2009 middle eastern international practicum on quality ... · 2009 middle eastern international...
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2009 Middle Eastern International Practicum on Quality Improvement and Accreditation
Joint Commission InternationalAmman, JordanGrand Hyatt Amman13 - 17 December 2009
Joint Commission International (JCI) would like to graciously thank the Jordanian Private Hospital Association for their assistance in hosting the 2009 Amman International Practicum. JCI would also like to thank our tracer demonstration hosts, The Specialty Hospital and the King Hussein Cancer Center, for their generous contribution of time and resources.
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Table of Contents Day 1: The JCI Process and Standards Agenda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Overview of JCI and Practicum Logistics . . . . . . . . . . . . . . . . . . . . . . . . . 9 JCI Process 1: Introduction to the JCI Standards . . . . . . . . . . . . . . . . . . .25 JCI Process 2: Introduction to the Evaluation Methodology . . . . . . . . . .36 Patient-Centered Standards Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Organizational Management Standards Review. . . . . . . . . . . . . . . . . . . .61 Access to Care and Continuity of Care Standards. . . . . . . . . . . . . . . . . . .81 JCI Process 3: After the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Day 2: The Survey Process Tracer Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 The Survey Simulation: What to expect. . . . . . . . . . . . . . . . . . . . . . . . . . .114 Case Study 1: Answering Tracer Questions . . . . . . . . . . . . . . . . . . . . . . . 123 Root Cause Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Day 3: The Survey and Continual Improvement Failure Modes and Effects Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148 Failure Modes and Effects Analysis Example Sheets . . . . . . . . . . . . . . .169 Day 4: The Survey and International Patient Safety Goals Last Survey Simulation Discussion and Reflective Learning . . . . . . . . . .177 Four Steps for Continual Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Day 5: Tools and Techniques Communication Between Hospital Staff, Patients, and Families . . . . . . 191 International Patient Safety Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .205 How to Get Started with JCI Accreditation. . . . . . . . . . . . . . . . . . . . . . . . 214 Appendix Tracer Activity Data Collection Tool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Speaker Biographies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
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2009 Amman Practicum Agenda
Day 1: The JCI Process and Standards 13 DecemberStart End Speaker7:30 - 9:00
9:00 - 9:30Dr. Ashraf Ismail and Dr. Fawzi Al
Hammouri, MD, President, Jordanian Private Hospital Association
9:30 - 9:45 Mr. Matt Spurgeon
9:45 - 10:15 Dr. Ashraf Ismail
10:15 - 10:30
10:30 - 11:00 Ms. Sherry Kaufield
11:00 - 12:15 Dr. Ashraf Ismail
12:15 - 13:15
13:15 - 14:30 Ms. Sherry Kaufield
14:30 - 14:45
14:45 - 15:30 Ms. Sherry Kaufield
15:30 - 16:15 Dr. Ashraf Ismail
SessionRegistration
Welcome
Introduction of Joint Commission International and Practicum Overview
The JCI Process 1: Introduction to JCI Standards
Break
The JCI Process 2: Introduction to Evaluation Methodologies
Patient-Centered Standards Review
Lunch
Organizational Management Standards Review
Break
Standards in Detail: Access to Care and Continuity of Care (ACC)
The JCI Process 3: After the Survey
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2009 Amman Practicum Agenda
Day 2: The Survey Process 14 December
Start End Speaker
9:00 - 10:00 Ms. Sherry Kaufield
10:00 - 10:30 Ms. Sherry Kaufield
10:30 - 10:45
10:45 - 11:45 The Speciality Hospital Leadership and Consultants, Moderator: Dr. Ashraf Ismail
11:45 - 13:15
13:15 - 14:15 AM Goup: Case Study 1 Ms. Sherry Kaufield and Mr. Matt Spurgeon
14:15 - 15:15 Root Cause Analysis Ms. Sherry Kaufield and Mr. Matt Spurgeon
AM Group Adjourns at 3:15 PM
Day 3: The Survey and Continual Improvement 15 December
Start End Speaker
9:00 - 10:20 PM Group: Survey Simulation Discussion and Reflective Learning Ms. Sherry Kaufield and Mr. Matt Spurgeon
10:20 - 10:40 Break
10:40 - 12:00 PM Group: Advanced Quality Strategies: FMEA Ms. Sherry Kaufield and Mr. Matt Spurgeon
12:00 - 13:30
13:30 - 14:50 AM Group: Survey Simulation Discussion and Reflective Learning Ms. Sherry Kaufield and Mr. Matt Spurgeon
14:50 - 15:10 Break
15:10 - 16:30 AM Group: Advanced Quality Strategies: FMEA Ms. Sherry Kaufield and Mr. Matt Spurgeon
AM Group: Introductory Tracer Simulation
Session
15:15 - 16:30
PM Group: Final Tracer Simulation
JCI Evaluation Methods: Tracer
Session
The Survey Simulation
Break
Mock Opening Conference
Lunch and Travel
PM Group: Introductory Tracer Simulation
Lunch and travel
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2009 Amman Practicum Agenda
16 December
Start End Speaker
9:00 - 9:45 PM Group: Survey Simulation Discussion and Reflective Learning Ms. Sherry Kaufield and Mr. Matt Spurgeon
9:45 - 10:00 Break
10:00 - 11:00 Root Cause Analysis Ms. Sherry Kaufield and Mr. Matt Spurgeon
11:00 - 12:00 PM Group: Case Study 1 Ms. Sherry Kaufield and Mr. Matt Spurgeon
12:00 - 13:15
13:15 - 14:00 Dr. Ashraf Ismail
14:00 - 14:15
14:15 - 15:30 Moderated by Ms. Sherry Kaufield
15:30 16:00 Dr. Ashraf Ismail
PM Group adjourns at 4:00 PM Ms. Sherry Kaufield and Mr. Matt Spurgeon
Day 5: Tools and Techniques 17 December
Start End Speaker
9:00 - 10:00 All Faculty
10:00 - 10:30
10:30 - 11:30 Dr. Ashraf Ismail
11:30 - 12:00 Ms. Sherry Kaufield
12:00 - 13:00
13:00 - 13:45 Moderated by Dr. Ashraf Ismail
13:45 - 14:30 Ms. Sherry Kaufield
14:30 - 15:00 All Faculty
Break
Challenging Standards
AM Group: Final Tracer Simulation
Session
Day 4: The Survey and International Patient Safety Goals
16:00 16:45-
Lunch
Getting Started: Advice for those seeking their first Accreditation
Closing Remarks and Presentation of Certificates
Session
Small Group Discussions
Check-Out Break
Communication Between Hosptial Staff, Patients, and Families
Lessons Learned From Local Accredited Organizations: The Specialty Hospital
AM Group: Survey Simulation Discussion and Reflective Learning
Lunch and Travel
The Cost of Accreditation
Lessons Learned From Local Accredited Organizations: King Hussein Cancer Center
International Patient Safety Goals
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Learning Objectives 2009 Middle Eastern International Practicum on Quality Improvement and Accreditation Amman, Jordan 13 – 17 December Course Objectives Participants who complete this program will be able to:
1. Use the 3rd Edition of Hospital Standards to identify and understand accreditation requirements
2. Explain the most challenging and difficult standards 3. Implement needed measures to comply with JCI Accreditation Standards for
Hospitals 4. Explain the activities that take place during a survey 5. Implement the processes necessary to reduce the risks for errors and improve safety
Specific Session Objectives Understanding the Tracer Methodology Survey Process Participants who complete this learning section will be able to:
1. Explain the major attributes of the tracer methodology process 2. Begin to use elements of the tracer methodology to improve the delivery of
healthcare in their organization 3. Use the tracer methodology to assess relationships and communications among
disciplines and across important functions Root Cause Analysis Participants who complete this learning section will be able to:
1. Explain the major attributes of the root cause analysis method 2. Use RCA to understand how and why adverse events occur in their organization 3. Use RCA data to minimize the repetition of similar adverse events
Getting Started: The Road to Accreditation Participants who complete this learning section will be able to:
1. Explain how the accreditation process functions 2. Explain the timeline for accreditation 3. Develop a plan for meeting the requirements of accreditation
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International Patient Safety Goals Participants who complete this learning section will be able to:
1. Explain how the International Patient Safety Goals (IPSGs) function within the context of the International Standards for Hospitals, 3rd Edition
2. Explain the changes that the IPSGs bring to the accreditation process 3. Explain the current set of IPSGs
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Day 1: The JCI Process
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Joint Commission InternationalWelcome to
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Overview of JCI and Practicum LogisticsMatthew SpurgeonAssociate Director, International ServiceJoint Commission International
Introduction to JCI and Accreditation
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Welcome
– We are pleased to welcome you to the first Amman Practicum
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Introduction to JCI and Accreditation
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– To improve the safety and quality of care in the international community
– Thank you for joining us in our shared mission to positively impact the lives of patients around the world.
Mission of Joint Commission International
Introduction to JCI and Accreditation
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What is JCI?
– Joint Commission International (JCI) is the international arm of The Joint Commission (USA).
– Both organizations are independent, non-profit, non-governmental agencies
Introduction to JCI and Accreditation
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JCI’s International Structure
– International Board of Directors (of JCR)– International Accreditation Committee– International Standards Committee– Regional Advisory Councils – Four International Offices
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Introduction to JCI and Accreditation
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Mission Work at Three Levels
– Individual organizations– accreditation, consultation, and education
– Country level efforts– assist Ministries of Health and
Governmental Agencies to strengthen the role of quality oversight
– International level– build consensus; share quality and safety
information
Introduction to JCI and Accreditation
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The Joint Commission Family of Organizations
Accreditation Consulting
Introduction to JCI and Accreditation
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Accreditation Consulting
The Joint Commission Family of Organizations
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Introduction to JCI and Accreditation
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Accreditation Consulting
The Joint Commission Family of Organizations
Introduction to JCI and Accreditation
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Accreditation Consulting
The Joint Commission Family of Organizations
•Accreditation survey
•Education for accredited organizations
•Development of new standards
•Assist organizations in meeting their patient safety and accreditation goals
•Consulting service
•Custom Education
•Accreditation and Quality Improvement education for all organizations.
Introduction to JCI and Accreditation
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– Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standards that require continuous improvement in structures, processes, and outcomes.
Accreditation – A Definition
– Usually a voluntary process– Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions
– Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standards
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JCI Accredited Organizations
Currently, JCI has accredited over 273 of the world’s best healthcare organizations
Bermuda
Brazil
Mexico
Barbados
Chile
Costa Rica
Pakistan
India
Thailand
Singapore
Philippines
China
Hong Kong
Taiwan
S. Korea
Bangladesh
Indonesia
Malaysia
Turkey
Egypt
Ethiopia
Saudi Arabia
QatarUAE
JordanLebanon
Spain
Ireland
Demark
Germany
Cz. R.
Aus
Italy
Swz.
JCI Accredited Organizations
Currently, JCI has accredited over 273 of the world’s best healthcare organizations
Bermuda
Brazil
Mexico
Barbados
Chile
Costa Rica
Pakistan
India
Thailand
Singapore
Philippines
China
Hong Kong
Taiwan
S. Korea
Bangladesh
Indonesia
Malaysia
Turkey
Egypt
Ethiopia
Saudi Arabia
QatarUAE
JordanLebanon
Spain
Ireland
Demark
Germany
Cz. R.
Aus
Italy
Swz.
