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The Joint Commission is a Chicago-based organization which accredits 15,000 hospitals in the United States. The Joint Commission International (JCI) is its subsidiary which accredits hospitals outside the U.S. As the medical travel trend grows, JCI accreditation is becoming an important benchmark for quality standards.

Patients are concerned about ensuring quality and safety when traveling abroad for medical care. JCI accreditation sounds like a logical way of screening unknown hospitals. Can you explain how JCI accreditation ensures the consumer of quality and safety?

The need to focus on safety is at the center of all of JCI accreditation activities. All accreditation standards support quality and safety efforts, whether a person is seeking services from a JCI–accredited hospital, ambulatory care organization, clinical laboratory, across the care continuum, at a medical transport organization, or via a JCI–certified disease-specific care provider. More specifically, standards related to safety and to reducing adverse events provide a framework for helping to reduce the risk to and ensure the safety of individuals who receive care, treatment, and services in a health care organization.

Your question referred to a consumer’s “screening” process, and to that point, consumers “screen” in the effort to avoid risking their good health in a substandard health care facility. JCI accreditation is essentially a risk-reduction activity. Compliance with JCI accreditation standards is intended to reduce the risk of adverse outcomes and improve safety. JCI standards emphasize the need to consider risks and to take action to reduce risks before an unwanted event affects patients or staff. This focus on reducing risks to patients and staff can be seen in both JCI’s patient-related standards and organization-related standards.

JCI is a subsidiary of the Joint Commission, which has accredited 15,000 U.S. hospitals. How do the international accreditation standards differ from the U.S. standards?

Development of our international accreditation standards is actively overseen by a global task force, whose members were drawn from each of the world’s populated continents. Although many of the JCI standards are similar to those of the United States–based Joint Commission, U.S. standards reflect many local, state and national laws which do not apply internationally. JCI standards are broader-based in order to respect country and cultural differences.

With each revision, though—especially in the upcoming third edition of our hospital standards, which will be published in July 2007 and enforced January 2008—international standards are becoming more challenging, rapidly closing the gap between JCI and U.S. standards.

There are currently about 110 hospitals with JCI accreditation. Why are there relatively few hospitals accredited by JCI? Is it because very few hospitals in the world meet your standards? Or is it because the accreditation process is expensive?

JCI’s hospital accreditation numbers are lesser than those of The Joint Commission and there are two major reasons for the disparity:

First, JCI is in its infancy when compared The Joint Commission’s 56-year tenure as an accrediting body. JCI launched its accreditation program in 1999 and has steadily built on its cadre of participating organizations each year. We’re not where we want to be yet, but we’re comfortable that we’re moving rapidly in the right direction.

Second, JCI accreditation is voluntary, not mandatory. Organizations choose JCI accreditation not because they have to—it’s because they want to. Our accredited organizations want an external quality evaluation model. They want to bring the common understanding of key quality and patient safety concepts such as good medication management, infection control, facility management, community disaster planning, and other risk reduction strategies to their organization. And, finally, they know that providing the highest quality and safety of health services for their patients makes not only good management sense, but good business sense.

What must a hospital typically do in order to get ready for an initial JCI inspection? How long does it generally take to prepare for this?

We tell organizations that preparing for their initial JCI accreditation survey is likely to take 12 to 24 months. Leaders who insist on setting an achievable time frame communicate the importance of taking a steady, comprehensive approach to accreditation. This approach seeks systems improvements that require thoughtful analysis to establish, implement, and sustain. Organizations perform a baseline assessment, measure the gap between their performance and JCI standards, and then spend the ensuing months refining their policies and procedures to make certain they are in compliance. Rushing through the accreditation preparation misses the point that quality and safety standards must become part of routine operations in order to have a meaningful, lasting impact that improves quality and safety.

Having said that, it is also important to note that once an organization has gone through a survey and has been accredited by JCI, we encourage—and expect—the organization to strive for continuous standards compliance; that is, to always be ready for a survey. Organizations that are continually performing in the patient’s best interests don’t have to prepare for a survey; they’re ready all day, every day.

Renewal of accreditation is every three years. Are there any spot checks in the interim?

