business/Organization Organization
ResultsResults
UKUKQAQA
Total Quality Management
MMalcolmalcolm BBaldrigealdrige NNationalational QQualityuality AAwardward
MBNQAMBNQA
JJQAQA EEQAQA
Singapore Quality Award
European Quality Assurance
Japan Quality Award
UK Quality Award
Leadership Information& Analysis
World class
JJCIACIA
Joint commissionInternational Accreditation
HA 2006 JCIA 2008
Clinical Tracer of QualityHA-Thailand PSGs
Tracer Methodology/DSC2007 IPSGs
HAStandard
JCI Standard
3C- PDSA
Innovation
KMKMMng
PI/CQI
Safety
Pt careprocess
QA
HA and JCI
JCI StandardJCI Standard
HA Standard
HA and JCI
JCI Standard
QA QA (Process)
PICQI
ToolTool/KM
HA Standard
HA and JCI
JCI Standard
Unit Daily JOB responsibility
TrainingEducation
Team
P&PLeader
HA Standard
HA and JCI
JCI StandardJCI Standard
HA Standard
HA and JCI
Patient Tracer
• Follows the care and needs of the patient
An Overview of care as a System
Mesosystem
Macrosystem
Microsystem
The Whole
Work Units
Clinics
The System
of
Care
Lean
Con
sumpti
on
User F
riend
lyan
d
Oriente
d
Teamness
Everyone Is Involved and Optimizes the Processes in the System
Change Occurs at All Levels
CARE SYSTEM
IMPACT Theory
Leadership and System
Transformation
Improvement on the front
lines
Joint Commission InternationalJoint Commission International-- Accreditation Accreditation PhilosophyPhilosophy
Process stimulates continuous improvement
Maximum achievable standardsMaximum achievable standards
PatientPatient--centeredcentered
Culturally adaptableCulturally adaptable
External, objective evaluation : 1,032 MEUses consensus standards : fields reviewInvolves the health professions : microsystemProactive not reactive eg. OpenMRR, processOrganization wide : tracer methodologyFocus on systems not individuals : P&P, TrainingStimulates quality culture in the organization : disciplinePeriodic re-evaluation against standards : PI
Strengths of Accreditation
Components of Standards Development
Multiple Information SourcesScientific literatureSurvey compliance dataResearch FindingsIndividual input from field experts and key stakeholders
Benefits for the Hospital
Improves care and enhances public confidenceStimulates continuous improvementDemonstrates commitment to quality careRaises community confidenceComparison with self and other similar organizations
Benefits for the Medical Staff and Nursing Staff
Improves professional staff developmentProvides education on consensus standardsProvides leadership for quality improvement within medicine and nursingIncreases satisfaction with working conditions, leadership and accountability
JAMA,111 (4) July 23, 1938,Page 327
1938 or 2005?
What do you mean: „Don’t expect miracles“?Why shouldn’t I expect miracles?
Benefits for Hospital Employees
Values employee opinions Measures employee satisfactionInvolvement in quality activitiesImproved employee safety and securityClearer lines of authority and accountabilityPromotes teamwork
TeamworkTeamwork
Benefits for Patients
Access to a quality focused organizationRights are respected and protectedUnderstandable education and communicationSatisfaction is evaluatedInvolvement in care decisions and care processFocus on patient safety
Characteristics of Excellent Hospitals
Patient centered with good customer serviceCoordinated and efficient care processesSafe, low risk facility and environmentStaff with good skills and knowledgeQuality culture supported by leaders and managersUse standards and guidelines to continually improve safety and quality of care and the environment
University Hospital
< 1,000 Beds
1. Clínica Universitaria de Navarra Navarra, Spain Accredited: 29 May 2004