JCI HeadquartersChicago, USA
JCI European OfficeFerney-Voltaire, France
JCI Middle East OfficeDubai, UAE
JCI Asia-Pacific OfficeSingapore
JCI Accredited Organizations
JCI’s work is supported by our headquarters and three regional offices
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JCI Accreditation and Quality Improvement AssistanceConsulting, Education, Publications, Tools
Introduction to JCI and Accreditation
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Assistance from JCI
– JCI recognizes that the accreditation and quality improvement process can be difficult and confusing.
– JCI has assembled a global group of experts and resources to help organizations achieve our common goal: Increased patient safety and continuous quality improvement
Introduction to JCI and Accreditation
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Assistance from JCI
– JCI’s assistance is separated into three categories:– Consulting Assistance– Education Programs– Publications
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Introduction to JCI and Accreditation
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The Joint Commission Firewall
Accreditation Consulting
Introduction to JCI and Accreditation
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The Firewall
– No sharing of organization-specific information
– Neither side may share their “client” list.– Ensures the integrity of our accreditation
decisions and consultation advice.
Accreditation Consulting
Introduction to JCI and Accreditation
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JCI Consulting Assistance
– JCI Consultants are available to provide expert education and advice.
– JCI Consultants provide a wide scope of services, designed to meet the needs of our partner organizations.
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Introduction to JCI and Accreditation
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18-24 Months
Typical Preparation Process
Organizational
Assessment
Ongoing
Technical
Assistance
Off-site Document
Review
Mock Survey
JCIA Survey
Ongoing
Technical
Assistance
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Practicum Logistics
Matthew SpurgeonAssociate Director, International ServiceJoint Commission International
Introduction to JCI and Accreditation
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Learning Objectives
1. Use the 3rd Edition of Hospital Standards to identify and understand accreditation requirements
2. Explain the most challenging and difficult standards3. Implement needed measures to comply with JCI
Accreditation Standards for Hospitals4. Explain the activities that take place during a survey5. Implement the processes necessary to reduce the
risks for errors and improve safety
After completing this course, participants will be able to:
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Introduction to JCI and Accreditation
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Day 1: The JCI Process
– Overview of the entire accreditation process
– Overview of the JCI’smethodology
– Comprehensive review of individual standards replaced by overviews of challenging standards and case studies.
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Day 2: The Survey Process
– In depth exploration of how JCI surveys organizations– Tracer methodology– The survey– Mock leadership interview
– Our first “split session” is scheduled for Tuesday afternoon
– AM group will break early
Introduction to JCI and Accreditation
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How Are Participants Divided?
Practicum Participants (100 ppl)
Green Morning Group (50)
Team 1 (8)Team 2 (8)
Team 3 (9) Team 4 (8)Team 5 (8)
Team 6 (9)
Blue Afternoon Group (50)
Team 7 (8)Team 8 (8)
Team 9 (9)
A Section (25) B Section (25) C Section (25) D Section (25)
Team 10 (8)Team 11 (8)
Team 12 (9)
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Introduction to JCI and Accreditation
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Your Name Badge
– Please note your group and team assignments
– Unfortunately, we cannot change your group assignment
– Please write your preferred name in the box
Elvis
Introduction to JCI and Accreditation
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Tracer Demonstration Assignments
A
B
D
C
B
A
C
D
AM PMTuesday
AM PMWednesday
AM PMThursday
Tracer Team 1
Tracer Team 2
Introduction to JCI and Accreditation
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Day 3: The Survey and Continual Improvement– Both groups will
participate in a tracer today
– When not tracing patients, groups will:– Discussion and
reflective learning– Five steps for
continual improvement
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Introduction to JCI and Accreditation
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Day 4: The Survey and International Patient Safety Goals– The Morning group
finishes their second tracer
– Mock closing conference
– International Patient Safety Goals
– Afternoon group breaks early
Introduction to JCI and Accreditation
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Day 5: Tools and Techniques
– Discuss how organizations prepare for the accreditation process
– Advanced Quality Strategies
– Closing remarks
Introduction to JCI and Accreditation
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Help us…
– Please complete an evaluation form– If we have spelled your name incorrectly
on your name badge, please see us before the end of the day on Tuesday
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Introduction to JCI and Accreditation
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Thank You
– Questions?
Introduction to JCI and Accreditation
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Next Presentation
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Notes
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Notes
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Introduction to the JCI Standards
Client name/ Presentation Name/ 12pt - 2
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The Transparent JCI Process
International Standards
On-siteEvaluation of
Standards
Accreditation Decision
Rules
Accreditation Certificate
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Joint Commission International Standards
– Set optimum, achievable expectations
– Focus on the patient– Designed to be
interpreted/surveyed within the local culture and legal framework
– Stimulates continuous improvement
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Sources of Input for Standards
– Scientific literature– Research findings– Survey compliance data– Input from field experts and key
stakeholders– Regional Advisory Councils– JCI staff and surveyors
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Review and Approval Process
– Consensus of the Standards Subcommittee (12 members)
– Review by individual experts or expert panels – Focus groups on select areas– Internet review by as many international
users as possible– Final approval by Accreditation Committee
and the Board of JCI
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Standards Subcommittee– Subcommittee members from:
– Singapore (2) - Chair– Czech Republic– United States (3)– Brazil– Saudi Arabia– Denmark– P. R. China– South Africa– A JCI Surveyor
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Client name/ Presentation Name/ 12pt - 7
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What is a standard?
A statement of the safety A statement of the safety and and
quality expectedquality expected
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Types of Expectationsin Standards
– Inputs (Structures): Resource
– Processes: Activities
– Outcomes: Results
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InputsInputsPersonnelPersonnelEquipmentEquipmentSuppliesSupplies
ProcessesProcessesAdmissionAdmissionTest ProceduresTest ProceduresPatient EducationPatient EducationTreatmentTreatment
OutcomesOutcomesImproved health Improved health
statusstatusEfficient Efficient
servicesservicesPatient Patient
satisfactionsatisfaction
At the System Level
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InputsInputsPhysicianPhysicianMidwifeMidwifeClampsClampsDrapesDrapesGlovesGloves
ProcessesProcessesCut the umbilical cordCut the umbilical cordAssess the newbornAssess the newbornDeliver the placentaDeliver the placenta
OutcomesOutcomesA healthy baby A healthy baby
is bornis bornMother has no Mother has no
complicationscomplications
System Example -Delivery
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Comparisons with other standards regimens
– International standards include all topics found in Joint Commission (USA) standards
– International standards contain all the quality control and quality leadership ISO 9000 criteria
– International standards include the criteria of the European (EFQM) and U.S. (Baldridge) quality awards
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Translation of StandardsThe JCI hospital standards have been
translated into:– Chinese– Spanish– German– Danish– Italian
–Portuguese–Turkish–Czech–Brazilian Portuguese–Arabic
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Hospital Standards-3rd
Edition ChaptersPatient-Centered Standards
– Access to Care and Continuity of Care– Patient and Family Rights– Assessment of Patients– Care of Patients– Anesthesia and Surgical Care– Medication Management and Use– Patient and Family Education
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Hospital Standards-3rd
Edition ChaptersHealth Care Organization and
Management Standards– Quality Improvement and Patient Safety– Prevention and Control of Infections– Governance, Leadership, and Direction– Facility Management and Safety– Staff Qualifications and Education– Management of Communication and
Information
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Standards Components
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Standards Content– Each JCI standard contains three
components:– The standard represents the
principle– The intent describes the rationale of
the standard– The measurable elements are the
detailed requirements from the standard and intent that are scored
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Hospital Standards and Requirements
– Over 300 standards– Over 1000 criteria measured during the
survey/evaluation process– Required compliance with the
International Patient Safety Goals– International Core Measures are
voluntary
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Scoring of Lists in Intent Statements
– Note that there are two ways the lists in the Intent Statements are scored.– The list may be all scored as part of one
measurable element.– The list may be scored with each a
separate measurable element– The difference is the type of evidence of
compliance or the critical nature of each item on the list
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Introduction to the JCI StandardsEvaluation Methodology
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The Transparent JCI Process
International Standards
On-siteEvaluation of
Standards
Accreditation Decision
Rules
Accreditation Certificate
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ampleSample Sample Sample Sample Sample
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ampleSample Sample Sample Sample Sample
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The JCI Evaluation Process
– Covers all portions of an organization and all systems of care and management
– Is focused on what happens to patients – patient tracers used
– Is proactive – evaluates the likely quality and safety of patient care in the future
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What is the Tracer Methodology?
An evaluation method that is an effective way to assess a healthcare organization’s performance of care and the services provided as viewed or experienced by the patient.
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Tracer Methodology
Tracers provide the methodology to assess an organization’s systems and
processes by; – Following the treatment path an individual
patient has taken in the hospital, or– Following a process in the hospital from a
beginning to an endpoint.– It is about areas for improvement
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Tracer Selection Criteria Top diagnoses and procedures. (surgical, medical, intensive care)A patient on dialysis. A psychiatric patient. A pediatric patient. A patient receiving lab/imaging services. A patient receiving rehabilitation services.Patients due for discharge that day or the next day System tracers.
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Opening Conference– Introductions
– Staff– Hospital leadership
– Review agenda– Discussion of key survey activities
– Patient and System Tracers– Process for requesting staff files for review– Daily briefings
– Surveyor Scoring Process– Orientation of surveyors by hospital (30 min)
– The hospital and its scope of services– QI model used by hospital & a process that had been
improved
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Patient Tracer: Systems Analysis
– Set of components that work together toward common goal
– Evaluation of how - and how well - the organization’s systems function
– Addresses interrelationships of elements– Translates standards compliance issues into
potential vulnerabilities as far as patient quality and safety
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System Tracers– Medication Management
– Traces:– medication management processes– processes in use of medications of a patient
– Infection Control– Traces:
– infection control process– hospital practice in prevention of health-care
associated infections– use of a particular antibiotic
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Tracer of Use of Data– Evaluates effectiveness of data
gathering and analysis in improving processes– Validate implementation of QI plan– Review analysis and use of measurement
data– Determine improvements in quality of care
and patient safety
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Tracer of Use of Data– The Processes
– Data collection– Data analysis– Use of information to improve processes – Sustainment of improvements
– Data use in proactive risk reduction
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Facility Tour
–Addresses issues related to– Physical facility– Security– Medical and other equipment– Hazardous waste– Fire safety– Utility systems– Patient and visitor safety– Infection control
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Staff Qualifications and Education Interviews
–Reviews processes for– Recruitment;– Orientation;– Education;– Evaluation of staff
–Review of staff files– Surveyors will request
specific files after tracers on 1st day of survey
Separate interviews for medical staff and nursing & other health care staff
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Assessment of Complaints– Any complaint about the hospital received by JCI
before the survey will be assessed by the survey team
– The team will be provided with specific complaint information
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Assessment of Complaints– Surveyors address issues identified in the
complaint during the survey – During scheduled activities or in special
sessions, as appropriate – Team leader will share pertinent information
with the CEO at an appropriate time and report assessment findings
– Findings included in the survey report to JCI
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Feedback Sessions:Daily Briefings
– Conducted each morning except first day
– Provides senior leaders with pertinent observations from previous day’s activities
– Allows organization to clarify issues or provide additional needed documents for consideration
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Feedback Sessions:Exit Conference
– Surveyors confer with organization’s CEO and other leaders at end of survey
– Provides strictly preliminary information about findings
– Written preliminary report
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StandardsReview
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Hospital Standards-3rd
Edition ChaptersPatient-Centered Standards
– Access to Care and Continuity of Care– Patient and Family Rights– Assessment of Patients– Care of Patients– Anesthesia and Surgical Care– Medication Management and Use– Patient and Family Education
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Access to Care andContinuity of Care (ACC)
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Intent– Care should be seamless from when a
patient enters the org to discharge.– Care should be seamless to both the care
provider and the patient. – The patient’s health needs should match
the services available.– Services provided should be coordinated.– Discharge should be planned and
followed-up
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ACC-Five Areas of Focus
1. Admission to the Organization2. Continuity of Care3. Discharge, Referral, and Follow-up4. Transfer of Patients5. Transportation
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Questions– Is there a type of patient that you
would not admit to your organization?
