Accreditation As a Means to Improve Healthcare R. Scott Altman, MD, MBA, MPH Managing Consultant Joint Commission International

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Accreditation As a Means to Improve Healthcare
R. Scott Altman, MD, MBA, MPHManaging
ConsultantJoint Commission International
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Quick Tour

• Quality Evaluation in Health Care
• What is Accreditation
• Philosophy of Accreditation
• Benefits of Accreditation (Why)
• Who is the JCAHO
• Joint Commission International
• The Standards
• The Survey Process (How)

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Desirable Elements of a Quality Evaluation System

• Proactive (not Reactive)
• Organization Wide
• Focus on Systems, not Individuals
• Stimulates Continuous Improvements
• Periodic Re-evaluation

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Comparisons

• JCI Has All Topics in JCAHO U.S. Standards
• JCI Contains Many of the Quality Control and
  Quality Leadership ISO 9000 Criteria
• JCI Includes the Criteria of the European (EFQM)
  and U.S. (Baldrige) Quality Awards

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What is Accreditation
Licensure Certification Accreditation
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Licensure

• Government Administered
• Mandatory
• Meet Minimal Standards for Operation
• Require Minimal Staff Practice Conditions
• Education, Experience, Training, and/ or Skills

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Certification

• Voluntary (Governmental or Non-Governmental)
• Grants Recognition
• Meet Pre-Determined Standards
• To Advertise Services or Qualify for Reimbursement

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Accreditation

• Usually Voluntary (Non-governmental,
  non-punitive)
• Grants Recognition
• Meet Pre-determined Standards
• Based upon Cycle of Standards Development,
  Auditing, Improvement Training/Education.
• Recognized and Endorsed by WHO, World Bank, and
  development banks.

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Common Base of Accreditation

• Recognized body
• Establishes and publishes standards
• Conducts objective on-site evaluations
• Publishes decision
• Professional involvement
• Help develop consensus standards
• Volunteer as peer evaluators/surveyors
• Focus on continuous improvement
• Structures, Procedures, Outcomes

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Needs Addressed

• Maintain or Improve Quality
• Ensure Public Safety
• Establish Entry Level Requirements
• Monitoring New Settings
• Address National Public Health Issues
• Recognize Benchmark Practices

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History of Accreditation

• 1910 Ernest A. Codman, MD
• 1918 American College of Surgeons
• 1951 Joint Commission on Accreditation of
  Hospitals
• 1958 Canadian Council on Hospital Accreditation
• 1974 Australian Council on Hospital Standards
• 1999 First International Hospital Accreditation
• 2002 First Medical Transport Agency Accredited

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Philosophy of Accreditation
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Philosophy of Accreditation

• Voluntary Mandatory
• Non-Governmental Governmental
• Optimal Requirements Basic
• Outcome Oriented System/Process
• Improvement Punishment
• Innovation Conformance
• Public Confidential

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Voluntary vs Mandatory

• Voluntary Systems Need Incentives
• Quality, Pride (recognition), and/or Financial
• Without Incentive, Participation Will Be Low
• Mandatory Systems Have High Participation Levels
  but Low Commitment to the Process
• Accreditation is Seen as the End Point,
• Rather Than a Continuous Improvement Journey

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Non-Governmental vs Governmental

• Accreditation System Needs
• Governmental Approval
• Some Level of Governmental Participation
• Governmental Systems
• Less Flexible
• Become Regulatory in Nature
• Usually Set Minimal Rather Than Optimal Standards

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RequirementsOptimal vs Minimal

• Basic Requirements
• Protect the Public
• (Such As Through Professional and Facility
  Licensure)
• Optimal Requirements
• Stimulate Improvement and Innovation

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Outcome Oriented vs Systems/Process

• Most Accreditation Systems Address
• Structures
• Processes
• Outcomes
• Without Standards, Outcomes
• Do Not Result in Continuous Improvement (Outcome
  Data Does Not Address What Needs to Change to
  Improve)

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Improvement vs Punishment

• When Used for Punishment
• The System Will Be Manipulated to Get the Least
  Punishment, Not the most Improvement
• Market and Societal Forces
• Automatically Provide Some Level of Punishment
  When Organizations Have Poor Results

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Innovation vs Conformance

• Health Care Is Changing Rapidly which Demands
  Innovation
• Private, Voluntary Accreditation Systems
  Stimulate Innovation (the Risks Are Low)
• Governmental Accreditation Systems Stimulate
  Conformance (the Risks Are High)

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Public Release vs Confidential Results

• Accreditation Systems Seek to Improve the Quality
  of Care Provided to the Public
• The Public Thus Deserves to Have Sufficient
  Information to Make Informed Care Choices
• The Public Does Need Help in Interpreting the
  Results of Accreditation and Need Comparison
  Information
• The Confidentiality of the People in the
  Accreditation Process Is Important to Protect
  Them From Influence to Manipulate the System

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Benefits of Accreditation
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Benefits of Accreditation

• Improves Health Care
• Increases Flexibility
• Balances Competing Interests
• Enhances Benchmarking
• Optimizes Role of Government
• Increases Private Incentives
• Micro-Economic Efficiency
• Reduces Risk
• Increases Satisfaction

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SummaryAccreditation Benefits

• Ensures That an Organization Is Doing the Right
  Things, Well
• Thereby Significantly Reducing the Risk of Harm
  in the Delivery of Care
• Optimizing the Likelihood of Good Outcomes
• Finding Problems Before They Become Ones.

