Joint Commission International: Nepomuceno, Rose Ann T

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Joint Commission
International
NEPOMUCENO, ROSE ANN T.
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WHAT IS JCI?
It
is
considered
STANDARD
the
GOLD
in global health care.

JCI consultants are the most skilled and
experienced in the industry.
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WHO ARE THEY?
identifies, measures, and shares best
practices in quality and patient safety with the world.
They
We
provide
leadership
and
innovative
solutions
to help health care organizations across all

settings improve performance and outcomes.
JCI helps organizations to help themselves through:
Earning JCI accreditation and certification, recognized as the
global Gold Seal of Approval
leading education
Delivering evidence-based advisory services
Singular focus on the highest patient care standards
and results-oriented process improvement has
Providing
earned the respect of health care leaders from around the world.
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JCI HISTORY
Founded in 1994 by The Joint Commission, JCI has

touched more than 90 countries. Today, the
organization helps patients in five continents and fields
a well-trained team of international accreditation
surveyors
and
consultants.
JCI
enjoys
a
20percentannual growth in the number of accredited
organizations, just one metric of how we help health
care leaders to improve quality, safety, and efficiency
as a shared goal.
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THE PATHWAY: STEP 1
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THE PATHWAY: STEP 2
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STEP 3
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STEP 4
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STEP 5
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STEP 6
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STEP 7 AND 8
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STEP 9 AND 10
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WHAT ARE THE STANDARDS?
PATIENT CENTERED STANDARDS
1.
International Patient Safety Goals
2.
Access to Care and Continuity of Care
3.
Patient and Family Rights
4.
Assessment of Patients
5.
Care of Patients
6.
Anesthesia and Surgical Care
7.
Medication Management and Use
8.
Patient and Family Education
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HEALTH CARE ORGANIZATION MANAGEMENT

STANDARDS
1.
Quality Improvement and Patient

Safety
2.
Prevention and Control of Infection
3.
Governance, Leadership and Direction
4.
Facility Management and Safety
5.
Staff Qualification and Education
6.
Management of Information
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ACADEMIC MEDICAL CENTER HOSPITAL STANDARDS
1.
Medical Professionalism Education
2.
Human Subjects Research Programs
International Patient Safety Goals

(IPSG)
INTERNATIONAL PATIENT SAFETY

GOALS
Goal 1: Identify Patients

Correctly

GOALS
Standard IPSG.1
The hospital develops and implements a
process to improve accuracy of patient
identification.
POLICY: CSMC -01-007-04 Patient

Identification in the
Hospital

GOALS
Measurable Elements - IPSG.1
1. Patients are identified using two patient
identifiers, not including the use of the
patients room number or location.
2. Patients are identified before providing
treatments and procedures.
3. Patients are identified before any
diagnostic procedures.

GOALS
Goal 2: Improve Effective

Communication
POLICY:
NUR-01-040 -Carrying out doctors order
MEDDV-01-019- Policies on Effective
Communication and Exchange of
Critical Information for the safe
conduct of the operation

GOALS
Standard
IPSG.2
The
hospital
develops
and
implements
a
process to improve
the effectiveness of
verbal
and/or
telephone
communication
among caregivers.
Measurable
IPSG.2
Elements
of
1. The complete verbal order is

documented and read back by
the receiver and confirmed by the
individual giving the order.
2. The complete telephone order
is documented and read back by
individual giving the order.
3. The complete test result is
documented and read back by
individual giving the result.

GOALS
Standard
IPSG.2.1
The
hospital
develops
and
implements
a
process
for
reporting critical
results
of
diagnostic tests.
Measurable
of IPSG.2.1
Elements
1. The hospital has defined

critical values for each type of
diagnostic test.
2. The hospital has identified
by whom and to whom critical
results of diagnostic tests are
reported.
3. The hospital has identified
what
information
is
documented in the patient
record.

GOALS
Standard
IPSG.2.2
Measurable
of IPSG.2.2
Elements
1. Standardized
critical
The
hospital content is communicated
health
care
develops
and between
during
implements
a providers
handovers of patient care.
process for handover

communication.
2. Standardized forms, tools,
POLICY: CSMC- 01043-01Intrafacility
Transfer
and methods support a

consistent and complete
handover process. 3. Data
from
handover
communications
are
tracked
and
used
to

GOALS
Goal 3: Improve the Safety of

High-Alert Medications

GOALS
Standard
IPSG.3
Measurable Elements of IPSG.3
1. The hospital has a list of all high-alert

medications, including look-alike/soundalike medications, that is developed from
The
hospital hospital-specific data.
The hospital implements strategies to
develops
and 2. improve
the
safety
of
high-alert
implements a medications, which may include specific
prescribing,
preparation,
process
to storage,
administration, or monitoring processes.
improve
the 3. The location, labeling, and storage of highsafety of high- alert medications, including lookalike/sound-alike medications, are uniform
alert
throughout the hospital.
medications.

GOALS
Standard
IPSG.3.1
The
hospital
develops
and
implements
a
process
to
manage
the
safe
use
of
concentrated
electrolytes.
Measurable Elements of
IPSG.3.1
1. The hospital has a process that
prevents
inadvertent
administration of concentrated
electrolytes.
2. Concentrated electrolytes are
present only in patient care
units identified as clinically
necessary.
3. Concentrated electrolytes that
are stored in patient care units
are clearly labeled and stored
in a manner that promotes safe
use.