– Is there a standard that would support or prohibit this policy?
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Patient and Family Rights (PFR)
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Intent– Patients are unique and should be
treated as individuals. – Their rights should be respected.
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PFR – Four Areas of Focus
1. Identify, Protect and Promote Patient Rights
2. Informed Consent3. Research4. Organ Donation
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Questions– Is there a right that is missing from
the PFR chapter?– Why is it important?
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Assessment of Patients (AOP)
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Intent– Effective patient assessment process
results in decisions about the patient's immediate and continuing treatment needs.
– Patient assessment consists of:– Collecting patient information– Analyzing this information– Developing a plan of care
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Questions
– What is your personal role in patient assessment/reassessment in your organization?
– List the specific tasks you perform– Open the manual, and find at least three
standards that explain what you might be accountable for doing or documenting.
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AOP – Three Areas of Focus1. Collecting and Analyzing Patient
Data and Information2. Laboratory Services3. Radiology and Diagnostic Imaging
Services
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Care of Patients (COP)
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Intent– Patient care is a health care organization’s
main purpose. To provide the best possible care, organizations must:– Plan and deliver care– Monitor the patients to understand the results
of care– Modify care when necessary– Complete the care– Plan follow-up
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Questions– If you take care of patients…stand up.– What do you do to take care of patients?– I need two people that both treat patients in the
same organization.– How do you know that you are giving the same care to
the same type of patient?– Find standard that relates to refusing or
discontinuing treatment– Has anyone disagreed with a patient that refused
treatment? What did you do? What do the standards say? Is there another chapter that might apply?
– For those of you not standing, what do you do?
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COP-Four Areas of Focus1. Care Delivery for All Patients2. Care of High – Risk Patients and
Provision of High – Risk Services3. Food and Nutrition Therapy4. Pain Management and End-of Life
Care
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Care of Patients– Treatments– Feeding– Meeting their needs– Any interaction with patients
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Anesthesia and Surgical Care (ASC)
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Intent– Anesthesia, sedation, and surgical
interventions are common and complex.– They require:
– Complete and comprehensive assessment– Integrated care planning– Continued patient monitoring– Criteria-determined transfer for continuing
care– Rehabilitation– Eventual transfer and discharge
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Questions– How many of you use anesthesia in
your organization?– How many do so in different places
in the org?– What are the biggest risk factors in
delivering anesthesia?
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ASC-Four Areas of Focus
1. Organization and Management2. Sedation Care3. Anesthesia Care4. Surgical Care
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SedationModerate Sedation:•Patients respond purposefully to verbal commands•No interventions are needed to maintain a patent airway•Cardiovascular function is usually maintained
Deep Sedation:•Patients cannot be easily aroused but respond purposefully after repeated or painful stimulation•Airway may be impaired•Cardiovascular function is usually maintained
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Medication Management and Use (MMU)
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Intent– Medication Management encompasses the
system and processes an organization uses to provide pharmacotherapies to its patients.
– This usually includes:– Coordinated staff efforts– Effective process design– Procurement and storage– Transcribing– Dispensing– Monitoring
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The Medication Management Processes
Selection andProcurement
Storage
DispensingAdministrationMonitoring
Ordering andTranscribing
Preparing and
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The Medication Use ProcessOrder
Review
Administer
Monitor
Verify
Prepare Dispense
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Patient and Family Education (PFE)
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Intent– Patient education helps patients and
their families make informed care decisions.
– The best processes:– Use a multidisciplinary approach– Suits an individual’s learning
preferences, values, and language skills– Provide education at an appropriate
time
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PFE – Four Areas of Focus
1. Education to Support Patient Decisions2. Education Tailored to Each Patient3. Collaborative Delivery of Education4. Education to Support Care at Home
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Questions– Stand up if you educate patients in your
organization– Nurses: What are most important things
that physicians can teach their patients?– Physicians: What are most important
things that nurses can teach their patients?
– Others?
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Final Discussion– Are there any chapters that you think
do not apply to your job or role?
– Find the standard that deals with…
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StandardsReview
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Hospital Standards-3rd
Edition ChaptersHealth Care Organization and
Management Standards– Quality Improvement and Patient Safety– Prevention and Control of Infections– Governance, Leadership, and Direction– Facility Management and Safety– Staff Qualifications and Education– Management of Communication and
Information
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Quality Improvement and Patient Safety (QPS)
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Intent– Integral to overall improvement in quality is the
ongoing reduction of risk to patients and staff– Risks may be found in clinical processes and the
physical environment– The approach includes:
– Leading and planning the quality improvement and patient safety process
– Designing effective clinical and managerial processes– Monitoring how well processes work– Analyzing this data– Implementing and sustaining improvements
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QPS - Five Areas of Focus1. Leadership and Planning2. Design of New and Modified
Processes3. Data Collection for Quality
Monitoring4. Analysis of Data5. Process Improvement
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Leadership and PlanningKey concepts:– Those at the highest levels of the
organization are very involved in all aspects of planning and monitoring the quality and patient safety program
– Leader prioritize activities– Leaders provide the resources needed
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Design of New and Modified Processes
Key concepts:– Information on how safe, quality
processes should work comes from many sources
– Clinical practice guidelines and clinical paths are to be used
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Data Collection for Quality Monitoring
Key concepts:– Leaders set priorities and select
measures– Contracted services are monitored
as well
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Required Clinical Measures IClinical monitoring includes the following
selected by the leaders:– Aspects of patient assessment – Aspects of laboratory services – Aspects of radiology services – Aspects of surgical procedures – Aspects of antibiotic and other medication use
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Required Clinical Measures II– Monitoring of medication errors and near
misses– Aspects of anesthesia and sedation use – Aspects of the use of blood and blood
products – Aspects of availability, content, and use of
patient records – Aspects of infection control, surveillance, and
reporting – Aspects of clinical research
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Required Managerial MeasuresManagerial monitoring includes aspects of the
following selected by the leaders:– procurement of routinely required supplies and
medications essential to meet patient needs – reporting of activities as required by law and regulation – risk management – utilization management – patient and family expectations and satisfaction – staff expectations and satisfaction – patient demographics and clinical diagnoses – financial management – prevention and control of events that jeopardize the safety
of patients, families, and staff, including the IPSGs
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Analysis of DataKey concepts:– You will need individuals with experience
in data display and analysis– Comparison with self, others and best
practices is essential– Root cause analysis of sentinel events– Analysis of all adverse events– Monitoring near misses
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Process ImprovementKey concepts:– Consider priority areas– Ensure that improvement actually
occurred and was maintained– Use proactive risk reduction
strategies to identify needed improvements
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Prevention and Control of Infections (PCI)
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Intent– Infection prevention and control programs
seek to reduce the risk of acquiring and transmitting infection.
– Effective programs have:– Identified leaders– Well-trained staff– Methods to identify and proactively address
infection risks– Appropraite policies and procedures– Staff education– Coordination throughout the organization
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PCI - Six Areas of Focus1. Program Leadership and
Coordination2. Focus of the Program3. Isolation Procedures4. Barrier Techniques and Hand
Hygiene5. Integration of Program with Quality
Improvement and Patient Safety6. Education of Staff About the Program
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Program Leadership and Coordination
Key questions:– Who will lead the program and what are
their qualifications?– Who and what mechanism will we use to
coordinate activities?– What is the science on which to base the
program?– What resources will the program need to
be effective?
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Focus of the ProgramKey questions:– What is the scope of the program in terms
of places and people?– On what types of medical devices, and
clinical procedures, will we focus?– What are the essential elements of our
sterilization program?– How do we need to handle infectious
waste, sharps and needles?– What are the risks during construction?
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Isolation ProceduresKey questions:– What types of precautions and
procedures are needed to manage infectious patients?
– How about immunosuppressed patients?
– What do we do with many patients with a contagious disease?
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Barrier Techniques and Hand Hygiene
Key questions:– What supplies and equipment do we
need and where should they be located?
– How can we stimulate and monitor use?
– What guidelines for hand hygiene will we use? – See IPSG
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Integration of Program with Quality Improvement and
Patient SafetyKey questions:– What do we monitor?– How does this fit with other quality
monitoring going on?– How do we know if our program is weak or
strong?– What and when do we communicate
infection control information to all staff?
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Education of Staff About the Program
Key questions:– Who will provide the education?– What must all staff know about infections?– How do we educate and involve the
patient and their family in infection control?
– How should we communicate infection trends and other information to all staff?
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Governance, Leadership, and Direction (GLD)
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Intent– Excellent care requires effective
leadership– Leadership should:
– Identify the organization’s mission and ensure the resources needed to meet it.
– Coordinate and integrate activities– Understand how staff members work together,
along with their respective responsibilities– Overcome barriers and disputes between
departments
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GLD - Four Areas of Focus1. Governance of the Organization2. Leadership of the Organization3. Direction of Departments and
Services4. Organizational Ethics
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Governance of the Organization
Terminology:– Governance-the highest accountable group– Leadership-the senior mangers– Direction-the department or unit directorsKey decisions regarding governance:– The assignment of accountabilities to the
governance structure– The written documents that support this structure
and accountabilities
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Leadership of the Organization
Key decisions regarding leadership:– Identification of the leadership structure– Assignment of responsibilities– Planning with community leaders– Determination of services and supplies
and equipment to deliver the services– Management of contracts– Establish uniform HR programs
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Direction of Departments and Services
Key decisions regarding directors:– Their responsibilities for managing
the departments and units of the organization
– The process for recommending space, equipment and staff
– The process for monitoring quality and staff performance
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Organizational EthicsKey decisions regarding organizational
ethics:– The framework and ethical and legal
norms for operation– The content of the guiding documents– The application of the framework and
guiding documents to ethical dilemmas in patient care
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Facility Management (FMS)
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Intent– In order to provide a safe and
functional facility for all, the physical facility, medical equipment, and people must be effectively managed.