There are no “spot checks” in the truest sense of those words, but there are reasons for JCI to return to an organization sooner than the triennial survey. First, we have begun performing “validation surveys” in all organizations within 60 to 180 days of all initial or triennial re-surveys. These validation surveys are free to an organization and do not impact the organization’s accreditation decision, but they do provide JCI with immediate feedback on the validity of the survey’s results.

Also, if during an organization’s survey we find standards not met, we will respond by scheduling what we call a “focused survey” for that organization. A focused survey is exactly as it sounds—a concentrated examination of only the areas in which an organization does not meet standards. If, in the view of the JCI Accreditation Committee, the organization’s performance during the focused survey meets standards, the organization is then deemed accredited.

Does JCI collect safety data (mortality rates, hospital acquired infections, etc.) for international hospitals, benchmarked to U.S. averages? If not, does any other organization collect such information so that consumers can check the track record of an international hospital?

We do collect data and we intend to do even more collection in the future. JCI introduced the Hospital Quality Indicator project in January 2006 in response to accredited hospitals expressing an interest in performance measurement to support quality improvement efforts and to provide a valid base for local, national, and international comparisons. This initiative focuses on data collection for seven standardized performance indicators currently in use in the United States:

For Acute Myocardial Infarction:
Measure 1. Aspirin at Arrival
Measure 2. Aspirin Prescribed at Discharge
Measure 3. Angiotensin Converting Enzyme Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction
Measure 4. Beta Blocker Prescribed at Discharge
Measure 5. Beta Blocker at Arrival

For Heart Failure:
Measure 1. Left Ventricular Function Assessment
Measure 2. Angiotensin Converting Enzyme Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction

Measures are assessed for interpretability, applicability, and usefulness to the international community, feasibility of data collection, data collection effort, and overall resource use. In addition to indicator evaluation, assessment of the potential limitations related to electronic data transmission, preferences for data feedback mechanisms, expectations regarding support services, and data use by JCI in accreditation activities are also being addressed. Evaluation findings are being used to assist in planning for a voluntary, automated, standardized indicator set.

Accredited hospital organizations, which volunteer to participate, collect indicator data using tools provided by JCI. These tools include a data dictionary, data elements, and Indicator Information Forms for the seven indicators.

Although these data are not currently available to the public, we envision a future public-reporting scenario similar to The Joint Commission’s Quality Check Web portal, which provides public access to United States hospitals’ performance on The Joint Commission’s National Patient Safety Goals and National Quality Improvement Goals. The latter goals allow hospitals to report quarterly on key quality of care indicators in up to five treatment areas: heart attack, heart failure, community acquired pneumonia, pregnancy and related conditions, and surgical infection prevention.

In your presentation, you mentioned that JCI has a policy about “truth and admission.” Could you elaborate?

Patient safety has made significant strides in some parts of the world during the past 10 years, thanks to a willingness to acknowledge that adverse events occur in health care and that a systematic approach must be employed to reduce the very real risk of patient harm. We feel that honesty from all parties—caregivers, patients, and patients’ families—is an essential aspect of safe heath care. Just as caregivers expect patients to provide honest answers in order to discern the proper course of the patient’s care, patients and their families have the right to honest communication with caregivers to help the patients or loved ones make informed decisions.

There is a growing body of research indicating that patients and families will forgive medical errors more readily if the caregiver will admit them. Likewise, with increased public reporting of medical errors—in the United States, The Joint Commission has required its accredited organizations to report their adverse events since 2001, which are then compiled into what is called the Sentinel Event Database—and infection control data and the like, there is a positive trend toward more open and honest communication between caregiver and patients. We agree wholeheartedly, and our standards reflect this. One JCI hospital standard states that the hospital must inform patients and families about how they will be told about the outcomes of care and treatment, including unanticipated outcomes, and who will tell them. With that sort of communication model in place, patients and families can be assured that they know exactly what’s going on with their care and treatment at all times.

You are CEO of both JCR and JCI, which handle consulting and accreditation respectively. Can you address the relationship between the two organizations? Are the people who do the consulting the same people who do the accreditation inspections?

