Dr.Ihab Nada,M.D
Director of education
MSKMC
MISSION
 The
mission of Joint Commission
International (JCI) is to improve
the safety and quality of care in
the international community
JCI was created in 1998 as the international
arm of The Joint Commission (United
States)
The
process
of
developing
standards
is
,
actively overseen by an expert international
task force, whose members are drawn from
each of the world’s populated continents
.JCI standards are the basis for accreditation
and certification of individual health care
facilities and programs around the world.
What is accreditation?

Accreditation is a process in which an
entity, usually nongovernmental,
assesses the health care organization to
determine if it meets a set of
requirements (standards) designed to
improve the safety and quality of care.
What are the benefits of
accreditation?
Accreditation has gained worldwide
attention as an effective quality
evaluation and management tool.
 improve public trust that the organization
is concerned for patient safety and the
quality of care;
 provide a safe and efficient work
environment that contributes to worker
satisfaction;


negotiate with sources of payment for
care with data on the quality of care;
How frequently will the standards
be updated?

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

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.


MSKMC will inform pts & family with
diagnosis ,ttt plan , complications and
consequences of refusing or
discontinuing ttt
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.
Thank you
………………..