JCI 2nd Edition

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Transcript of JCI 2nd Edition

  1. 1. Joint Commission International Accreditation Hospital S u r v e y P r o c e s s G u i d e 4 t h E d i t i o n Effective 1 January 2011 Version 2
  2. 2. Senior Editor: Maria R. Aviles, M.A. Project Manager: Andrew Bernotas Manager, Publications: Paul Reis Associate Director, Production: Johanna Harris Executive Director: Catherine Chopp Hinckley, Ph.D. Joint Commission International Reviewers: Ann Jacobson, Claudia Jorgenson, Paul van Ostenberg, Brenda White Joint Commission International A division of Joint Commission Resources, Inc. The mission of Joint Commission International (JCI) is to improve the safety and quality of care in the international community through the provision of education, publications, consultation, and evaluation services. Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of Joint Commission International. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. 2010 Joint Commission International All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Printed in the U.S.A. 5 4 3 2 1 Requests for permission to make copies of any part of this work should be mailed to Permissions Editor Department of Publications Joint Commission Resources One Renaissance Boulevard Oakbrook Terrace, Illinois 60181 U.S.A. [email protected] ISBN: 978-1-59940-404-2 Library of Congress Control Number: 2010930481 For more information about Joint Commission Resources, please visit http://www.jcrinc.com. For more information about Joint Commission International, please visit http://www.jointcommissioninternational.org.
  3. 3. Contact Directory ........................................................................................................................................................................1 Introduction ..................................................................................................................................................................................1 The Value of Joint Commission International Accreditation ........................................................................................................2 Joint Commission InternationalWho Are We?..........................................................................................................................2 Who Is Eligible for an International Hospital Accreditation Survey?............................................................................................4 How to Request an International Hospital Accreditation Survey ................................................................................................4 Survey Scheduling, Postponements, and Cancellations ............................................................................................................5 The Standards Manual ................................................................................................................................................................6 Scoring Guidelines for Survey Consistency ................................................................................................................................8 Accreditation Decision Rules (Effective 1 January 2011)..........................................................................................................14 Accreditation Preparation ..........................................................................................................................................................16 Preparation Timeline ............................................................................................................................................................17 Accreditation Process Timeline ............................................................................................................................................20 The On-Site Survey ..................................................................................................................................................................21 Sample Survey Agenda ............................................................................................................................................................22 Tracer Methodology ..................................................................................................................................................................27 The Accreditation Decision ........................................................................................................................................................30 Survey Agenda: Detailed Descriptions ......................................................................................................31 Opening Conference..................................................................................................................................................................32 Orientation to the Hospitals Services and the Quality Improvement Plan................................................................................34 Surveyor Planning Session........................................................................................................................................................35 Document Review......................................................................................................................................................................37 Documents Available in English ..........................................................................................................................................37 Daily Briefing..............................................................................................................................................................................41 Facility Tour................................................................................................................................................................................43 Sample Outline of a Facility Inspection Report ....................................................................................................................45 Individual Patient Tracer Activity................................................................................................................................................46 System Tracer: Medication Management ..................................................................................................................................49 System Tracer: Infection Control ..............................................................................................................................................52 System Tracer: Improvement in Quality and Patient Safety......................................................................................................54 Quality Improvement and Patient Safety (QPS) Monitoring Plan: Measures Documentation Tool......................................57 System Tracer: Facility Management and Safety System ........................................................................................................59 Undetermined Survey Activities ................................................................................................................................................63 Education Session: Hospital Decision Rules, Scoring Guidelines, and Strategic Improvement Plan ......................................64 Staff Qualifications and Education Session ..............................................................................................................................65 Medical Staff Qualifications Worksheet ................................................................................................................................67 Competency Assessment Process Review Forms ..............................................................................................................68 Closed Medical Record Review ................................................................................................................................................70 Medical Record Review Tool ................................................................................................................................................71 Leadership Conference ............................................................................................................................................................76 Surveyor Team Meeting ............................................................................................................................................................78 iii Table of Contents
  4. 4. Surveyor Report Preparation ....................................................................................................................................................79 Leadership Exit Conference ......................................................................................................................................................80 Survey Planning: Reference Lists ..............................................................................................................81 Required Quality Monitors ........................................................................................................................................................82 Required Hospital Plans ............................................................................................................................................................83 Required Policies and Procedures, Written Documents, or Bylaws...............................................................