– Management must strive to:– Reduce and control risks and hazards– Prevent accidents and injuries– Maintain safe conditions
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FMS - Eight Areas of Focus
1. Leadership and Planning2. Safety and Security3. Hazardous Materials4. Emergency Management5. Fire Safety6. Medical Equipment7. Utility Systems8. Staff Education
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Considerations for All Areas– Relevant laws and regulations– Separate plans or one overall plan– Knowledge of the type and location of
risks for each area– Plans to reduce or mitigate risks– Integration of facility quality and safety
information with all other such information– Ensuring that the right staff have correct
information to ensure safety of staff and patients
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Staff Qualifications and Education (SQE)
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Intent– Leaders collaborate to identify the numbers and
types of staff needed to fulfill the organization’s mission
– Recruiting, evaluating, and appointing staff are best accomplished through a coordinated and uniform process
– Documentation is a critical part of this process:– Applicant skills– Knowledge– Education– Previous work experience– Credential review (for clinical staff)
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SQE - Five Areas of Focus1. Planning2. Orientation and Education3. Medical Staff 4. Nursing Staff 5. Other Professional Staff
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PlanningKey considerations:– How to determine and define the desired
number and skill level for all staff– What will job descriptions look like and
contain– Defining the processes for recruitment,
etc.– Setting up staff files– Final judgment that staff capabilities are
consistent with patient need
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Orientation and EducationKey considerations:– Process to orient everyone to the
organization, his/her department and actual job responsibilities
– Provision on ongoing staff education– The management of student education in
the organization– Special education such as resuscitative
techniques
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Medical StaffKey considerations:– Setting up a process to gather and verify
(from the primary source) all the credentials of the physician
– Setting up the decision process to decide staff membership and what services they will provide
– Using a process for ongoing clinical practice evaluation
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Nursing Staff Key considerations:– Setting up a process to gather and verify
(from the primary source) all the credentials of the nurse
– Setting up the decision process to decide competencies and job description or assignment
– Choosing a procedure to evaluate participation in the quality program
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Other Professional StaffKey considerations:– Setting up a process to gather and verify
(from the primary source) all the credentials of the individual
– Setting up the decision process to decide competencies and job description or assignment
– Choosing a procedure to evaluate participation in the quality program
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Management of Communication and
Information (MCI)
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Intent– Failures in communication is one of the
most common root causes of patient safety incidents.
– Over time, organizations should increase their ability to:– Identify information needs– Design an information management system– Define and capture data and information– Analyze data and transform it into information
that can be reported– Integrating and using information
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MCI – Six Areas of Focus1. Communication with the Community2. Communication with Patients and
Families3. Communication Between Providers
Within and Outside the Organization4. Leadership and Planning5. Patient Clinical Record6. Aggregate Data and Information
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Major Considerations for All Focus Areas
– Open communications are key with clear content in an understandable format to enhance patient safety
– Special considerations for the communication of patient information such as confidentiality and security
– Patient records with a consistent format and content
– Understanding the importance of data and the use of data for quality and safety
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Access to Care andContinuity of Care (ACC)
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ACC-Five Areas of Focus
1. Admission to the Organization2. Continuity of Care3. Discharge, Referral, and Follow-up4. Transfer of Patients5. Transportation
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ACC.1 “ADMISSION” of In-Patients & “REGISTRATION” of Out-Patients
– Screening at point of first contact– Determine if care can be provided– Diagnostic test are available for
decision making-standardized by policy
– Patients are informed if any wait or delay and reasons (waiting list)
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ACC.1.1 Process of Admission or Registration
– Policies & Procedures (PP) standardize admission and registration
– PP Admitting Emergency patients– PP Holding patients for observation– PP Managing patients when bed space not
available
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ACC.1.1.1 Emergency Patients– Criteria are developed and used to prioritize patients with
immediate needs (“triage”)– Criteria are physiologic-based whenever possible– Staff use criteria to prioritize patients based on urgency of
needs
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ACC.1.1.2 Needs are Prioritizedfor In-patients
– Screening Assessment focuses on deciding which service to meet the patient first
– Preventative– Palliative– Curative– Rehabilitative
–Appropriate selection of services of treatment unit
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ACC.1.2 Information Provided– Patient and Family receive information
during the admission process on:– Proposed care– Expected out comes of care– Expected costs– Sufficient information to make
knowledgeable decisions
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ACC.1.3 Reduction of Barriers– Leaders and staff understand most
common barriers for patients– Physical– Language– Cultural– Other
– A process is identified and implemented – to overcome or limit identified barriers– to limit impact of barriers on delivery of
services
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ACC.1.4 Criteria for Admission or Transfer to Intensive Care
– Admission/transfer criteria established for Intensive and Specialized Units
– Criteria are physiologic-based– Appropriate individuals are involved in developing
and implementing the criteria– Patients meet the criteria (documented)– Patients are discharged/transferred when they no
longer meet criteria
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ACC.2 Continuity of Patient Care – Leaders design and support continuity (coordination
& resources)– Criteria or policies determine transfers within the
organization– Processes support continuity and coordination of
care and are implemented between/among: (reference to bullet points in intent statement)– Emergency and Inpatient care– Surgical and Non-surgical care– The Organization and other care settings– Ambulatory Care Programs
– Continuity and coordination is evident to the patient –(coordinator).
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ACC.2.1 Individual Responsible
– There is an individual responsible for patient’s care who is– a physician or other person– qualified to assume responsibility for
care– identified to the hospital staff
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ACC.3 Referral and Discharge Policy
– Policy for the appropriate referral or discharge of patients– Based on patient’s needs for continuing
care– The patient’s readiness for discharge– Discharge planning begins early and
includes the family as appropriate– Policy guides patients “on pass” for a defined period
of time
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ACC.3.1 Cooperation with Community Practitioners
– Discharge planning for both supportiveand continuing medical services
– Community providers, organizations and individuals are identified
– Appropriate referrals are made (in the patient’s home community whenever possible)
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ACC.3.2 Discharge Summary– Prepared at discharge, documented in the
patient’s record and contains:– Reason for admission– Significant physical and other findings– Significant diagnoses and co-morbidities– Diagnostic and therapeutic procedures– Significant medication and treatments– Condition at discharge– Discharge medications and all medications to be
taken at home– Follow up instructions
Continued on next page…..
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ACC.3.2 Discharge Summary
– Unless contrary to policy, laws, or culture, patients are given a copy
– A copy is provided to the practitioner responsible for patient’s continuing or follow-up care
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ACC.3.3 Follow-up Instructions– Patients and/or family receive follow-
up instructions that:– are provided in an understandable form
and manner– include any return for follow-up care– include when to obtain urgent care– are appropriate to the patient’s
condition
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ACC.4 Transfer Policy– Guiding policy for transferring patients to
include:– Appropriateness of transfer using criteria– Based on need for continuing care– Transfer of responsibility to another provider
or setting– Criteria define when transfer is appropriate– Who is responsible during transfer– Situations where transfer is not possible
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ACC.4.1 Referring and Receiving Organizations
– Referring organization determines whether receiving organization can meet patient’s needs
– Arrangements (formal or informal) are in place when patients are frequently transferred
ACC.4.2 Written Summary– Clinical summary is transferred with patient & includes:– Patient status– Procedures and other interventions provided– Patient’s continuing care needs
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ACC.4.3 Monitoring Patients during Transfer
– All patients are monitored during direct transfer
– Qualifications of the staff member doing the monitoring are appropriate for patient’s condition
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ACC.4.4 Documentation of Transfer
– Documentation includes:– Name of organization and individual
agreeing to receive patient– Reason for transfer– Any special conditions related to
transfer– Any change of patient’s condition or
status during transfer– Any other notes require by the
transferring organization
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ACC.5 Transportation Needs– Transportation is appropriate to the
patient’s need – Transportation needs are considered
when:– Referring– Transferring– Discharging
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ACC.6 – ACC.6.1Medical Transport
– Standards are relevant only if the medical transport services are owned and operated by the hospital
ACC.6 Meeting Legal Requirements
– Service meets relevant laws & regulations– Current license maintained when required
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ACC.6.1 Safety and Quality– Qualified individual directs the service– Medical oversight during transfer for:
– Patient Assessment– Medical Services
– Quality and safety are monitored – Qualified individuals triage patients– Regular inspection of vehicles– Included in infection control program
– Exposures to biologic and chemical agents– Patient’s rights are respected during transport
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After the Survey:The Decision
Joint Commission InternationalHospital Accreditation Program
Accreditation Decision RulesEffective Date 1 January 2009
I ACCREDITATION DECISIONSINTRODUCTIONThe Accreditation Committee considers all information from the initial or
triennial full survey and any required follow-up Focused Survey in making its decision regarding accreditation. The outcome is thatthe organization meets the criteria for accreditation or does not meet the criteria and is denied accreditation. The criteria for these two potential outcomes are as follows:
A. ACCREDITEDThis decision results when an organization meets all the following
conditions.1. The organization demonstrates acceptable compliance with each
standard. Acceptable compliance is:A score of at least “5” on each standard.
2. The organization demonstrates acceptable compliance with the standards in each chapter. The International Patient Safety Goals are considered a Chapter. Acceptable compliance is:
An aggregate score of at least “8” for each chapter of standards.
3.The organization demonstrates overall acceptable compliance. Acceptable compliance is:
An aggregate score of at least “9” on all standards.4. The total number of measurable elements found to be “Not Met” or “Partially Met” is not above the mean (three or more standard deviations) for organizations surveyed under the hospital accreditation standards within the previous 24 months.5. The organization submits an acceptable Strategic Improvement Plan (SIP).
B. ACCREDITATION DENIEDThis decision results when an organization meets one or more of the
following conditions at the end of any required Focus Survey subsequent to an initial or triennial full survey, or during the period of accreditation as a result of a Focus Survey for the evaluation of one or more policy related conditions that may place the organization At Risk for Denial of Accreditation.*
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The Transparent JCI Process
International Standards
On-siteEvaluation of
Standards
Accreditation Decision
Rules
Accreditation Certificate
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Scoring the Survey Results
– Each Measurable Element (ME) is scored– Met (10)– Partially Met (5)– Not Met (0)
– All Measurable Elements are averaged to obtain the score for the standard
– All Standards are averaged to obtain the score of the chapter
– All Chapters are averaged to obtain the overall score
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Accreditation Decision Rules
– Each Standard must have a score of at least 55
– Each Chapter must have a score of at least 88
– All standards together must average at least 99
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Surveyor Report
– Surveyors complete their findings and leave a final copy with the surveyed organization
– If the organization disagrees with a finding and feels that proof of inaccuracy exists, appeal may be filed with JCIA, together with documentation that proves that the surveyors were in error
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JCIA Communication
– Ten (10) days after receipt of the surveyors’ report, JCIA notifies the organization whether a focused repeat survey or other follow up condition will be required– In which case the decision regarding accreditation will be
postponed.– If a focused resurvey or other follow up condition is
not required, the organization will be notified that Strategic Improvement Plans (SIPs) must be submitted for each Measurable Element that received a score of “Not Met” or Zero (0).
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Strategic Improvement Plans
– Due date of the SIPs is 45 days after notification.
– JCI will evaluate the SIPs for adequacy.– If the decision is that they are all adequate, AND
the Standards Scores and Averages meet the Decision Rules, the finding will be that there has been “Acceptable Compliance” with the standards (for exception see “Rule No. 4” or “Outlier Rule”)
– If the decision is that they are not all adequate, JCIA declare the organization “At Risk of Denial of Accreditation” (see later) .
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Focused Resurvey for Inadequate Compliance with Standards
– Focused visit will occur at 60 days from Initial or Triennial Survey
– There will be one or (rarely) two surveyors
– Focused survey will be restricted to areas or standards that have been identified
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Accreditation Decisions
– ACCREDITED– Acceptable compliance with all Standards – If there are follow-up conditions, they are
all met
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Accreditation DecisionsACCREDITATION DENIED1. One or more standard is scored less than a “5”.2. The aggregate score of one or more chapter of
standards is less than a “8”.3. The aggregate score for all standards is less than
“9”.For 1., 2., and 3. see item 5. for additional condition of
Denial.4. The total number of measurable elements found to
be “Not Met” or “Partially Met” is above the mean (three or more standard deviations) for organizations surveyed under the hospital accreditation standards within the previous 24 months (statistics updated every Quarter).
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Accreditation Decisions
ACCREDITATION DENIED5. A required Focused Survey subsequent to an initial
or triennial full survey has not resulted in acceptable compliance with applicable standards. .
6. One or more of the conditions that place the organization At Risk for Denial of Accreditation have not been resolved at the time of the Focused Survey to evaluate the condition.