2. National University Hospital, Singapore Accredited: 1 August 2004 928 Beds
3. Aga Khan University Hospital Karachi, Pakistan Accredited: 8 July 2006
4. Taipei Medical University-Wan Fang Medical Center, Taiwan Accredited: 22 July 2006 800 Beds
Nurse Smart & Professionalism
EngagementDoctor
Buy inLeader
Key Success Factor
Human as well as technical factors and processes
The science and
technology of improvement
The sociology and organisation of improvement
Scorecards, metrics, measurement systems and technology, clinical
pathways, EBM
Organisation, culture, language & cognition, identity,
leadership, structure, strategy, citizenship
etc
Dec 2006 23-26 Jan 2007Jan 2007Nov 2006
Review status
F/U Progression Focus on Core Standard Compliance meet to Mock Surveys Recommendations
ConclusionConclusion
Action Plan TimeframeAction Plan Timeframe
Mid-Point Strategies/Dec 15,06Continuous Performance reviewContinuous Performance review
Education Team StaffEducation Team Staff
Detailed Project Plan / Policies and Procedures redesign
Preparation along with Survey Process GuidePreparation along with Survey Process Guide
IQA
15
27-30
10
สรุปผลสรุปผล IQA IQA ตามตาม
JCIJCI
StandardStandard--22ndnd EditionsEditions
71%
29%
Partially met
Not met
ผลผล IQA IQA ของของ Samitivej SukumvitSamitivej Sukumvit
155
110
165
319
49
73
0
7666
3
87
6254
37 3826
6 09 3 0 5
0
50
100
150
200
250
300
350
Partially met Not met
ACC
PFR
AOP
COP
PFE
QPS
GLD
FMS
SQE
MOI
PCI
ผลผล IQA IQA ของของ Samitivej SukumvitSamitivej Sukumvit
JCI No. Fully Met Partially Met Not Met
Chapter 11 3 7 None
Standards 368 360 8 None
ME 1,032 1,011 21 None
Core 95 86 9 None
Non Core 273 259 12 None
Average =98.99% Core =9.5 Non-core=9.7
Healthcare Consultants -
Gooch &
Associates provides JCAHO ...Please visit our International Section.
A client in Turkey achievedan unofficial score of 99.5%99.5%
compliance on their initial JCI accreditation survey,
...
www.gooch-inc.com/ - 10k - หนาที่ถูกเก็บไว - หนาทีค่ลายกัน
ดังนั้นดังนั้น
Support different situations
by
specific tools
Quality Management (Excellent) Center Quality Management (Excellent) Center
INPUT PROCESS OUTPUT
•
Manpower
•
Material
•
Infrastructure
•
Mgt. system
•
MIS
Quality Mgt. System
•
Hospital Accreditation•
JCI Accreditation
•
Referral & Network Development
•
Hospital outcome
•
Quality Indicators
•
Quality Audit•
Satisfaction
Quality Control System
รพ. HA JCIA ReAcc
HA
JCIA
HA
JCIA
We care
Healing EnvironmentHealing Environment
NHS Estates: Improvement Patient Experience
สังคมตะวันตก
ความสุขเกิดจากการมีชวีิตที่ประสบความสําเรจ็ สุขภาพดี,มีฐานะ ทางเศรษฐกจิ และครอบครวัที่มั่นคง
“American dream..” ทําทุกอยางเพื่อใหไดเงินมีฐานะ, มีชื่อเสียง
ทางพุทธศาสนา ไมไดพูดถึงความสขุโดยตรง แต พูดถึงความทกุข ถามีความทุกขนอยคนจะมีความสุข
สังคมตะวันออก
Martin Seligman – พูดถึง Happiness วาประกอบดวย
Positive emotion
Positive activities.
ทางจิตวิทยาทางจิตวิทยา (POSITIVE PSYCHOLOGY)
และ
GNH GNH –– Gross National HappinessGross National Happiness
เริ่มโดยกษัตริยเริ่มโดยกษัตริย JigmeJigme SingheSinghe WangchukWangchuk
ขึ้นครองราชในปขึ้นครองราชในป พพ..ศศ.. 25152515
มีแนวคิดในการยึดนํามีแนวคิดในการยึดนํา ศาสนาศาสนา วฒันธรรมและวิถีชีวิตวฒันธรรมและวิถีชีวิต
ความเปนอยูมาเปนหลกัในการพัฒนาประเทศมากกวาความเปนอยูมาเปนหลกัในการพัฒนาประเทศมากกวา
มองเรื่องตัวเลขทางเศรษฐกิจมองเรื่องตัวเลขทางเศรษฐกิจ
"เจาชายวังชุก" พระราชอาคันตุกะ ผูทําให ''ภูฏาน'' เดนชัดบนแผนที่โลก
(six H plus) Human +Happiness +Humour +Help +Hope +Health +
ของ Edward de Bono
เปนหลัก 6 ประการ ในการดํารงชวีติอยางมีความสุข
Labor of LoveLabor of Love
Humanized Birth
Question?Question?