GOALS
Goal 4: Ensure CorrectSite, Correct- Procedure,

Correct-Patient Surgery

GOALS
Standard IPSG.4
process for ensuring correct-site, correctprocedure, and correct-patient surgery.
POLICY: MEDDV-01-012-00-Correct
patient Identification and Prevention

of Wrong site, side Procedure

GOALS
1. The hospital uses an instantly recognizable
mark for surgical- and invasive proceduresite
identification that is consistent throughout the
hospital.
2. Surgical- and invasive proceduresite marking
is done by the person performing the procedure
and involves the patient in the marking process.
3. The hospital uses a checklist or other process to
document, before the procedure, that the
informed consent is appropriate to the
procedure; that the correct site, correct
procedure, and correct patient are identified;
and that all documents and medical technology

GOALS
Standard IPSG.4.1
process for the time-out that is performed in
the operating theatre immediately prior to the
start of surgery to ensure correct-site, correctprocedure, and correct-patient surgery.

GOALS
Measurable Elements of IPSG.4.1
1. The full surgical team conducts and documents a timeout procedure in the area in which the
surgery/invasive procedure will be performed, just
before starting a surgical/invasive procedure.
2. The components of the time-out include correct patient
identification, correct side and site, agreement of the
procedure to be done, and confirmation that the
verification process has been completed.
3. When surgery is performed, including medical and
dental procedures done in settings other than the
operating theatre, the hospital uses uniform processes to
ensure the correct site, correct procedure, and correct
patient.

GOALS
Goal 5: Reduce the Risk of

Health CareAssociated
Infections

GOALS
Standard IPSG.5
The hospital adopts and implements evidencebased hand-hygiene guidelines to reduce the
risk of health careassociated infections.
POLICY: ICO-01-049-02 Policies on Nosocomial Health
Care Associated Infections

GOALS
1. The hospital has adopted currently published,
evidence-based hand-hygiene guidelines.
2. The hospital implements an effective handhygiene program throughout the hospital.
3.
Hand-washing
and
hand-disinfection
procedures are used in accordance with handhygiene guidelines throughout the hospital.

GOALS
Goal 6: Reduce the Risk

of Patient Harm
Resulting from Falls
PATIENT AND FAMILY RIGHTS
Standard
IPSG.6
process to reduce the risk of patient
harm resulting from falls.
PATIENT AND FAMILY RIGHTS

1. The hospital implements a process for
assessing all inpatients and those outpatients
whose condition, diagnosis, situation, or
location identifies them as at high risk for
falls.
2. The hospital implements a process for the
initial and ongoing assessment,
reassessment, and intervention of inpatients
and outpatients identified as at risk for falls
based on documented criteria.
3. Measures are implemented to reduce fall risk
for those identified patients, situations, and
locations assessed to be at risk.
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WHAT IS OUR ROLE?
Be
a ROLE MODEL
Study!
Observe!
Share!
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in global health care.

to help health care organizations across all

JCI helps organizations to help themselves through:

Earning JCI accreditation and certification, recognized as the

global Gold Seal of Approval

Founded in 1994 by The Joint Commission, JCI has

PATIENT CENTERED STANDARDS

International Patient Safety Goals

Access to Care and Continuity of Care

Patient and Family Rights

Anesthesia and Surgical Care

Medication Management and Use

Patient and Family Education

HEALTH CARE ORGANIZATION MANAGEMENT

Quality Improvement and Patient

Prevention and Control of Infection

Governance, Leadership and Direction

Facility Management and Safety

Staff Qualification and Education

ACADEMIC MEDICAL CENTER HOSPITAL STANDARDS

Medical Professionalism Education

Human Subjects Research Programs

International Patient Safety Goals

INTERNATIONAL PATIENT SAFETY

Goal 1: Identify Patients

INTERNATIONAL PATIENT SAFETY

POLICY: CSMC -01-007-04 Patient

INTERNATIONAL PATIENT SAFETY

INTERNATIONAL PATIENT SAFETY

Goal 2: Improve Effective

INTERNATIONAL PATIENT SAFETY

1. The complete verbal order is

INTERNATIONAL PATIENT SAFETY

1. The hospital has defined

INTERNATIONAL PATIENT SAFETY

process for handover

and methods support a

INTERNATIONAL PATIENT SAFETY

Goal 3: Improve the Safety of

INTERNATIONAL PATIENT SAFETY

Measurable Elements of IPSG.3

1. The hospital has a list of all high-alert

INTERNATIONAL PATIENT SAFETY

INTERNATIONAL PATIENT SAFETY

Goal 4: Ensure CorrectSite, Correct- Procedure,

INTERNATIONAL PATIENT SAFETY

patient Identification and Prevention

INTERNATIONAL PATIENT SAFETY

INTERNATIONAL PATIENT SAFETY

INTERNATIONAL PATIENT SAFETY

INTERNATIONAL PATIENT SAFETY

Goal 5: Reduce the Risk of

INTERNATIONAL PATIENT SAFETY

Care Associated Infections

INTERNATIONAL PATIENT SAFETY

INTERNATIONAL PATIENT SAFETY

Goal 6: Reduce the Risk

PATIENT AND FAMILY RIGHTS