7. The organization voluntarily withdraws from the accreditation process.
8. The organization does not permit the performance of any survey by Joint Commission International
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Rule No. 4 (“Outlier Rule”)
The total number of measurable elements found to be “Not Met” or “Partially Met” is not above the mean (three or more standard deviations)for organizations surveyed under the hospital accreditation standards within the previous 24 months.
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2008
1214
2008
1104
2008
1006
2008
0914
2008
0707
2008
0602
2008
0512
2008
0421
2008
0312
2008
0121
60
50
40
30
20
10
0
N = 87
Sam
ple
Coun
t
_C=27.54
UCL=43.28
LCL=11.80
1
11
1
1
1
11
11
1
1
2008 Surveys (Initial and Triennial)
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Reporting Requirements
– For all accredited organizations– Interim self-assessment report on status of standards
compliance at 18 months– Response to annual query about updated contact addresses
– For accredited organizations that meet the following:– Change of ownership or top management– Establishment of new service covered by JCI standards– Discontinuation of existing service– Increased volume (>25%) or contraction (>25%) of service
(e.g. number of beds, OPD clinics, etc.) – New location or significant change in current location of at
least 25% of services– Development of more intensive services– Merger with or acquisition of organization that provides
services for which JCI has standards
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Types of Focused Surveys
– Follow-up: performed after a full initial or triennial survey to evaluate selected standards noted at the time of the survey. – Conducted at 90 days following the original survey
– For Cause: performed whenever – JCI is persuaded that there is a risk to patients and staff or– JCI receives a quality incident report that requires on-site
evaluation or– organization has been placed “At Risk of Denial of
Accreditation.”– Focused Surveys evaluate a preset group of
standards
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Conditions that Place an Organization “At Risk for Denial of Accreditation”
1. An immediate threat to patient/public health or staff safety exists within the organization.
2. An individual who does not possess a license, registration, or certification is providing or has provided health care services in the organization that would, under applicable law or regulation, require such a license, registration, or certification and which placed the organization’s patients at risk for a serious adverse outcome.
3. Joint Commission International is reasonably persuaded that the organization submitted falsified documents or misrepresented information in seeking to achieve or retain accreditation, as required by the Information Accuracy and Truthfulness Policy.
4. A number of not compliant standards (Not Met or Partially Met) at the time of survey is above the mean (three or more standard deviations) for organizations in the same program surveyed during the previous 24 months.
5. The organization does not possess a license, certificate, and/or permit, as, or when, required by applicable law and regulation, to provide the health care services for which the organization is seeking accreditation.
6. The organization has not met the accreditation policy for “Reporting Requirements between Surveys”.
7. The organization fails to submit an acceptable Strategic Improvement Plan (SIP) within 45 days of the organization’s survey.
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Day 2: The Survey Process
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Tracer Methodology
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What is a Tracer?– JCI’s key assessment method
– “Traces” a real patient’s journey through the hospital, using their record as a guide
– Along the path, JCI observes and assess compliance with the standards
– Allows us to understand hospital’s performance from patient’s perspective
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Why Conduct Tracers?– Complex organizations (like those found in
healthcare) are made up of a series of systems and subsystems.
– Tracers are an effective way to study complex systems.
– If we can identify the imperfections or flaws within a system, we can understand how to correct errors that may cause patient harm.
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Outcomes of Tracers• Integrated and cross sectional review of those
areas most critical to quality and safety of the patient
• Patient focused analysis of standard compliance
• Organizational specific information that can be used to design and target improvements
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Types of TracersTwo types of Tracers
1. Patient Tracer: Follow the treatment path of an individual patient within the hospital
2. System Tracer: Follow a process in the hospital from beginning to end.
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Patient Tracer
An individual patient tracer:– Follows the experiences of a
patient throughout the healthcare system.
– Illustrates the relationship between a patient’s care and the JCI standards
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System Tracers– A system tracer follows a complex process
throughout the healthcare system. – Traces the path of a complex process
Examples:– Medication Management System– Infection Control Management System– Data Management System
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Medication Management System Tracer
• Selection of medications• Procurement of
medications• Storage of medications• Medication ordering
Policy & Procedure• Verifying prescriptions
• Allergy reconciliation• IT support for verification
• Controlled substance storage, monitoring and use
•High-risk therapy• IV mixing, TPN prep,
chemo agents prep• Concentrated
electrolytes• Look alike, sound alike
drugs• Preparation• Dispensing
•Pharmacy role in discharge planning and patient/family education
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Medication Management System Tracer
Includes:Group discussion• Explore the process ; identify concerns• Discuss medication occurrences or errors• Review International Pt. Safety Goals (INPSG 1,
2, 3, 5, and 6)Focused Medication Tracer• Explore the path of a selected high risk medication
based on the group discussion or previous information identified through patient tracers
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Medication Management Functions
• Selection• Procurement• Storage• Prescribing and Ordering• Preparation• Dispensing• Administration• Monitoring
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Tracing
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Determine Your Purpose
• What is the purpose of your tracer?• Assess overall JCI standards compliance• Assess organizational policy compliance• Learn more about a specific process
• Your purpose will determine where you go and what you do
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Pre-Work• At first, do not plan to do tracers within
your own department• Know and interpret the standards
correctly• Understand the intent of the standard• Consider pre-determining types of
questions (i.e. a focused topic area) until you are proficient at free-flowing
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Effective Tracing Tips
• Don’t review the medical record by yourself—review with a staff member, so that you can ask for the “patient’s story.”
• Don’t conduct “peer” review.• Don’t indicate staff did something
“wrong”• Don’t assess best practices, focus on
what the standards require
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Effective Tracing Tips• Follow the path of the patient or process • Assess standards based on the patient’s
experience of care• Observe patient care, procedures, and
processes• Use the patient record to identify “system”
issues based on the patient’s journey.
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Effective Tracing Tips• Seize the moment, but don’t interrupt
patient care• Stay time aware and topic focused• Remain flexible• Maintain patient confidentiality• Set the proper tone
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Set the Overall Tone• Put the staff at ease• Explain purpose of tracer• Dress professionally• Use a serious but approachable style• Educate and evaluate• Pretend you do not know the staff members
you are interviewing• Thank staff for participating
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Interviewing Strategy
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Questions to Keep in Mind While Tracing Any Process
Think about asking questions that will help you know the following:
1. Is this step standardized? If not, why?2. Does the step occur consistently?3. Does it need improvement?4. Is it an unnecessary or impractical step?5. Is something absent that should be present?6. What are the risk points?7. How are the risk points mitigated?
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Questioning Strategies• Use active listening.• Drill down until issues are fully developed• Don’t pursue one standard; focus on
several standards related to a process.• Avoid hypothetical situations—pose
questions around the patient being traced.
• Base questions and findings on the standards.
• Question staff, not management• Question patients when feasible
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Interviewing Patients• Ask questions based on your review of the
patient’s medical record (diet, education).• Talk to patients/families about relevant
issues/experiences; use caution not to alarm the patient.
• Observe environment of care in the patient’s room.
• Don’t “quiz” patient but engage in conversation.
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How are Questions Asked?• Use “I” statements
• “I see that the patient was given Aspirin”• Not, “You gave the patient Aspirin.”
• Avoid a confrontational tone; the goal is to gather information, not “catch” someone
• Use opening question followed by “drill-downs.”• The same question, asked slightly different, may
deepen understanding of compliance
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Leading QuestionsLeading Questions: The question
suggests the correct answer
• “Do you always wash your hands before interacting with a patient?”
• “I assume you would put this type of patient in a negative-pressure room.
• You keep this door locked, right?
Whenever possible, surveyors avoid this type of question.
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Leading vs. Neutral QuestionsLeading questions suggest the correct answerNeutral questions do not suggest the correct answer
Leading“Do you always wash your hands before interacting with a patient?”
Neutral“What kind of hand-washing protocols have you adopted? How effective have hand-washing protocols been?”
Leading“I assume you would put this type of patient in a negative-pressure room. How would you treat this patient?”
Neutral“There are many different ways to treat this type of patient. How would you handle this case?”
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Closed QuestionsClosed Questions: Only allow a choice of
two options, typically “yes” or “no.”
• Have you been trained to operate this equipment?• Did you follow your organization’s policy when
admitting this patient?• Do you educate patients on their treatment?
• The respondent supplies a very limited amount of information to the questioner.
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Closed Vs. Open QuestionsClosed questions have very few responses (yes/no)Open questions require a full, elaborative response
Closed“Have you been trained to operate this equipment?”
Open
How do you know the correct way to operate this equipment?
Closed
Did you follow your organization’s policy when admitting this patient?
OpenHow did you admit this patient? What is your organization’s admission policy?
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After the Question• Make sure the question was understood.• Restate answers for clarification.• Pause after an answer to encourage more
information.• Give positive feedback for well-thought out
answers.• Ask for more information if you need it in
order to understand the answer.
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Validate When you notice a policy violation or an
inconsistency in clinical practice, you should:• Drill down
Ask probing questions to more fully understand the problem
• ValidateLook for examples of the problem in other
settings or with other practitioners. Is this an isolated incident, or a trend?
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After the Tracer: Share your Findings
• Share with leadership• Share all findings to lay groundwork for new
improvements; communicate incremental responses to changes
• Share with staff• Share successes and challenges • The clearest and most accurate picture creates
respect for the tracer process• Issues should be shared in a non-punitive,
positive, and educational manner
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Questions?
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The Survey Simulation:What to expect
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The Purpose of the Survey Simulation
– You will observe the consultant/surveyor gathering information about how the organization complies with JCI standards.
– The purpose is to demonstrate the Tracer methodology and Tracer process, so that you might be able to better prepare for your upcoming survey.
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Inside the Host Hospital– Our host hospitals have been very
generous to allow us to visit their facility.
– Please respect their staff and patients by following the following guidelines:
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1. Appropriate Questioning– Only the JCI faculty member that
serves as the “surveyor” should ask questions of the staff, patients, or administration.
– Any questions you have should be directed to your faculty member.
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1. Appropriate Questioning– Please also remember that the
objective of this session is to help you understand the survey process, not to survey this particular organization.
– It takes a full survey to have sufficient information to draw any conclusions about the organization.
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2. Requests– During the course of the simulation, you
may be shown a great many different forms, policies, and other resources that may be useful to you.
– Please do not ask the hospital staff for these resources directly.
– You may ask your JCI faculty member to acquire these documents. If possible and appropriate, they will attempt to secure these documents for you.
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3. Stay with the Group– In order to move through the
simulation as efficiently as possible, please stay with your group and group leader at all times.
– We have already arranged to “survey” certain specific areas. Straying into other areas tests the goodwill of our hosts.
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4. Minimize Impact– No cell phones
– Please turn your phones off, or set them on silent.
– Please also refrain from taking calls during the session.
– No photos/videos– Please feel free to take notes, but
photos and videos are not permitted.
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Discussion Questions– When do we have enough data to
draw conclusions?
– What kind of conclusions can be drawn from this process?
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What you should hear
– The neutral tone in which the questions are asked
– The way the same question, asked slightly differently, moves deeper into understanding compliance
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What you should hear, see, and discover
– We will discuss your observations when we return.
– During your first tracer demonstration session, observe as much as you can about:– The survey simulator’s method– Those being interviewed by the survey
simulator
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See if you discover…1. How the consultant discovered
information that resulted in a modification to the tracer and a change in direction?
2. Inconsistencies in the responses to similar questions that would lead you to suspect that all staff were not trained in the same way or the same content.