The easiest way to explain the relationship between Joint Commission International (JCI), Joint Commission Resources (JCR), and The Joint Commission is that The Joint Commission is the parent organization of both JCR and JCI. JCR is an educational unit, disseminating information regarding accreditation, standards development and compliance, good practices, and health care quality improvement around the world. JCI is the international accreditation division of the organization. JCR consultants are never JCI surveyors, and JCI surveyors are never JCR consultants. There is a virtual firewall between JCI’s accreditation personnel and JCR that is strictly enforced. JCI accreditation personnel are never permitted to discuss or otherwise communicate about accreditation operation or decisions with JCR personnel, and, conversely, JCR representatives must never convey any ongoing or past consulting or education arrangements regarding present or future accredited organizations with JCI accreditation personnel. We believe that maintaining that level of privacy is essential to preserving the value of JCI accreditation.

From a consumer’s (or patient’s) standpoint, what is the difference between JCI accreditation and other accreditations, such as ISO? As long as a hospital has some sort of accreditation, is that a reasonable assurance of quality and safety?

ISO is not truly a health care accreditation body; it is more of a federation of national standards bodies. While concepts within ISO requirements may apply to health care, many of the concepts do not easily apply, especially to the clinical aspects of health care. ISO requirements are more focused on manufacturing, and ISO standards concentrate on adhering to a specified process of quality management designed to consistently produce a product (or service) that meets pre-established specifications and on assessing that conformity.

Although I think it’s safe to say that some sort of accreditation is better than none, we are convinced that JCI’s accreditation process provides the best organizational available path to health care excellence.

What is the function of JCI’s Center for Patient Safety?

The Joint Commission International Center for Patient Safety (ICPS) is virtual organization that allows The Joint Commission, JCR, and JCI to further its patient safety mission: to continuously improve patient safety in all health care settings.

The Center’s Web site is a valuable online resource for health care professionals, patients, and their families. Nearly 1,000 articles and Web links covering topics ranging from adverse events and product safety to the National and International Patient Safety Goals are available for download, free of charge. A monthly electronic newsletter, Patient Safety Links, is available at no cost to subscribers.

The Center is also the operational arm for the World Health Organization (WHO) Collaborating Centre on Patient Safety, the world’s first such organization dedicated solely to patient safety. The Collaborating Centre focuses worldwide attention on patient safety solutions and best practices with the intent of reducing safety risks to patients, and it helps coordinate international efforts to share, develop, and disseminate these solutions as broadly as possible.

Tell me more about JCI's collaboration with the WHO?

Since its launch in August 2005, the WHO Collaborating Centre for Patient Safety has been building an international network to identify, evaluate, adapt and disseminate patient safety solutions worldwide. The Collaborating Centre is identifying existing solutions that would be applicable to a wide variety of countries and health-care settings.

Patient safety solutions are any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from health care processes. Solutions disseminated by the Collaborating Centre will be evidence-based, and presented in a standard format.

In order to facilitate the accurate identification of solutions and the adaptation of solutions to different needs, an international steering committee composed of recognized leaders and experts in patient safety was convened. At the inaugural meeting of the International Steering Committee in June 2006, the following nine solutions were prioritized for further development:

  1. Look-alike/Sound-alike Medications
  2. Patient Identification
  3. Hand-Off Communication
  4. Wrong Site, Wrong Procedure, Wrong Person Surgery
  5. High-Concentration Medications
  6. Medication Reconciliation
  7. Catheter and Tubing Misconnections
  8. Needle Reuse
  9. Hand Hygiene

Three Regional Advisory Groups were also established to review the priority draft solutions and provide feedback on how the solutions need to be adapted for different regions of the world. A large international field review via electronic survey was undertaken to determine the relevance, adaptability, feasibility, and barriers to acceptance of the solutions in different regions of the world. The field review audience includes leading patient safety entities, accrediting bodies, Ministries of Health international health professional associations, and WHO and Joint Commission International network of contacts. The target date for dissemination of the initial set of Solutions is May 2007.

