1、What is JCI?何谓何谓JCI?JCI is an international accreditation arm of JCAHO(Joint Commission on Accreditation of Health Care Organisations)40 hospitals are accredited with JCI across 11 other countries(1 in Thailand,1 in Philippines,1 in China)5000 US hospitals(96%of bed capacity)are accredited with JCAH
2、OJCAHO is dedicated to improving clinical quality and patient safetyJCI Standard Hinges On 2 Broad Areas:JCI 标准视以下两大方面而定标准视以下两大方面而定:Equivalent&Complements ISO standards与与 ISO 标准相似并互补标准相似并互补v Patient-centred Standards 以病人为中心的标准以病人为中心的标准v Health Organisation Mgmt Standards 医疗机构管理的标准医疗机构管理的标准Standards标
3、准标准Core Standards核心标准核心标准About JCI Standards 有关有关JCI标准标准MeasurableElements可衡量元素可衡量元素Must Meet all Core Standards 必定要达到所必定要达到所有核心标准有核心标准About JCI Standards 有关有关JCI标准标准Patient-Centered Standards以病人为中心的标准以病人为中心的标准 Access to care and continuity of care(ACC)能享有医护和连续性的医护能享有医护和连续性的医护 Patient and Family Rig
4、hts(PFR)病人及家属的权利病人及家属的权利 Assessment of Patient(AOP)诊断病情诊断病情 Care of Patients(COP)医治及护理病人医治及护理病人 Patient and Family Education(PFE)教育病人及家属教育病人及家属Health Organization Mgmt Standards医疗机构管理的标准医疗机构管理的标准 Quality improvement and patient safety(QPS)素质改进及病人安全素质改进及病人安全 Prevention and control of infections(PCI)预
5、防及控制传染预防及控制传染 Governance,leadership,and direction(GLD)管理、领导和引导方向管理、领导和引导方向 Facility management and safety(FMS)设施管理和安全设施管理和安全 Staff qualifications and education(SQE)职员的资历和教育职员的资历和教育 Management of information(MOI)咨汛管理咨汛管理Why JCI for NUH?为什么本院追求为什么本院追求JCI品质认证品质认证?Commitment To Enhance:承诺加强承诺加强:v Patien
6、t Safety 病人的安全病人的安全v Co-ordination of Care 护理的协调护理的协调Continuity of Care 连续性的医护连续性的医护Patient&Family Rights 病人及家属的权利病人及家属的权利Patient&Family Education 教育病人及家属教育病人及家属Quality Improvement&Patient Safety 素质改进及病人安全素质改进及病人安全Prevention&Control of Infections 预防及控制传染预防及控制传染Management of Information 咨汛管理咨汛管理Staff
7、 Qualifications&Education 职员的资历和教育职员的资历和教育Facility Management&Safety 设施管理和安全设施管理和安全Governance,Leadership&Direction 管理、领导和引导方向管理、领导和引导方向Using JCI to Manage&Improve Clinical Care利用利用JCI标准来管理和改善医疗护理标准来管理和改善医疗护理Assessment of Patients诊断病情诊断病情Care of Patients医治及护理病人医治及护理病人Access to Care能享有医护能享有医护Billing&D
8、ischarge开给账单和出院开给账单和出院Clinical 医护Medical 医疗Nursing 护理Clinical Support医护辅助 Services 服务Patient Services 病人服务Financial Services 财务服务Environmental Services 环境设备服务Food Services 膳食服务Patient Services病人服务Financial Services财务服务Patient-Centered Standards 以病人为中心的标准以病人为中心的标准HealthCare Organization Management St
9、andards医疗机构管理的标准医疗机构管理的标准Appointment 预约Marketing 促销Registration 登记Admission 入院JCI Provides A FrameworkJCI 提供一个结构框架提供一个结构框架JCI requirements provide the framework to strengthen patient care processes and the management structure required to sustain excellence in standards of care.JCI 的要求为加强病患护理的程序及的要求