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Who is the Joint Commission
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Governance

• Independent, Not-for-Profit, Non-Governmental
• 28 Member Board
• Representing Medicine, Nursing, Health Admin,
  Dentistry, Public, Religious, Ethics, Business,
  Government
• Subsidiary Joint Commission Resources
• International Accreditation
• International Consulting
• More Than 10 Advisory Groups

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Mission of the Joint Commission

• To Improve the Quality of Care Provided to
• the Public Through
• The Provision of Health Care Accreditation and
• Related Services that Support Performance
  Improvement in Health Care Organizations.

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Current Activities

• Almost 20,000 Accredited Organizations
• Includes
• Hospitals, Networks, Nursing Homes (Long-Term
  Care), Home Care, Laboratories, Behavioral Health
  Care, Ambulatory Care, Long-term Care Pharmacies,
  Hospice, and Disease Specific Programs
• Employees 600 in Central Office and 600 Surveyors

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Joint Commission International
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Organizational Base

• The Joint Commission on Accreditation of
  Healthcare Organizations (JCAHO), the USA
  accreditation agency, is the organizational
  parent of Joint Commission International (JCI)
• Both organizations are based outside Chicago, USA

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Accreditation Represents a Risk Reduction Strategy

• That an organization is doing the right things
  and doing them well
• Thereby significantly reducing the risk of harm
  in the delivery of care and
• Optimizing the likelihood of good outcomes.

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International Accreditation

• Process Began in 1997
• Based on Work in Over 30 Countries
• Due to Requests for Evaluation Against Joint
  Commission Benchmark Standards
• New Set of Standards Developed by an
  International Task Force
• International Review and Testing
• First Hospital Accredited in 1999 (Brazil)

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JCI Philosophy

• Stimulate Continuous Improvement
• Maximum Achievable Standards
• Patient-Focused
• Culturally Adaptable
• Fit into Local Legal Frameworks
• Consultation and Accreditation Provided Through
  Separate Divisions

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Current Activity

• Over Forty Hospitals Accredited in
• Austria, Brazil, Denmark, Germany, Ireland, Saudi
  Arabia, Spain, Thailand, Turkey UAE
• Thirty Organizations are Currently Preparing for
  JCI Accreditation
• Including Austria, Brazil, China, Czech Republic,
  Denmark, Germany, Ireland, Pakistan, Philippines,
  Spain, Thailand, Turkey
• Two Partners Offer a Joint Award
• Brazil and Spain
• Provide Assistance to Several Ministries of Health

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Standards
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Origin of JCIA Standards

• JCIA Principles and Standards Task Force
• 14 World Region Representatives
• Consensus Standards
• Field Review
• Focus Groups
• Testing

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JCI Programs

• International Accreditation Programs
• Hospitals
• Clinical Laboratories
• Care Continuum (Long-term Care, Home Care,
  Rehabilitation and Chronic Care)
• Medical Transport Organizations

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Definition of a Standard

• A Standard Is a Statement of Expectation That
  Defines the Structures and Processes That Must Be
  Substantially in Place in an Organization to
  Enhance the Quality of Care.

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International Standards

• Organized Around Important Functions
• Organization Management Standards
• Patient-centered Standards
• Access to Care and Continuity of Care
• Patient and Family Rights
• Assessment of Patients
• Care of Patients
• Patient and Family Education

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Standards Cont.

• Organized Around Important Functions
• Organization Management Standards
• Quality Management and Improvement
• Prevention and Control of Infections
• Governance, Leadership, and Direction
• Facility Management and Safety
• Staff Qualifications and Education
• Management of Information
• Patient-centered Standards

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Standards Content

• Standard
• Intent
• Measurable Elements

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Sample Standards

• GLD.1 Governance responsibilities and
  accountabilities are described in bylaws,
  policies and procedures, or similar documents
  that guide how they are to be carried out.

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The Intent

• GLD.1 There is an entity (for example, a
  ministry of health), an owner(s), or a group of
  identified individuals (for example, a board or
  governing body) responsible for overseeing the
  operation of the organization and accountable for
  providing quality health care services to its
  community or to the population that seeks care.
  The responsibilities and accountabilities of this
  entity are described in a document that
  identifies how they are to be carried out.
• The organizations governance and management
  structure is presented in an organizational chart
  or other document. Lines of authority and
  accountability are shown in this chart. The
  individuals represented on the chart are
  identified by title or name.

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The Measurable Elements

• GLD.1
• The organizations governance structure is
  described in written documents.
• Governance responsibilities and accountabilities
  are described in the documents.
• There is an organization chart or document.
• Those responsible for governing and managing are
  identified by title or name.

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Summary

• Quality Evaluation in Health Care
• What is Accreditation
• Philosophy of Accreditation
• Benefits of Accreditation (Why)
• Who is the JCAHO
• Joint Commission International
• The Standards
• The Survey Process (How)

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Conclusions

• Accreditation Is the Most Comprehensive and
  Powerful Tool for Quality Improvement
• Accreditation Has Been Found to Be Effective in
  Many Cultures and Countries With Very Different
  Systems
• The Joint Commission and Others Are Working to
  Advance Accreditation in our Global Society

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Thank You
Joint Commission International R. Scott Altman,
MD, MPH, MBA SAltman_at_EMerge1st.com One Lincoln
Centre, Suite 1340 Oakbrook Terrace, Illinois
60181 USA Phone [phone] Fax
630.268.7405 Website www.jcrinc.com