Transcript ภาพนิ่ง 1

Mahidol U.
Thailand
Joint Commission International
(JCI)
ศ.นพ.ประสิ ทธิ์ วัฒนาภา
มหาวิทยาลัยมหิดล
22/01/2552
Accreditation : A World Trend
Mahidol U.
Thailand
• The U.S., Canada, and Australia have the oldest accreditation
systems
• In Europe, Germany, France, Ireland and Spain have new
accreditation systems
• In Japan, Korea, Malaysia, and Thailand there are new
systems with government role
• The WHO, World Bank and development banks recognize
and endorse the accreditation model
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About JCI
Mahidol U.
Thailand
The Joint Commission International (JCI) Is a Major Subsidiary
of Joint Commission Accreditation of Healthcare Organizations
(JCAHO)
Mission of JCI
To Improve the Safety and Quality of Care in the International
Community Through the Provision of Education, Publications,
Consultation and Evaluation Services
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JCAHO - History
Mahidol U.
Thailand
• 1910 – 1913 : Concerned for the Quality of Hospital Care
in the U.S.A.
• 1910 : Ernest A Codman Focused on Results
• 1918 : American College of Surgeons Began a Hospital
Standardization Program
• 1951 : Joint Commission on Accreditation of Hospitals
Formed to Continue the Challenge
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Joint Commission on Accreditation
Mahidol U.
Thailand
• Non-profit Affiliate of JCAHO
• Separate Board with International Members
• Accreditation Committee with International Members
• Advisory Structure with International Members
• International Division Is Known As Joint Commission
International (JCI)
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Thailand
Origin and Content of
JCI Standards
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International Hospital Standards
Mahidol U.
Thailand
• International Principles and Standards Development
Task Force Formed February 1998
• First Meeting of the Task Force in June 1998
• Meeting Held in Chicago, Budapest, Barcelona in 1998
and 1999
• Publication of Standards in October 1999
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Standards Subcommittee Members
Mahidol U.
Thailand
• Brazil
• China
• Czech Republic
• Germany
• Italy
• Poland
• Portugal (pending)
• Republic of South Africa
• Ireland (pending)
• Saudi Arabia
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Mahidol U.
Thailand
ACCREDITATION
Benefits and Characteristics
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Benefits for the Hospital
Mahidol U.
Thailand
• Improves Care and Enhances Public Confidence
• Stimulates Continuous Improvement
• Demonstrates Commitment to Quality Care
• Raises Community Confidence
• Comparison with Self and Other Similar Organization
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Benefits for the Medical & Nursing Staff
Mahidol U.
Thailand
• Improves Professional Staff Development
• Provides Education on Consensus Standards
• Provides Leadership for Quality Improvement within
Medicine and Nursing
• Increases Satisfaction with Working Conditions,
Leadership and Accountability
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Benefits for Hospital Employees
Mahidol U.
Thailand
• Values Employee Opinions
• Measures Employee Satisfaction
• Involvement in Quality Activities
• Improved Employee Safety and Security
• Clearer Lines of Authority and Accountability
• Promotes Teamwork
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Benefits for Patients
Mahidol U.
Thailand
• Access to a Quality Focused Organization
• Rights Are Respected and Protected
• Understandable Education and Communication
• Satisfaction Is Evaluated
• Involvement in Care Decisions and Care Process
• Focus on Patient Safety
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Characteristics
Mahidol U.
Thailand
• Usually a VOLUNTARY Process by Which a
Government or Non-Government Agency Grants
RECOGNITION to Health Care Institutions Which Meet
Certain STANDARDS That Require Continuous
IMPROVEMENT in Structures, Processes, and Outcomes
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JCIA
Definition of Standards
Mahidol U.
Thailand
• Requirements That Define Performance Expectations
with Respect to STRUCTURE, PROCESS, and
OUTCOMES That Must Be Substantially in Place in an
Organization to Enhance the Safety and Quality for Patient
Care
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Performance Components
Mahidol U.
Thailand
• STRUCTURE : Resources
• E.g. Adequate Staff, Supplies, Building
• PROCESS : Activities
• E.g. Patient Education, Nursing Assessment
• OUTCOMES : Results
• E.g. Infection Rates, Maternal Mortality
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Standards
Mahidol U.
Thailand
• A System Framework (i.e. Policy, Procedures, Indicators,
Monitor, Feed-Back)
• Address All the Important Managerial and Clinical
Functions of a Healthcare Organization
• Focus on Patient in Context of Their Family
• A Balance of Structure, Process and Outcomes Standards
• Set Optimal, Achievable Expectations
• Set Measurable Expectations
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Components of Standards Development
Mahidol U.
Thailand
• Multiple Information Sources
• Scientific Literature
• Survey Compliance Data
• Research Findings
• Individual Input from Field Experts and Key
Stakeholders
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Mahidol U.
Thailand
JCI Standards
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Patient-Centered Standards
• Access to Care and Continuity of Care (ACC)
• Patient and Family Rights (PFR)
• Assessment of Patient (AOP)
• Care of Patients (COP)
• Anesthetic and Surgical Care (ASC)
•Medical Management and Use (MMU)
• Patient and Family Education (PFE)
Mahidol U.
Thailand
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Health Care Organization
Management Standards
Mahidol U.
Thailand
• Quality Improvement and Patient Safety (QPS)
• Prevention and Control of Infection (PCI)
• Government, Leadership & Direction (GLD)
• Facility Management & Safety (FMS)
• Staff Qualification & Education (SQE)
• Management of Information (MOI)
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Quality Improvement & Patient Safety (QPS)
Facility Management & Safety (FMS)
Prevention & Control of Infections (PCI)
Access to Care and Continuity of Care (ACC)
Patient and Family Rights (PFR)
Assessment of Patients (AOP)
Care of Patients (COP)
Patient and Family Education (PFE)
Cause - Effect
Driver
Mahidol U.
Thailand
System
Governance,
Leadership, and Direction
(GLD)
Results
Staff Qualifications
& Education
(SQE)
Performance
Review
Patient and
Family Rights
(PFR)
Management
of Information
(MOI)
Priority
Focus
Process
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Cause - Effect
Driver
1. Leadership
1. Risk, Safety, and Quality Management
2. Professional Governance
3. Physical Structure and Environment of Care
4. Prevention and Control of Infection
5. Medical Record System
6. Medication Management System
7. Diagnostic Investigation and Related Services
8. Disease and Health Hazard Surveillance
9. Working with Community
System
2. Strategic
Management
Mahidol U.
Thailand
1. Entry
2. Patient Assessment
3. Planning of Care
4. Patient Care Delivery
5. Information and Empowerment
6. Discharge Planning & Continuity of Care
Results
5. Staff Focus (HR)
1. Health Care Results
2. Patient and Other Customer-focused Results
3. Financial Results
4. Staff and Work System Results
5. Organizational Effectiveness Results
6. Governance and Social Responsibility Results
7. Health Promotion Results
3. Focus on
Patients/Customers
4. Information and
Knowledge
Management
6. Process
Management
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HA 2006
Clinical Tracer of Quality
HA-Thailand PSGs
JCIA 2008
Tracer Methodology/DSC
2007 IPSGs
Mahidol U.
Thailand
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Thailand
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