LM Unit-XIV Accreditation For Institutions PDF

ACCREDITATION FOR INSTITUTIONS(JCIA & ISO) Presented by Ms. Nazish Lakhani  Objectives On completion of this unit students will be able to:  Describe the historical back ground of the accreditation of institutions.  Define Accreditation.  Understand the role of the accreditation of inst...

ACCREDITATION FOR INSTITUTIONS(JCIA & ISO) Presented by Ms. Nazish Lakhani  Objectives On completion of this unit students will be able to:  Describe the historical back ground of the accreditation of institutions.  Define Accreditation.  Understand the role of the accreditation of institution.  Discuss the importance of accreditation in growth of the institutions.  Differentiate between ISO 9000 and JCIA.  Discuss its implementation in other hospitals / organization. 3-2  Brief History  Earnest Codman: End result system (effectiveness of treatment) 1910  The era of minimal standards 1917-1965  The era of optimal achievable standards 1966-1987  The era of performance evaluation 1988….. 3-3  Accreditation  Accreditation is a third-party certification process in which an organization or institution is evaluated against established standards by an independent body. The goal is to ensure that the entity adheres to predetermined quality and performance standards, thereby providing assurance of its competency and reliability. American National Standards Institute (ANSI) 3-4  Accreditation.  Hospital accreditation has been defined as “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve” 3-5  Healthcare Accreditation:  In the healthcare sector, accreditation is the process by which healthcare organizations such as hospitals, clinics, and laboratories are evaluated and certified by an external body to ensure they meet standards related to quality of care, patient safety, and operational performance Joint Commission International (JCI) Copyright 2006 John Wiley & Sons, Inc. 3-6  Role of Accreditation Institutions  Shows commitment to quality  Improves communication and collaboration within the organisation  Promotes team building  Increases credibility  Demonstrates accountability  Improves productivity  Obtaining advice from surveyors (mentoring) 3-7  Importance of Accreditation in Growth of the Institutions  Improve public trust that the organization is concerned for patient safety and quality of care.  Provide a safe and efficient work environment that contributes to worker satisfaction.  Listen to patient and their families, respect their rights, and involving them in the care process as partners.  Create a culture that is open to learning from the timely reporting of adverse events and safety concerned.  Established collaborative leadership that sets priorities for and continues leadership for quality and patient safety levels. 3-8  Importance of Accreditation in Growth of the Institutions  Identify systemic break-down and close gaps or loopholes.  Provide ways to detect and correct error and problems.  Ensure conformance to and effectiveness of documented processes.  Focus on patient and provider needs and expectation.  Streamline work flow and maximize resource utilization.  Maximize customer satisfaction 3-9  International Organization for Standardization (ISO) 9000  In February 1947 the International Organization for Standardization (ISO) was founded with 67 technical committees.  Originally develop for the industry.  Increasing use of standards in other areas (e.g.,Health Care) There are many different standards in the ISO 9000 family:  ISO 9001:2008 – defines requirements of a quality management system  ISO 9000:2005 - describes basic concepts and language  ISO 9004:2009 - focuses on how to improve a quality management system  ISO 19011:2011 - sets out guidance on internal and external audits of quality management systems. 3-10  The Joint Commission on Accreditation of Healthcare Organization (JCAHO)  Founded in 1951, based in Oakbrook Terrace, Illinois, US  Independent, not-for-profit organization.  Define quality standards specially tailored (design) for health care facilities.  Focuses on safety quality of medical services, patient and employee satisfaction.  All processes are assessed (from patient registration, examination, treatment up to the transfer and discharge of a patient) 3-11  The Joint Commission on Accreditation of Healthcare Organization (JCAHO)  Accredits and certified more than 19,000 health care organizations and programs in the US.  The whole organization, not just individual departments are being evaluated. 3-12  Joint Commission International (JCI)  Created in 1994  Implement the goals of the JCAHO (Joint Commission on Accreditation of Healthcare Organizations) at an international level  Support health care organizations through accreditation, education, and technical assistance.  Accreditation of an organization: is a recognition given to the health care organization, which meet the JCI standards.  JCI has a presence in organizations in more than 90 countries. 3-13  Differentiate between ISO 9000 and JCIA & ISO Standards Implementation: ISO JCIA ISO 9001: Focuses on quality management Patient Safety: Emphasizes patient safety, systems. quality of care, and organizational ISO 13485: Specific to medical device performance. manufacturing. Core Standards: Include governance, patient ISO 15189: For medical laboratories. care, infection control, and facility ISO 27001: Pertains to information security management. management. Training and Awareness: Training and Awareness: Staff Training: Educate employees about the Staff Education: Train staff on JCIA relevant ISO standards and their roles in standards, focusing on patient safety, care compliance. protocols, and compliance. Ongoing Education: Regular updates and Leadership Training: Ensure leadership refresher courses to keep staff informed. understands their role in supporting accreditation. 3-14  Cont.…. Certification: Survey Preparation: Selecting a Certification Body: Mock Surveys: Conduct internal mock Choose an accredited certification body to surveys to prepare for the official JCIA survey. perform the certification audit. Documentation Review: Ensure all required Audit: Undergo an audit where the documentation is in place and up-to-date. certification body assesses the compliance of the organization’s processes and systems with ISO standards. Certification: If successful, the organization receives certification, which must be maintained through periodic reviews and audits. Continuous Improvement : Maintaining Accreditation: Feedback and Reviews: Use feedback and Continuous Compliance: Continue to adhere to audit results to continuously improve JCIA standards and implement improvements processes. as needed. Ongoing Training: Ensure that all staff are Periodic Surveys: Prepare for periodic updated on changes and improvements in reaccreditation surveys to maintain standards. accreditation status 3-15 Thank you 3-16  References  Marquis, L.B., & Huston, C.D. (2006). Leadership roles and management functions in nursing: “Theory & Application”, Philadelphia: Lippincott.  Sulllivan.J. Decker. (2005). “Effective leadership and management in nursing”, Addison Wesley Longman.  M.A.Tomy. (2004). “Guide Nursing Management and Leadership” Mosby. 3-17