10、为加强病患护理的程序及维持管理架构所需的杰出护理标准提维持管理架构所需的杰出护理标准提供基础框架。供基础框架。How JCI sits in NUHs overall Framework?JCI 如何融入本院的整体结构框架如何融入本院的整体结构框架?SystemsFramework体系框架体系框架ContinualImprovement持续改进持续改进Improve Care&Lower Costs 改进护理并减低成本改进护理并减低成本Quality 素质认证素质认证ISO 9001Health&Safety 卫生和安全素质认证卫生和安全素质认证OHSAS 18001People 人力资源素质
11、认证人力资源素质认证PDS&People ExcellenceReduce Health&Safety Risks减低对健康及安全的威胁减低对健康及安全的威胁Singapore Quality Framework 新加坡素质认证框架新加坡素质认证框架Spore Quality Class 新加坡素质认证等级新加坡素质认证等级CORE VALUES 核心价值观核心价值观Clinical,Process&Service Excellence卓越的医疗护理、流程及服务卓越的医疗护理、流程及服务Balanced Scorecard 平衡记分卡平衡记分卡High Level Outcomes高层绩效高层
12、绩效OrganisationalExcellence机构优异表现机构优异表现Environment 环境素质认证环境素质认证ISO 14001CPIP,6 Sigma&IQC Projects CPIP,6 Sigma&IQC 项项目目Learning&Growth学习与成长学习与成长Service 服务服务Process 流程流程Clinical 医疗护理医疗护理Quality,Environmental,Health&Safety Management Systems Culture,Systems&Tools素质，环境，健康和安全管理系统文化，体系素质，环境，健康和安全管理系统文化，体系
13、及及工具工具JCI Accreditation JCI 素质认证素质认证MISSION&VISION 使命及远景使命及远景People Excellence 杰出人力资源杰出人力资源Learning Environment学习环境学习环境Quality&Cost-Effective Care&Service优质及经济效益的优质及经济效益的 护理和服务护理和服务Social Responsibility to Environment&Community对环境及社区承担对环境及社区承担的社会责任的社会责任Safe Work Environment for Staff&Patients为员工和病人提
14、供安全为员工和病人提供安全 的工作环境的工作环境Reduce,Reuse&Recycle Resources&Waste减少、再用和再循环资源及废弃物减少、再用和再循环资源及废弃物Our JCI Journey我们迈向我们迈向JCI的历程的历程JCI 专家到访专家到访20032004Publicise,Awareness,Documentation&Implementation宣传，提高意识宣传，提高意识,文件笔录及贯彻完成文件笔录及贯彻完成Phase 1第一阶段第一阶段Phase 2第二阶段第二阶段Phase 3第三阶段第三阶段OctoberNovember DecemberJanuaryF
15、ebruaryMarch to April May to June July十月十月十一月十一月十二月十二月一月一月二月二月三至四月三至四月 五至六月五至六月 七月七月Road Shows路展路展New MOs新的医疗人员新的医疗人员Self AssessmentIdentify GapsBridge GapsJCI Expert VisitJCI 专家到访专家到访Self Audit,Review&ImplementationRoadshows路展路展Survey自我评估自我评估认识差距认识差距弥补差距弥补差距自我审计、评审及自我审计、评审及贯彻完成贯彻完成调查调查Workshop&Mock
16、 SurveyCompletion of Documentation实习班及模拟调查实习班及模拟调查完成文件的纪录完成文件的纪录Overview of JCI Survey Process纵观纵观JCI评审调查过程评审调查过程Continuous Quality Improvement 持续的素质改进持续的素质改进Initial Review of Core Standards初始评审核心标准初始评审核心标准Identify Gaps辨别差距辨别差距Close Gaps with Inputs from JCI Champions从从JCI得主吸取经验弥补差距得主吸取经验弥补差距Repeat
17、Review of Core Standards多次评审核心标准多次评审核心标准Implement Strategies to Improve Work Process实行策略改进工作程序实行策略改进工作程序Quality Improvement Framework素质改进的结构框架素质改进的结构框架Sentinel Eventseg surgical mishaps,ADEsFrequent Adverse Eventseg Transfusion reactions,nosocomial infections,falls,medication errors,pressure ulcersN
18、ear Misseseg mislabelling,prescription&administration of drugsUnderuse,Overuse,MisuseSentinel Event Review/Root Cause AnalysisDETECTION觉察觉察 IMPROVEMENT改进改进Review by QA/Peer Review Committees(eg Infection Control&Blood Transfusion Committees)ANALYSIS分析分析Monitor and Evaluate Change No-fault reporting(
