Joint Commission

International
 JOINT COMMISSION
INTERNATIONAL
Joint Commission International (JCI) is a
division of Joint Commission Resources (JCR),
the subsidiary of the Joint Commission on
Accreditation of Healthcare Organizations
(JCAHO). Its mission is to continuously
improve the safety and quality of care in the
international community through the
provision of education and consultation
services and international accreditation.
Evolution of the Joint Commission

• 1910 – 1913: Concern for the quality of hospital care in the U.S.
• 1910: Ernest A. Codman, M.D., focused on results & outcomes of
treatment.
• 1918: American College of Surgeons began Hospital Standardization
Program.
• 1951: Joint Commission on Accreditation of Hospitals (JCAH) formed
to continue the challenge.
• 1965: Social Security Act Ammendments added credibility to the
JCAH’s functions.
• 1987: JCAH renamed as Joint commission for Accreditation of
Healthcare Organisations (JCAHO) to widen the scope
• 1999: Joint Commission International (JCI) launched International
Accreditation Programmes.
 JCI Accreditation
According to JCI, accreditation is a process in which an entity, separate
and distinct from the health care organization, usually non-
governmental, assesses the health care organization to determine if it
meets a set of standards designed to improve quality of care.
Accreditation is usually voluntary and standards are usually regarded
as optimal and achievable. Accreditation also provides a visible
commitment by an organization to improve the quality of patient care,
to ensure a safe environment and to continually work to reduce risks to
patients and staff.

Joint Commission launched its international accreditation program in

1999. Its standards are based on international consensus standards and
set uniform, achievable expectations for structures, processes and
outcomes for hospitals. The accreditation process is designed to
accommodate specific legal, religious and cultural factors within a
country.
JCI provides four accreditation programs:

• International Standards for Hospitals.

• International Clinical Lab Standards.
• International Standards for the Care Continuum.
• International Standards for Medical Transport
Organizations.
MISSION
• The mission of Joint Commission International (JCI) is to improve the safety and quality of care in
the international community
SERVICES OF JCI
• Advance certification
• Hospitals
• Ambulatory healthcare
• Behavioral healthcare
• Critical Access Hospital
• Disease Specific Care
• Home care
• Health Care Staffing Service
• Laboratory Services
• Long term care
• Nursing care center
• Office based Surgery
 JCI 5TH Edition
• Is effective from 1st April 2014
• Consists of four sections
• Section one consists of accreditation participation requirements APR
• Section two Patient centered standards
1.IPSG
2. ACC (Access to care and continuity of care)
3. PFR (Patient and Family Rights)
4. AOP (Assessment Of Patients)
5. COP (Care Of Patients) ambulatory
6. ASC (Anesthesia and Surgical Care)
7. MMU (Medication Management and Use)
8. PFE (Patient and Family Education)
JCI 5TH edition
Section three consists of Health care organization management standards
9. QPS (Quality improvement and Patient Safety)
10. PCI (Prevention and Control of Infections) laboratory
11. GLD (Governance, Leadership and Direction) for hospitals and academic medical
institutions
12.FMS (Facility Management and Safety)
13.Staff qualification and education SQE
14.Management of Information MOI
Section four academic medical center hospitals standards
15.Medical profession education MPE
16.Human subjects research Programs HRP
JCI 5th edition
5th edition of the Hospital Standards contains
• 285 Standards
• 1160 Measurable Elements
4thEdition of the Hospital Standards
• Contains 320 standards
• Over 1200 criteria measured during the survey/evaluation process

Formal on-site evaluation every 3 years to assess compliance with the

standards
Surveyors include a team of health care professionals such as physicians,
nurses, pharmacists, and health care executives
 Joint Commission International
Accreditation Standards for
Hospitals
Section I : Patient Centered Standards
Section II : Health Care Organization Management Standards
Standards Content
Each JCI Standards contains 3 components :
The Standard
Description of the intent of the standard
Measurable element(s) to be scored
 Measurable Elements
• Each standard has one or more measurable elements that
incorporate the major principles addressed in the intent statement
• Each applicable measurable elements is scored
• Met (10)
• Partially Met (5)
• Not Met (0)

The standards will be revised and published at least every three years.
Accreditation Surveys
• interview with staff and patients and other verbal information;
• on-site observations of patient care processes by surveyors;
• policies, procedures, clinical practice guidelines, and other documents
provided by the organization
Patient-Centered Standards

• Patient Safety Goals (IPSG)