Another one of the exciting programs spawned through the WHO Collaborating Centre on Patient Safety is the “Action on Patient Safety (High 5s) Initiative," a seven-country collaborative project that leverages the implementation of five standardized patient safety solutions to prevent avoidable catastrophic events in hospitals. The overall goal of the initiative is to achieve significant, sustained, and measurable reduction or elimination of five highly prevalent patient safety problems in selected hospitals worldwide over a five-year period—hence “High 5s.”

The initiative builds on the partnership established by the Commonwealth Fund with Australia, Canada, New Zealand, the United Kingdom, and the United States of America, and the more recent expansion of this international program to include Germany and The Netherlands.

The solution areas selected for the High 5s initiative were drawn from a broader set of patient safety solutions that are being developed by the WHO Collaborating Centre for Patient Safety for distribution to all of the WHO member nations later in 2007. These include:

  1. Prevention of patient care hand-over errors
  2. Prevention of wrong site/wrong procedure/wrong person surgical errors
  3. Prevention of continuity of medication errors
  4. Prevention of high concentration drug errors
  5. Promotion of effective hand hygiene practices

The Collaborating Centre will work with the participating countries to refine the current draft solutions through the development of standardized operating protocols similar to those used in high reliability industries such as aviation and nuclear energy.

We are excited about the innovative programs we have developed with WHO to date and we are open to more such alliances with WHO in the future.

Can you explain what ISQua is, and how your role there relates to JCI?

ISQua is The International Society for Quality in Health Care, and, simply put, is the “accreditor’s accreditor.” I’m proud of my role with ISQua and am so convinced of that organization’s value to the health care quality issue that JCI is currently undergoing ISQua accreditation. ISQua’s mission and ours are similar—excellent health care delivery for everyone—and we support that undertaking completely.

International Accreditations

"Driven by the rise in medical tourism, Asian healthcare organisations are fast embracing international accreditations and the awareness level is on the rise. Joint Commission International (JCI), the leading international accreditation body, has emerged as the gold standard in this area. It has already accredited 30 hospitals in the Asian region. JCI has also set up its first international office in Singapore recently.

1. What has been the response so far from Asian Hospitals to your accreditations? How do you view the demand for accreditations from Asia going forward?

I think the response so far has been very strong in Asia. Driven by the response JCI is opening its first Asia Pacific regional office in Singapore. Also, the hospitals are keenly interested in learning about issues like quality improvement, patient safety, Infection control or looking at how they can improve their care, for example, in the area of disease management, so the response really is strong.  A recently held five-day practicum at Singapore was fully booked about six weeks in advance! This shows that there is a very strong interest in education about quality standards in Asia. Going forward, I think the demand for accreditations will continue to be very strong. For one thing it’s such a huge region and there is a lot of activity - both at the public and private healthcare centres. And as we know, interest in healthcare tourism has really sparked off an interest in looking at some kind of distinction amongst hospitals. I think that the interest in accreditation will only continue to rise in the future.

2. Is your strategy for tapping the Asian market different from that for other markets in developed countries such as USA?

Asia, as I mentioned earlier, is a very broad and diverse region. In terms of strategy, JCI has just tried to be responsive to organizations that have expressed interest in some way working with us. It could be that they are interested in accreditations – this could be on a national level as well. For example, on July 31, 2006 JCI signed a memorandum of understanding with the government of China to work together in areas such as accreditations, quality improvement, patient safety and standards. Again, we have a very strong relationship with the Ministry of Health in Singapore and with some private associations in India. In Hong Kong the government’s priorities  are, looking at infection control and readiness for hospitals to handle major disease outbreaks, there may be very different issues for example in Malaysia and other countries.

I think we try to respond to the needs of the region. It’s often at a country level dealing with issues that may be going on over there.

3. Do you think that the accreditations accorded to a few hospitals in the region, should generate peer pressure among the hospitals in the region?

Well, I think that has already happened. In the unfolding of that scenario, JCI has been more of an observer. I think it is certainly true that almost any where in the world now, including the United States, healthcare is a very competitive market and as I mentioned before, particularly in the area of health tourism, where a hospital may be interested in attracting patients from outside its local market, definitely an accreditation is a way to distinguish for a hospital. Also a part of the competition is looking at working with multi-national corporations. For example, some large multi-national corporations are very interested in knowing where they should be sending their employees around the world for treatments.