19、eHOR)Clinical Review Program(Chart reviews)Patient Feedback/Survey Casemix Data Clinical AuditStrategies for Improvement Clinical Practice Improvement Programme(CPIP)Collaborative Projects (eg Ventilator Bundles)QA Programmes (eg QIP&ACHS Indicators)Process Improvements (eg Quality Circles,6 Sigma,W
20、ork Redesign)REPORT&SPREADCHANGE MANAGEMENT改变管理改变管理Clinical Outcomes Tracking System NHG 2004Annex 2(Refer to NUH-HAP-QIU-003 NUH QI&PS Plan Annex 2)Patient Info Brochure病人讯息小册子病人讯息小册子Patient Rights&Responsibilities Leaflet available at all SOCs,Wards and EMD在所有诊所、病房和急诊在所有诊所、病房和急诊部展放有关病人权利和责部展放有关病人权
21、利和责任的小册子任的小册子Patient Education教育病人教育病人A health information and resource centre for patients and visitors Our Patient Education HubAs part of our patient education efforts,posters on are displayed in our lift notice boards,wards and clinics/centres.Through this,we keep our patients informed of their
22、roles in helping to achieve the safest and best possible medical care and treatment.A JCI Initiative在电梯里，病房里和诊所里的布在电梯里，病房里和诊所里的布告版占卦教育病人的告版占卦教育病人的“五步安全五步安全医护医护”海报，借此灌输病人如何海报，借此灌输病人如何协助达到最安全和最佳的医护和协助达到最安全和最佳的医护和医疗。医疗。DO NOTDO NOTuse the following highuse the following high-risk risk abbreviations whe
23、n prescribing medications abbreviations when prescribing medications HHi ig gh hHHi ig gh h-R Ri is sk k A Ab bb br re ev vi ia at ti io on ns sR Ri is sk k A Ab bb br re ev vi ia at ti io on ns sSTOPSTOPHHi ig gh hHHi ig gh h-R Ri is sk k A Ab bb br re ev vi ia at ti io on ns sR Ri is sk k A Ab bb
24、br re ev vi ia at ti io on ns sSTOPSTOPSTOPSTOPMS or MSO4morphine sulphateMTXmethotrexateMgSO4magnesium sulphateOrder medications by their full nameDO NOT use abbreviationsQOD,qod or eodevery other dayug or UGmcgiu or IUinternational unitu or UunitDo Not WriteDo Not WriteSpell OutSpell OutMS or MSO4
25、morphine sulphateMTXmethotrexateMgSO4magnesium sulphateOrder medications by their full nameDO NOT use abbreviationsQOD,qod or eodevery other dayug or UGmcgiu or IUinternational unitu or UunitDo Not WriteDo Not WriteSpell OutSpell Out DO NOT USE a trailing zero when doses are expressed in whole numbe
26、rs.Write 10mg NOT 10.0mg USE a leading zero before the decimal when the dose is less than a whole unit.Write 0.5mg NOT.5mgWriting namesof drugs correctlyfor patient safety使用正确的药物名称，使用正确的药物名称，提高病人安全水准。提高病人安全水准。Attention all Healthcare Professionals!in accordance to the and when there is contact or ri