• Access to Care and Continuity of Care (ACC)
• Patient and Family Rights (PFR)
• Assessment of Patients (AOP)
• Care of Patients (COP)
• Anesthesia and Surgical Care (ASC)
• Medication Management and Use (MMU)
• Patient and Family Education (PFE) .
Health Care Organization
Management Standards
• 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 Information (MOI) ...........
 Section I : International Patient Safety Goals
(IPSG)
Goal 1: Identify Patients Correctly
• using two patient identifiers,
• before administering medications, blood,
• before taking blood and other specimens or providing treatments
Goal 2: Improve Effective
Communication
• The complete verbal and telephone order or test result is written
down , and is read back by the receiver of the order then it is
confirmed by the individual who gave the order or test result
 Goal 3: Improve the Safety of High-Alert Medications

• High-alert medications are those medications involved in a high percentage

of errors
• medications that carry a higher risk for adverse outcomes,
• look-alike/sound-alike medications
• example, concentrated electrolytes as potassium chloride 2 mEq/ml
concentrated
How to improve safety
• removing the concentrated electrolytes from the patient
care unit to the pharmacy.
• clearly labeled and stored in a manner that restricts access.
 Goal 4: Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery
• mark for surgical-site identification and involves the patient in the
marking process
• The organization uses a checklist to verify preoperatively the correct
site, correct procedure, and correct patient and that all documents
and equipment needed are on hand, correct, and functional.
• The full surgical team conducts and documents a time-out procedure
just before starting a surgical procedure.
 Goal 5: Reduce the Risk of Health Care–
Associated Infections
• include catheter-associated urinary tract infections, blood stream
infections, and pneumonia(often associated with mechanical
ventilation).
• Via effective hand-hygiene program.

Goal 6: Reduce the Risk of Patient Harm

Resulting from Falls

• initial assessment of patients for fall risk

• Measures are implemented to reduce fall risk for those assessed to
be at risk.
Access to Care and Continuity of Care (ACC)
1-Admission to the Organization

• To have a process for admitting inpatients and for registering outpatients.

• Patients with emergent, urgent, or immediate needs are given priority
• The organization considers the clinical needs of patients when there are
waiting periods or delays for diagnostic and/or treatment services.
• At admission as an inpatient, patients and families receive information on
the proposed care, the expected outcomes of that care, and any expected
cost to the patient for the care.
• Admission or transfer to or from units providing intensive or specialized
services is determined by established criteria.
2-Continuity of Care
• During all phases of inpatient care, there is a qualified individual identified as
responsible for the patient’s care.
3- Discharge, Referral, and Follow-Up
• The organization cooperates with health care practitioners and outside agencies to
ensure timely and appropriate referrals.
• The clinical records of inpatients contain a copy of the discharge summary.
• The clinical records of outpatients receiving continuing care contain a summary of all
known diagnoses, drug allergies, current medications, and any past surgical procedures
and hospitalizations.
• Patients and, their families are given understandable follow-up instructions.
• The organization has a process for the management and follow-up of patients who
leave against medical advice.
4-Transfer of Patients
• The transfer process addresses who is responsible during transfer and
what supplies and equipment are required during transport.
• The referring organization determines that the receiving organization
can meet the needs of the patient to be transferred.
• Patient clinical information or a clinical summary is transferred with
the patient.
• During direct transfer, a qualified staff member monitors the patient’s
condition.
• The transfer process is documented in the patient’s record.
5-Transportation
• The transportation provided or arranged is appropriate to the needs
and condition of the patient.
• There is a process in place to monitor the quality and safety of
transportation provided or arranged by the hospital, including a
complaint process.
 Patient and Family Rights

• Respond to the patient’s requests related to religious beliefs

• Care is respectful of the patient’s need for privacy.
• Patients are protected from physical assault.
• Patient information is confidential.
• The hospital will inform pts & family with diagnosis ,treatment plan , complications and consequences of
refusing or discontinuing treatment.

The organization supports the patient’s right to respectful and compassionate care at the end of life.
• Patient informed consent is obtained
• The organization informs patients and families about how to gain access to clinical research, clinical
investigation, or clinical trials involving human subjects.
• Informed consent is obtained before a patient participates in clinical research, clinical investigation, and
clinical trials.
Assessment of Patients (AOP)
• Each patient’s initial assessment(s) includes an evaluation of physical,
psychological, social, and economic factors, including a physical
examination and health history.
• Assessment findings are documented in the patient’s record and
readily available to those responsible for the patient’s care.
• All patients are reassessed at intervals based on their condition and
treatment to determine their response to treatment and to plan for
continued treatment or discharge.
• Qualified individuals conduct the assessments and reassessments.
Laboratory Services
• All equipment used for laboratory testing is regularly inspected, maintained, and
calibrated, and appropriate records are maintained for these activities.
• Procedures for collecting, identifying, handling, safely transporting, and disposing
of specimens are followed.
• A laboratory safety program is in place, followed, and documented.