4. What do you think about the incentives being offered by many American companies for getting treated in low-cost destinations like those in Asia?

There is sort of a growing movement among US companies. It is still relatively small.

5. What are the key pre-requisites for a hospital to get accredited successfully and retain it then on?

Well, one is that the hospital needs to have high level of commitment at the leadership level. I think that is perhaps the most important variable for a hospital to be able to be accredited. And the hospitals should also subject their processes to a very critical self-evaluation. They may break those processes up in terms of patient care or the safety of the facility or information management, but the standards really look at the overall framework of almost every aspect of the hospitals operations. So, it has to be the whole organization. It can’t just be one person or one department (the quality department) that’s told to look at this accreditation. This is something that ensures that the accreditation is sustained. And that starts with the leadership.

6. Given the industry demographics of the Asian hospitals (most of which are in the developing nations), do you think it is worthwhile for a mid-size Asian hospital to go for accreditation in cost-benefit terms?

That’s probably an individual decision for each hospital. But I have seen it in organizations with limited resources that JCI accreditation is still achievable and reach the standards. The way JCI has designed the standards we want it to be a very high level of care, but that could be how the organization meets the standards could allow some creativity. And I think ultimately by improving care and, for example, by reducing risks for patients it is a benefit in terms of cost benefit ratio. For example, there will be lower infection rates, better retention of staff, a general reduction in errors. That is also something that over a period of time we would like to study to see the specific improvements going forward with an organization. It would certainly be worthwhile in the long term for a smaller organization to be accredited.

7. What changes did Asian hospitals experience post-accreditation?

The difference is not so much to get the accreditation award, that’s the final step of the journey, but for the organization overtime. It takes about one to two years for an organization to become accredited. We have seen that the accreditation has made a lot of difference in terms of important aspects of care. Some of the feedback that we have got from hospitals in Asian region – and this is true about the hospitals around the world –is significant reduction in medication errors, reduced infection rates in hospital-acquired infections, improved pain management, and also a much developed system of assuring the competence level of the staff.

It’s interesting to note that some organizations have reduced medication errors by almost 75% to  80 %. That obviously translates into a better patient experience.

8. What challenges do hospitals face while preparing for accreditation and post accreditation?

I think it is important to be aware of what it takes to do this. It is not just “we’ll get ready for getting the accreditation” and then getting back to business as usual. It is really about transforming an organization and its processes. To really implement the processes and the policies, staff training is needed to ensure that this is sustained and I think the organizations that do this well really get to see a huge difference in the way they manage their hospitals. And this is a challenge; I mean that’s not something that is so easy to do. It takes strong commitment from the top management and particularly for some of the physician leaders. The physicians especially need to be very much on board with the entire process.

But while the top management needs to be fully committed, the role of the other staff cannot be ignored. We believe that their role is absolutely essential because so many of the standards touch on aspects of the patient rights, infection control, patient assessment and that’s actually by design –the way we have set up the standards. It is not like chapters of what nurses do or the staff does. It really is about taking a patient outward approach. And that is going to impact anybody who is involved in the running of the hospital or whose work interfaces with the patient’s stay at the hospital.

9. What effect does the implementation of accreditation standards has on the staff?

What we have heard from the organizations around the world, especially if this is done in a very positive way, as something like the entire organization is striving for, is that this can be enormously inspiring for the organization and they can take a lot of pride in things like team building. Again it’s the role of leadership to make it that way, and not really doing it because somebody else is doing it but because we think that it’s the right thing to do.

10. What is your message to the hospital directors of Asia?

We strongly believe that accreditations have been a very valuable organizing framework for looking at quality and patient safety and it demonstrates commitment to international standards to improve healthcare quality and patient safety. And JCI would encourage hospitals to go for the JCI or any other accreditation program and to really look at it as a management tool to monitor the operations on an ongoing basis. JCI would like very much to work with the hospitals in Asia in a supportive way and help them to understand the standards and help them to implement them by providing more education in the region which was emphasized by the Singapore Practicum with more to follow in countries like India, China and elsewhere in the region.