27、sk of contact with blood or body fluids.Protective barriers to potentially infective material.to protect skin on hands to protect the skin and mucosa on the face and to reduce risk due to inhalation of infective material to protect skin,eyes and/or mucosa on the face when splashes are likely to occu
28、r.减少感染，工作时应穿戴适当的保护装备如：手套、面罩、眼罩和外套！减少感染，工作时应穿戴适当的保护装备如：手套、面罩、眼罩和外套！Attention all Healthcare Professionals!MINIMISE YOUR RISK OF MINIMISE YOUR RISK OF INFECTION INFECTION FDo not recap needlesFDiscard sharps into the“Sharp”box personally FMaintain a safe working distance when yourcolleague is handling
29、 sharpsFDo not pass sharps from hand to hand减少感染，小心和适当的处理针头减少感染，小心和适当的处理针头！减少感染，小心和适当的处理针头减少感染，小心和适当的处理针头！Pain Assessment 疼痛评估疼痛评估 All patients will be assessed for pain为所有病人进行疼痛评估为所有病人进行疼痛评估 Assessment will be done every shift/as and when required在每个轮班或有需要时才在每个轮班或有需要时才进行进行 Inform doctors if patient
30、 complains of pain通知医生如果病人告知身体通知医生如果病人告知身体疼痛疼痛 Findings will be monitored as 5th vital signin the clinical chart调查结果将列为第五个至关重要调查结果将列为第五个至关重要的标志，在临床图表上观察。的标志，在临床图表上观察。Staff Emergency Info Card职员的紧急意外电话号码卡职员的紧急意外电话号码卡All staff carry an Emergency Information Card with important numbers to call for vari
31、ous emergencies.所有职员都携带一张所有职员都携带一张紧急意外电话号码卡紧急意外电话号码卡Front 前Back 后Clinical Practice Improvement Program A Model for Improvement 临床实践改进项目模式临床实践改进项目模式Act行动行动Plan策划策划Study研究研究Do实践实践What are we trying to accomplish?How will we know that a change is an improvement?What changes can we make that will result
32、 in an improvement?Clinicians driving improvement projects to improve Clinical Processes&Outcomes医疗人员推行改进项目为改善临床程序和效果医疗人员推行改进项目为改善临床程序和效果JCI Accreditation involves hard work,sweat,arguments,tough decisionsBut it is WORTH IT!取得JCI品质认证需要勤劳地工作、汗水、探讨、坚强的意志但这些都是值得的值得的!v A journey taken together 一个共同奋斗的历程
33、Between professional groups 专业小组之间Among professionals 专家之间v Cross-learning/dialogue 相互学习/对话v Working as a team for patients interest 发挥团队精神，以病人的利益为主Value of JCIJCI的价值观的价值观v Top leadership commitment(CEO&CMB)-Must Believe In It!高层领导者的承诺(CEO&CMB)-坚定的信念!v Leader-driven(esp.Clinician&Nursing)领导带头(尤其是医师及
34、护理人员)v Active involvement of doctors/nurses through JCI Clinician Core Group&Nursing Champions 通过JCI 临床核心组及看护得主让医生/护士积极参与v Awareness&Communication(handbook,emails,intranet,posters,briefings,daily logons)意识及沟通(笔记、电邮、企业网、海报、会议、电脑讯息)v Just do IT!(Fight against temptation to procrastinate)现在就做!(决不拖延)v P
35、ersevere.坚持.Some Lessons经验之谈经验之谈v JCI Accreditation is not an end nor a statement that an organisation has arrived!JCI 品质认证对一个机构而言既不是终点也不是一份声明！v It is the beginning of a commitment to make healthcare SAFER,Better,Faster&Cheaper 它是对更安全、优质、快捷及经济的医疗护理的承诺的一个开始v It is an on-going journey.这是一个持续不断的旅程.Conclusion总结总结Measurable Outcomes能衡量的结果能衡量的结果$