Radiology and Diagnostic Imaging Services

• Radiology and diagnostic imaging services are provided by the organization or are
readily available through arrangements with outside sources.
• Individuals with proper qualifications and experience perform diagnostic imaging
studies, interpret the results, and report the results.
 Care of Patients (COP)
Food and Nutrition Therapy
• A variety of food choices, appropriate for the patient’s nutritional status and
consistent with his or her clinical care, is regularly available.
Pain Management
• Patients are supported in managing pain effectively.
End-of-Life Care
Care of the dying patient optimizes his or her comfort and dignity.
Care Delivery for All Patients
Patients with the same health problems and care needs have a right to receive the
same quality of care throughout the organization.
Anesthesia and Surgical Care

• Anesthesia services (including moderate and deep sedation) are

available to meet patient needs,
• A qualified individual(s) is responsible for managing the anesthesia
services
• Each patient’s surgical care is planned and documented based on the
results of the assessment.
• Anesthesia & surgical care are documented in pts records
Medication Management and
Use
• An appropriately licensed pharmacist, technician, or other trained professional
supervises the pharmacy or pharmaceutical service.
• An appropriate selection of medications for prescribing or ordering is stocked or
readily available.
• Medications are properly and safely stored.
• Prescribing, ordering, and transcribing are guided by policies and procedures.
• The organization identifies those qualified individuals permitted to prescribe or to
order medications.
• A system is used to dispense medications in the right dose to the right patient at the
right time.
• The organization identifies those qualified individuals permitted to administer
medications.
• Medication effects on patients are monitored.
Patient and Family Education (PFE)

• The organization provides education that supports patient and family

participation in care decisions and care processes.
• Education and training help meet patients’ ongoing health needs.
• Health professionals caring for the patient collaborate to provide
education.
 Section II: Health Care Organization Management Standards
Quality Improvement and Patient Safety

Those responsible for governing and managing the organization

participate in planning and measuring a quality improvement and
patient safety program.
Design of Clinical and Managerial Processes
Data Collection for Quality Measurement
Analysis of Measurement Data
Improvement
Prevention and Control of Infections
• One or more individuals oversee all infection prevention and control activities.
This individual(s) is qualified in infection prevention and control practices through
education, training, experience, or certification.
• The organization designs and implements a comprehensive program to reduce
the risks of health care–associated infections in patients and health care workers.
• The organization provides barrier precautions and isolation procedures that
protect patients, visitors, and staff from communicable diseases and protects
immunosuppressed patients from acquiring infections to which they are uniquely
prone.
• Gloves, masks, eye protection, other protective equipment, soap, and
disinfectants are available and used correctly when required.
• The organization provides education on infection prevention and control practices
to staff, physicians, patients, families, and other caregivers when indicated by
their involvement in care.
Governance, Leadership, and Direction

• Governance responsibilities and accountabilities are described in bylaws, policies and

procedures, or similar documents that guide how they are to be carried out.
• A senior manager or director is responsible for operating the organization
• One or more qualified individuals provide direction for each department or service in
the organization.

Facility Management and Safety

• The organization complies with relevant laws, regulations, and facility inspection
requirements.
• The organization plans and implements a program to provide a safe and secure
physical environment.
• The organization has a plan for the inventory, handling, storage, and use of
hazardous materials and the control and disposal of hazardous materials and
waste.
• The organization develops and maintains an emergency management
plan and program to respond to likely community emergencies,
epidemics, and natural or other disasters.
• The organization plans and implements a program to ensure that all
occupants are safe from fire, smoke, or other emergencies in the facility.
• The organization plans and implements a program for inspecting,
testing, and maintaining medical equipment and documenting the
results.
• Potable water and electrical power are available 24 hours a day, seven
days a week,
• The organization educates and trains all staff members about their roles
in providing a safe and effective patient care facility.
Staff Qualifications and Education
• Organization leaders define the desired education, skills, knowledge, and other
requirements of all staff members.
• Organization leaders develop and implement processes for recruiting, evaluating, and
appointing staff as well as other related procedures identified by the organization.
• The organization uses a defined process to ensure that nonclinical staff knowledge and skills
are consistent with organization needs and the requirements of the position.
• All clinical and nonclinical staff members are oriented to the organization, the department,
or unit to which they are assigned and to their specific job responsibilities at appointment to
the staff.
• The organization uses an ongoing standardized process to evaluate the quality and safety of
the patient services provided by each medical staff member.
• The organization has an effective process to gather, to verify, and to evaluate the nursing
staff ’s credentials (license, education, training, and experience).
• The organization has a standardized procedure to gather, to verify, and to evaluate other
health professional staff members’ credentials (license, education, training, and experience).
Management of Communication and Information

• Communication with the Community

• Communication with Patients and Families
• Communication Between Practitioners Within and Outside of the
Organization
• Patient Clinical Record
• The organization initiates and maintains a clinical record for every
patient assessed or treated.
JCI & Environmental care
Numbering system