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See if you discover3. Any portion of the building where you
could not identify a safe exit in the event of an emergency
4. Characteristics of a patient record that made it easy to trace a patient’s journey
5. The primary ways the hospital’s staff demonstrated compliance – data, verbal explanation, policies, procedures, etc.
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QUESTIONS?
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Case Study 1
Answering Tracer Questions
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Case Study Overview
– For this exercise, we will be taking you on a “virtual” tracer.
– For your first case study, we want you to think carefully about what are the best answers you can give to a surveyor’s questions.
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Tracer Patient Selection–City Centre Medical Center–Surveyor traces a 68-year-old female patient:
– Mrs. Kale – admitted one week ago via the Emergency
Department (ED). – Admitted with:
– slurred speech– poor gait – completely dependent on help for all her needs.
– CT scan of the brain showed a right brain Ischemic Stroke.
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Medical Record Information
– History and Physical – she was treated for:
– hypertension, – Hyperlipidemia– diabetes mellitus.
– She was on diet control for the management of her diabetes.
– No bed available at the medical unit– Placed in a holding area for observations. – Her 70-year-old husband was with her and provided
relevant information.
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ContinuedThe surveyor noted from the nursing chart that Mrs. Kale was assessed to be at risk for the following:
o Fallo Bed soreso Aspirationo Deep vein thrombosis
Mrs. Kale's husband has also shared with her nurse yesterday that they have no means to pay for the hospital bill.
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Surveyor visits Emergency Department
Step 1: Surveyor Speaks with the ED Staff
–After reviewing the medical record, surveyor visits ED–Discussions cover triage criteria, admission criteria, patient and family communication.
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A. What processes were followed for admitting Mrs. Kale to the medical unit? B. What was the reason why she had to be in the ED for 6 hours? C. How did you communicate the reasons for her delayed admission?
(ACC.1.1 ME 5-6; MCI.2 ME 1; MCI.4 ME 4)
Surveyor visits Emergency Department
Step 1: Surveyors Speaks with the ED Staff
ExerciseExercise•Select one question.
•What is the worst answer you can give?
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Medical Unit
Step 2: Surveyor Speaks with Nurse and Physician
–Discussions cover assessment, reassessment, emergency care issues, IPSG.
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B. Who has access to patient’s medical record? C. What is your organization policy on health information ?(MCI.7 ME 1; MCI.10 ME 4)
A. What communication took place between the ED and the unit before Mrs. Kale arrived? (IPSG Goal 2 ME 1-4, MCI 8, ME 1-7)
Medical Unit
Step 2: Surveyor Speaks with Nurse and Physician
D. What process do you have in place to address Mrs. Kale's risk for fall? (IPSG Goal 6 ME 1-3)
ExerciseExercise•Select one question.
•What are the elements of a good answer?
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Bad Answers
– “Bad” answers:– Give too much information– Highlight a deficiency that was not
otherwise apparent– Ramble– Untruthful or misleading
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Medical Unit
Step 3: Surveyor Speaks with the Physician
–Discussions cover assessment and reassessment, clinical practice guidelines and pathways
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C. I noticed that there was no entry in the patient’s medical record by a physician on the weekend that Mrs. Kale was admitted. What is the hospital policy for assessment and reassessment of patients? (AOP.2 ME 4)
A. I noticed Mrs. Kale is on a stroke pathway. How is this pathway established? B. Who was involved in this decision?(QPS.2.1 ME 1-3)
Medical Unit
Step 3: Surveyor Speaks with the Physician
ExerciseExercise•Which question is the hardest to answer?
•What is an ideal answer to this question?
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C. How are staff educated in the management of infectious patients? D. How does the organization’s orientation program include infection control? E. Who attend this orientation? (PCI.8 ME 5; SQE.7 ME 1-3)
A. What hand hygiene guidelines do you follow?B. What hand hygiene products do you use? (IPSG Goal 5)
Medical Unit
Step 7: Surveyor talks to the staff and infection control practitioner
ExerciseExercise•In your organization, what is the best answer you can construct ?
•What would you change in your organization to have a better answer?
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QUESTIONS?QUESTIONS?
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Root Cause Analysis (RCA)
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What is a Root Cause– Root Cause: The underlying source
of an error, failure, or accident
– Most errors, failures, or accidents have multiple causes, but fewer (often one) root cause.
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What is a Root Cause Analysis?
– A Root Cause Analysis seeks to determine the root cause of an error, failure, or accident.
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Why Conduct an RCA?– Some portion of our system just
broke/failed– E.g. Sentinel event
– We want to determine what broke in our system
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What does Root Cause Analysis (RCA) do?
– Identify the causes that lead to variationfrom our performance expectation.
Types of Variation: Common Cause and Special Cause
Types of causes: Apparent and Underlying
Performance Expectation: What we want to happen (e.g. 0 Sentinel events)
In other words—what is causing us to miss our performance goals?
Multiple tools, including 5 Whys and Ishikawa
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Performance Expectations– A standard that we want to meet
– Room service delivered within 30 minutes– Zero Sentinel Events– Lab work completed within 24 hours
– Good performance expectations are– Measurable– Specific– Within our control
– RCAs are most effective when they analyze a failure of a clear performance expectation
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Types of Causes
–“Proximate Causes”–What factor(s) led directly to the “error”?–Usually, easy to see
–The causes that lead to our apparent cause–What factor(s):
– Allowed the “error” to happen
– Failed to prevent the “error”
– Started a chain of events that led to the “error”
–May be a Root Cause–Usually, harder to see
Apparent Causes Underlying Causes
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Why?
Why?
Types of Causes in a Car Accident
–Driver did not hit the brakes fast enough to avoid hitting the car in front of them
–Driver reaction time slow because of lack of sleep the previous night–Driver did not get enough sleep because they were stuck in the ED until 3 AM, but still needed to report for their 7 AM shift–Driver needed to report at 7 AM because the hospital was short-staffed on this holiday weekend.–The hospital was short staffed because they do not have a staffing plan that assures adequate staff on holidays.
Apparent Causes Underlying Causes
Why?
Why?
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The Five Whys– We have just performed a simplified
version of the first RCA technique: the Five Whys.
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How to Use the Five Whys– First, ask “Why did this error occur?”
– The driver didn’t hit the brakes fast enough.
– Then, ask “Why did that occur?”– They were tired
– Then, ask “Why did that occur?”– They were stuck in the ED until 3 AM
– Then, ask “Why did that occur?”
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Why not the Six Whys?– Asking “Why” five times is generally
sufficient to identify a root cause.– If you have not discovered a
satisfying root cause after asking “why” five times, keep going until you do.
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Exercise: The Five Whys– Arrange yourself in groups of 4-7.– Select a single error, accident, or
failure.– For the purposes of this exercise,
you may use a fictional failure.– Perform the Five Whys as a group, to
discover the root cause.
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What did you Learn?– What were your Root Causes?– If this were a real RCA, who would be
helpful to have on the team?– What kind of mindset is it important
that the team have in order to complete an effective RCA?
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RCA Team Makeup– Good RCA Teams often include the
following:– People involved (directly or indirectly) in the
failure– Team Leader
– Objective– Not part of the process– Experience conducing RCAs– Not always the most senior member of the
team– 5-8 members
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Problems with the Five Whys
– Although it is a useful tool, the “Five Whys” does have faults.– Root cause depends on the group’s knowledge– Different groups = different root causes– It can be difficult to know when you have
discovered the real root cause– There may be several answers that answer a
single “why?” By selecting one, we choose simplicity over complexity, and may miss important causes that are not the main cause
It may be helpful to consider a tool that attempts to collect all of the potential causes of an error.
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Tool 2: Ishikawa Diagram– If you are concerned about capturing
and assessing multiple root causes, consider using the Fishbone Tool.
– Like “5 Whys,” this tool requires a team to brainstorm causes.
– Also known as a “Fishbone Diagram”
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The Ishikawa ToolStart with an explanation of the “problem”
The basic explanation of the problem.
I missed my
flight
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The Ishikawa Tool– What are the categories of causes
that are leading to your problem?– Seek 3 to 6 categories– The “Four-M” categories are a good
place to start:–Materials–Machines–Manpower–Methods
137
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The Ishikawa ToolDraw “bones” for each category of causes
MaterialsMachines
ManpowerMethods
I missed my flight
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The Ishikawa ToolDrill down on each category
MaterialsMachines
ManpowerMethods
Materials Cause 1
I missed my flight
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Materials
Materials Cause 1
The Ishikawa Tool
Materials Cause 2
Subcause
Subcause
Subcause
Sub-subcause
Sub-subcauseSub-subcause
Sub-divide each cause into sensible divisions
The further you subdivide, the more specificthe cause.
Sub-subcause
Sub-subcause
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Materials
The Ishikawa ToolSub-divide each cause into sensible divisions
The further you subdivide, the more specificthe cause.
Ink smudged on my ticket
Passport doesn’t match ticket
Cheap penSweaty hands
Nervous about flight
Office too warm
Budget crisis
New pen supplier
New office
manager
wants to
lower costs
No A/C in
the summer
New office manager wants to lower costs
Bad
experience
Not enough
sleep
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The Ishikawa Tool
The basic explanation of the problem.
MaterialsMachines
ManpowerMethods
Materials Cause 2
Subcause
Subcause
Subcause
Sub-subcause
Sub-subcause
Sub-subcause
Manpower Cause 1
Sub-subcause
Sub-subcause
Sub-subcause
Sub-subcause
Sub-subcause
Machines Cause 1
Subcause
Subcause
Sub-subcause
Sub-subcause
Sub-subcause
Methods Cause 1Sub-subcause
Sub-subcause
Sub-subcause
Machines Cause 2
Subcause
Subcause
Sub-subcause
Sub-subcause
Sub-subcause
Sub-subcause
Machines Cause 3
Methods Cause 2Sub-subcause
Sub-subcause
Sub-subcause
Sub-subcause
Subc
ause
Subc
ause Su
bcau
se
Materials Cause 1
Subc
ause
Subc
ause
Subc
ause
Manpower Cause 2
4th lev
el ca
use
4thlev
el ca
use
4thlev
el ca
use
4thlev
el ca
use
4thlev
el ca
use
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How far down do we drill?– Keep separating causes into sensible
subdivisions. – You subdivided enough when the
“branches” are: – Specific– Measurable– Controllable
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Exercise: Ishikawa Diagram– In small groups, create your own
Ishikawa diagram.
The basic explanation of the problem.
MaterialsMachines
ManpowerMethods
Materials Cause 2
Subcause
Subcause
Subcause
Sub-subcause
Sub-subcause
Sub-subcause
Manpower Cause 1
Sub-subcause
Sub-subcause
Sub-subcause
Sub-subcause
Sub-subcause
Machines Cause 1
Subcause
Subcause
Sub-subcause
Sub-subcause
Sub-subcause
Methods Cause 1Sub-subcause
Sub-subcause
Sub-subcause
Machines Cause 2
Subcause
Subcause
Sub-subcause
Sub-subcause
Sub-subcause
Sub-subcause
Machines Cause 3
Methods Cause 2Sub-subcause
Sub-subcause
Sub-subcause
Sub-subcause
Subc
ause
Subc
ause Su
bcau
se
Materials Cause 1
Subc
ause
Subc
ause
Subc
ause
Manpower Cause 2
4th le
vel c
ause
4th le
vel c
ause
4th le
vel c
ause
4th le
vel c
ause
4th le
vel c
ause
The basic explanation of the problem.
MaterialsMaterialsMachinesMachines
ManpowerManpowerMethodsMethods
Materials Cause 2
Subcause
Subcause
Subcause
Subcause
Subcause
Subcause
Sub-subcause
Sub-subcause
Sub-subcause
Manpower Cause 1
Sub-subcauseSub-subcause
Sub-subcauseSub-subcause
Sub-subcauseSub-subcause
Sub-subcauseSub-subcause
Sub-subcauseSub-subcause
Machines Cause 1
Subcause
Subcause
Subcause
Subcause
Sub-subcauseSub-subcause
Sub-subcause
Sub-subcauseSub-subcause
Methods Cause 1Sub-subcauseSub-subcause
Sub-subcauseSub-subcause
Sub-subcauseSub-subcause
Machines Cause 2
Subcause
Subcause
Sub-subcause
Sub-subcause
Subcause
Subcause
Subcause
Subcause
Sub-subcause
Sub-subcause
Sub-subcause
Sub-subcause
Machines Cause 3
Methods Cause 2Sub-subcauseSub-subcause
Sub-subcause
Sub-subcause
Sub-subcause
Subc
ause
Subc
ause
Subc
ause
Subc
ause Su
bcau
se
Subc
ause
Materials Cause 1
Subc
ause
Subc
ause
Subc
ause
Subc
ause
Subc
ause
Subc
ause
Manpower Cause 2
4th le
vel c
ause
4th le
vel c
ause
4th le
vel c
ause
4th le
vel c
ause
4th le
vel c
ause
4th le
vel c
ause
4th le
vel c
ause
4th le
vel c
ause
4th le
vel c
ause
4th le
vel c
ause
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What did you Learn?– What were your root causes?– What were the most important
differences between Ishikawa and “five-whys”?
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Problems with Ishikawa Diagrams
– The complexity of the tool can be difficult to know which is the “key”root cause
– Requires more time
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Other RCA Tools– Five Whys and Ishikawa Diagrams
are two easy ways to conduct RCAson understandable processes
– For some problems, a statistically-based RCAs may be more useful
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Why Did Our Root Cause Happen?
– Most Root Causes happen because we either:– Do not have a process– Have a bad process– Something causes variation within our
process
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Variation from a process– Variation from an existing process is
one of the most difficult root causes to address.
– Two types of variation– Common Cause: The variation occurs
regularly as a result of the way the process operates
– Special Cause: The variation is rare, and is not a result of the process
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Common Cause Variation–A result of the process.–The process allows this amount of variation.
20 2317
2419
25 2226
19 1722 19
28 25 26
0
10
20
30
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Wait Times for Room Service
–We would not expect that it is always delivered in 22 minutes.–Normal variation is often expected and allowed.
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Common Cause Variation– Room Service sources of common
cause variation include:– Imprecise burner temperatures– Staff availability– Slow elevators
– Sources of common cause variation work together to deliver our food a little bit earlier or a little bit later than average.
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When is Common Cause Variation a Problem?
– When it fails to meet our “customer’s” needs.
8092
6896
76100 88
10476 68
88 76
112 100 104
020406080
100120
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Wait Times for Room Service
Our promise/customer requirement
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How do we Fix Common Cause Variation?
– Common Cause Variation suggests that your outcomes are a result of the process
– If the process does not meet customer needs, you must change the process
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Special Cause Variation– Special Cause Variation happens
outside of the normal process.
– The process is functioning normally, until some event happens
20 23 17 24 19 25 22 26 19 17
327
19 28 25 260
100200300400
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Wait Times for Room Service
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Special Cause Variation– Room Service sources of special
cause variation include:– A fire in the kitchen– Broken elevator– Crashing computer system
– A single sources of special cause variation causes us to miss our performance standard.
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How do we fix Special Cause Variation?
– Sources of special cause variation must be identified and eliminated
– Eliminating a single special cause does not always mean that the error cannot reoccur.
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Common vs. Special Cause Variation
–Attributed to less than 15% of the cause of the problem–Improvement requires change by an individual or avoidance of an isolated event
–Cause of at least 85% of the problem–Systems based–Improvement usually requires intense analysis of the system and changes to the system
Special Cause Variation
Common Cause Variation
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RCA Summary
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What does Root Cause Analysis (RCA) do?
– Identify the causes that lead to variationfrom our performance expectation.
Types of Variation: Common Cause and Special Cause
Types of causes: Apparent and Underlying
Performance Expectation: What we want to happen (e.g. 0 Sentinel events)
This analysis helps us understand why we have missed our performance goals
Multiple tools, including 5 Whys and Ishikawa
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RCA Tips
• Start with special causes in the clinical process and move to common causes in the organization process
• Repeatedly peel away the layers of the incident until no additional logical answers can be found
• Identify changes that could be made to systems and processes that would reduce the risk of such an event occurring in the future
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RCA Tips
• Eliminate culture of blame• Continue to study the process and
compare it over time to assure ongoing change and improvement
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Day 3: The Survey and Continual Improvement
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Advanced Quality Strategies
Failure Mode and Effects Analysis (FMEA)
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Failure Modes and Effects Analysis (FMEA)
– FMEA is a tool which helps identify and prioritize potential failures in a process.
– FMEA does not fix failures
– Failure Mode: What one observes when a failure occurs.
– Effect: The consequences of a failure
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A Failure?
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A Failure in Pisa–Failure Mode:
–Effects:
•The tower was built on ground that could not support it.
•The tower leans to one side.
•Visitors must be careful when climbing the stairs.
•The building is unsafe.
•The building must be reinforced.
•More staff must be hired to accommodate additional visitors.
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Root Cause Analysis v. FMEA
Design
Root Cau
se
AnalysisFMEA
Building
Redes
ignFMEA
Impro
ve
FMEA is an early part of processimprovement
RCA examines why a specificfailure happened
FMEA can also be used to improve an existing system
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JCI Hospital Std QPS.10
– An ongoing program of identifying and reducing unanticipated adverse events and safety risks to patients and staff is defined and implemented.– Identify high risk processes– Prioritize risks annually– Proactive risk reduction annually– Redesign process, based on activity
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What will an FMEA give us?– A prioritized list of potential failures/risks
that include:
– What we will see when a failure occurs– How that failure impacts our “customers”– What is the likely cause of the failure
– Best for analysis of a system not an incident
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What will we do with a completed FMEA?
– Use the prioritized failures/risks to focus our improvement efforts on the most pressing problems
– Predict possible failures– Eliminate the possibility of intolerable
errors– Minimize the consequences of
unavoidable errors
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The FMEA Process
150
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FMEA Process Steps
1. Select a process2. Assemble a team3. Diagram the process4. Brainstorm5. Complete the FMEA form6. Redesign the process/design controls7. Analyze and test the new process8. Implement & monitor redesigned
process
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Step 1: Select a Process
– High-risk process
•Variable input•Complex•Non-standardized•Heavily dependent on human interaction•Hierarchical (not team) orientation
•Humans•Many processes•Many lack standards•High degree of human interaction•Very hierarchical
High Risk Process Healthcare
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Step 2: Form a Team– 4 to 8 members– Experts on the process examined:
– If clinical at least one nurse and one doctor– Preferably individuals who command respect
– FMEA Expert (act as facilitator)– Hospital Leader with decision-making power– Team Leader (can be same as one of above)– At least one person unfamiliar with the
process to be examined
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A Successful FMEA Needs
– Leadership support– Trained and qualified personnel– Honesty– Creativity
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Step 3: Diagram the Process– Multiple ways to diagram any process
– Value Stream Mapping– Flow Charting
– Involve representation for everyone involved in the process
– Allocate plenty of time for this step
– Be as detailed and complete as possible
– Learn the flow chart process and symbols
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Value Stream Map Example
Cola Factory
Cola unloaded at Conference Center
Carried to conference
room
Wait for program to
startCola carried to storage
room
Customer
Wait for Cola order
Cola refrigerated
Cola put on
ice
120 mins 30 mins
30 mins
17,280 mins
30 mins
120 mins 60 mins
Value Added
Non-Value
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Cola Factory
Cola unloaded at Conference Center
Carried to conference
room
Wait for program to
startCola carried to storage
room
Customer
Wait for Cola order
Cola refrigerated
Cola put on
ice
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Flow Charting
Physicianwrites order
Medicationorder
Order pulledfrom chart
Order transcribed
into medication administrationrecord (MAR)
Order transcribedinto Pharmacy
system
Copy oforder sent to
Pharmacy
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Exercise 1: Flow Charting
Physicianwrites order
Medicationorder
Order pulledfrom chart
Order transcribed
into medication administrationrecord (MAR)
Order transcribedinto Pharmacy
system
Copy oforder sent to
Pharmacy
Physicianwrites order
Medicationorder
Order pulledfrom chart
Order transcribed
into medication administrationrecord (MAR)
Order transcribedinto Pharmacy
system
Copy oforder sent to
Pharmacy
–Ordering medication–Cleaning dishes–Making travel arrangement
–Minimum of 4 steps–Maximum of 8 steps–Pick something everyone in the group can understand
ExamplesInstructions
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Value Stream Map Legend
Electronic Info Flow
PullSupply only when
consumed
PushSupply regardless if
consumed
External Customer/Supplier
Blood drawn by technician
Process StepWe are actually doing something
Hard Copy Info Flow
WaitSomething is
“sitting”
TransportingSomeone moved
something
ReworkSomething done
again
ShipmentSomething is
mailed/shipped externally
Cola Factory
Cola unloaded at Conference Center
Carried to conference
room
Wait for program to
startCola carried to storage
room
Customer
Wait for Cola order
Cola refrigerated
Cola put on
ice
Cola Factory
Cola Factory
Cola unloaded at Conference CenterCola unloaded at
Conference CenterCarried to
conference room
Carried to conference
room
Wait for program to
start
Wait for program to
startCola carried to storage
room
Cola carried to storage
room
CustomerCustomer
Wait for Cola order
Wait for Cola order
Cola refrigerated
Cola refrigerated
Cola put on
ice
Cola put on
ice
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Soda opened
and left out
Soda served
warm
No soda
served
Custom
er drin
ks
flat sod
a
Customer avo
ids
soda-remains
thirsty
Customer leaves
to find unopened
soda
Custom
er must
find ice
Customer avo
ids
soda-remains
thirsty
Customer leaves
to find unopened
soda
Custom
er must
drink w
ater
Customer
remains thirsty
Customer leaves
to find soda
Soda decarbonation
Soda decarbonation
Soda decarbonation
Refrigerator
broken
No ice available
Not enough time
to cool after
delivery
Distributor did
not deliver soda
Soda sent to
wrong room
Staff forgot to
deliver
Soda left out
too long
Distributor did
not deliver soda
Soda sent to
wrong room
Staff forgot to
deliver
Cannot drink
other options
FMEA Brainstorming
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Step 4: FMEA Brainstorming– This FMEA looks for potential failure
points in the process we are implementing
– Essentially, FMEAs are very large brain-storming projects
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Exercise 2: Brainstorm Failure Modes
– Brainstorm potential Failure Modes in your process– Failure Mode: What you
observe when a failure happens.
– Do not list causes, effects, or reasons at this point.
– Brainstorm at least 3 potential failure modes within your process.
– In a “real” FMEA, brainstorm until you run out of ideas.
– Leave plenty of room on your page!
Soda opened and left out
Soda served warm
No soda served
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Exercise 3: Brainstorm Effects– Brainstorm the potential
effects for each failure mode– Effect: How the failure
impacts the customer.– Do not list causes or
reasons at this point.– Brainstorm at least 3
effects for each failure mode.
– In a “real” FMEA, brainstorm until you run out of ideas.
– Leave plenty of room on your page!
Soda opened and left out
Soda served warm
No soda served
Customer drin
ks
flat soda
Customer avoids soda-remains thirstyCustomer leaves to find unopened soda
Customer must
find ice
Customer avoids soda-remains thirstyCustomer leaves to find unopened soda
Customer must
drink water
Customer remains thirsty
Customer leaves to find soda
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Exercise 4: Brainstorm Causes– Brainstorm the likely
cause(s) for each effect– Cause: Whatever made
the effect or failure mode occur.
– Brainstorm at least 1 cause for each failure mode.
– In a “real” FMEA, brainstorm until you run out of ideas.
– Leave plenty of room on your page!
Soda opened and left out
Soda served warm
No soda served
Customer drin
ks
flat soda
Customer avoids soda-remains thirstyCustomer leaves to find unopened soda
Customer must
find ice
Customer avoids soda-remains thirstyCustomer leaves to find unopened soda
Customer must
drink water
Customer remains thirsty
Customer leaves to find soda
Soda decarbonation
Soda decarbonation
Soda decarbonation
Refrigerator broken
No ice available
Not enough time to cool after delivery
Distributor did not deliver sodaSoda sent to wrong room
Staff forgot to deliver
Soda left out too long
Distributor did not deliver sodaSoda sent to wrong room
Staff forgot to deliver
Cannot drink other options
155
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Complete the FMEA Form
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Filling Out the FMEA
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What Does the FMEA Form Help us Do?
– The FMEA form guides us through two questions:– 1. What are the important elements of a
potential failure?
– 2. Which potential failures should we start working on first?
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Elements of a Potential Failure
– What will we observe when something fails?
– How will the failure impact our “customers”?
– What do we think might cause this failure?
3
1
2
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What is your first Failure Mode?– Failure Mode: What you observe
when a failure occurs
1
Failure ModeWhat you observe when a failure occurs
Soda opened and left out
1
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What is the first effect of your first Failure Mode?
– Determine the effect on the customer
Failure Mode EffectWhat you observe when a failure occurs
How the failure impacts the ultimate “customer”
Customer drinks “flat” sodaSoda opened and left out
2
2
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Severity– Determine the severity of the effect on the
customer– This is step 4, so skip it for now.
Mode Effecte when a failure How the failure impacts the
ultimate “customer”
Customer drinks “flat” sodaleft out
4
Severity
10 5 1
4
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Mode Effecte when a failure How the failure impacts the
ultimate “customer”
orm X
g ordered
Customer drinks “flat” sodaleft out
ame ordered
Severity
10 5 1
Severity– Determine the severity of the effect on the
customer– This is step 4, so skip it for now.
4
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Potential Cause– Determine the most likely cause of each
Failure Mode/Effect– List as many as apply
ffectimpacts the
mer”
s “flat” soda
Severity
10 5 1
Potential CauseThe most likely cause of the failure
Busy staff
Incorrect meeting times
Soda opened too early
Soda decarbonation
3
3Failure ModeWhat you observe when a failure occurs
Soda opened and left out
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Repeat Steps , , – Do you have all of the Potential Causes of
an Effect?– Now, go back and brainstorm another
Effect of the Failure Mode you are examining.
– What are the Potential Causes of that Effect?
– Exhaust all causes before moving on to a new effect. Exhaust all effects before moving on to a new failure mode.
31 2
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Soda served warm Customer avoids soda, still thirsty
What’s the first failure mode?
Yes No
Yes
NoAre there more failure modes?
Yes
No
Cold soda left out too long
Customer leaves venue to find soda
Are there more likely effects of the failure mode?
Soda served warm
What’s the first effect of that failure mode?
What’s the next most likely cause of that effect?
Refrigerator broken
Are there more likely causes of the effect?
81 2 34 5 6 7
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No soda served Customer leaves venue to find unopened soda Distributor did not deliver soda
Soda not ordered from distributor
Soda sent to the wrong room
Soda too warm to serve
Staff forgot to deliver soda
Soda opened and left out Customer drinks “flat” soda Soda decarbonation
Customer avoids soda-remains thirsty Soda decarbonation
Customer bumps table and spills open soda Soda decarbonation
Shaky table
Customer thinks open sodas belong to others Soda decarbonation
Customer leaves venue to find unopened soda Soda decarbonation
Soda served warm Customer avoids soda-remains thirsty Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
Customer leaves venue to find cold soda Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
81 2 34 5 6 7
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No soda served Customer leaves venue to find unopened soda Distributor did not deliver soda
Soda not ordered from distributor
Soda sent to the wrong room
Soda too warm to serve
Staff forgot to deliver soda
Soda opened and left out Customer drinks “flat” soda Soda decarbonation
Customer avoids soda-remains thirsty Soda decarbonation
Customer bumps table and spills open soda Soda decarbonation
Shaky table
Customer thinks open sodas belong to others Soda decarbonation
Customer leaves venue to find unopened soda Soda decarbonation
Soda served warm Customer avoids soda-remains thirsty Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
Customer leaves venue to find cold soda Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
Some effects have the same set of causes
Different failure modesmay have the same
effects
Effects may have multiple or single
causes
81 2 34 5 6 7
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Exercise: Brainstorming the FMEA
– Fill in , & only– In a real FMEA, brainstorm until you are
out of ideas.– Use the brainstorming you completed
earlier to fill in this form. – For this exercise, please limit yourself to
three causes, three effects, and two failure modes.
– Remember:– Many lines will remain blank– No idea is a bad idea
31 2
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Soda served warm Customer avoids soda-remains thirsty Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
Customer leaves venue to find cold soda Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
1 2 34 5
Soda opened and left out
Soda served warm
No soda served
Customer drin
ks
flat soda
Customer avoids soda-remains thirstyCustomer leaves to find unopened soda
Customer must
find ice
Customer avoids soda-remains thirstyCustomer leaves to find unopened soda
Customer must
drink water
Customer remains thirsty
Customer leaves to find soda
Soda decarbonation
Soda decarbonation
Soda decarbonation
Refrigerator broken
No ice available
Not enough time to cool after delivery
Distributor did not deliver sodaSoda sent to wrong room
Staff forgot to deliver
Soda left out too long
Distributor did not deliver sodaSoda sent to wrong room
Staff forgot to deliver
Cannot drink other options
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What Does the FMEA Form Help us Do?
– An FMEA helps us answer two questions:– 1. What are the important elements of a potential failure?
– What will we observe when something fails?– How will the failure impact our “customers”?– What do we think might cause this failure?
– 2. Which potential failures should we start working on first?– Which failures are most severe?– Which failures occur most often– Which failures are hard to detect before they impact
our customers?
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Scoring the FMEA– In steps , & , you will assign a set
of numerical scores to your effects and causes.
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Severity
– Determine the severity of the effect on the customer
– 10=Extreme (death)– 1=Customer doesn’t
care (not customer is happy)
4Severity
10 5 1
4
No soda served Customer leaves venue to find unopened soda
Soda opened and left out Customer drinks “flat” soda
Customer avoids soda-remains thirsty
Customer bumps table and spills open soda
Customer thinks open sodas belong to others
Customer leaves venue to find unopened soda
Soda served warm Customer avoids soda-remains thirsty
Customer leaves venue to find cold soda
1 2 4
No soda served Customer leaves venue to find unopened soda
Soda opened and left out Customer drinks “flat” soda
Customer avoids soda-remains thirsty
Customer bumps table and spills open soda
Customer thinks open sodas belong to others
Customer leaves venue to find unopened soda
Soda served warm Customer avoids soda-remains thirsty
Customer leaves venue to find cold soda
1 2 41 2 4
Customer leaves venue to find unopened soda
Customer drinks “flat” soda
Customer avoids soda-remains thirsty
Customer bumps table and spills open soda
Customer thinks open sodas belong to others
Customer leaves venue to find unopened soda
Customer avoids soda-remains thirsty
Customer leaves venue to find cold soda
2 4
Customer leaves venue to find unopened soda
Customer drinks “flat” soda
Customer avoids soda-remains thirsty
Customer bumps table and spills open soda
Customer thinks open sodas belong to others
Customer leaves venue to find unopened soda
Customer avoids soda-remains thirsty
Customer leaves venue to find cold soda
2 42 4
4
7
248
277
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Occurrence
– How often does the cause occur?
– 10=Very often– 1= Very rare
5Occurrence
RareCommon
10 5 1
Distributor did not deliver soda
Soda decarbonation
Soda decarbonation
Soda decarbonation
Shaky table
Soda decarbonation
Soda decarbonation
Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
3 5 6
Distributor did not deliver soda
Soda decarbonation
Soda decarbonation
Soda decarbonation
Shaky table
Soda decarbonation
Soda decarbonation
Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
3 5 63 5 6
441
442
834
327
278
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Soda decarbonation
Soda decarbonation
Soda decarbonation
Shaky table
Soda decarbonation
Soda decarbonation
Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
3 5 6
Distributor did not deliver soda
Soda decarbonation
Soda decarbonation
Soda decarbonation
Shaky table
Soda decarbonation
Soda decarbonation
Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
3 5 63 5 6
441
442
834
327
278
6 Detectability
– How likely are we to detect problem before it effects the customer?
– 10=Unlikely– 1= Certain
Detectability
5 1
LikelyUnlikely
10
339
339
753
523
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Scoring Hints– Big number = worse outcome– Precision is not important.
– Don’t waste time discussing if something should be scored a three or four.
– Keep the rest of the FMEA in mind as you score. – The first item may seem like a 10, but is it a 10
compared to the other items on the list?
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Exercise: Scoring The FMEA
– Score the , & columns. – Remember:
– Score in relation to every item on your list.
– Precision is not important—there is very little difference between a score of 2, 3, or 4.
– Big number = worse outcome
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No soda served Customer leaves venue to find unopened soda Distributor did not deliver soda
Soda not ordered from distributor
Soda sent to the wrong room
Soda too warm to serve
Staff forgot to deliver soda
Soda opened and left out Customer drinks “flat” soda Soda decarbonation
Customer avoids soda-remains thirsty Soda decarbonation
Customer bumps table and spills open soda Soda decarbonation
Shaky table
Customer thinks open sodas belong to others Soda decarbonation
Customer leaves venue to find unopened soda Soda decarbonation
Soda served warm Customer avoids soda-remains thirsty Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
Customer leaves venue to find cold soda Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
5555777745884777777
1463146388838813724
98389838999399101279
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Risk Priority Number– The Risk Priority Number determines
where our greatest danger lies– Severity X Occurrence X Detectability
5
7
Detectability
5 1
LikelyUnlikely
10
8
8
OccurrenceRareCommon
10 5 1
9
3
Severity
10 5 1
360
168
RPN
6
7
1
5
9
6
54
210
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Risk Priority Number– The Risk Priority Number determines
where our greatest danger lies– Severity X Occurrence X Detectability
360
168
RPN
5
7
Detectability
5 1
LikelyUnlikely
10
8
8
OccurrenceRareCommon
10 5 1
9
3
Severity
10 5 1
6
7
1
5
9
6
54
210
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Rank by RPN– Once you determine the RPN,
determine the rank.– Higher numbers mean greater risk.
Failure ModeWhat you observe when a failure occurs
Used felt pen on form X
Non-formulary drug ordered
Soda opened and left out
Look alike drug name ordered 360
168
RPN
54
210
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Rank by RPN– Use the RPN to determine where to
focus your limited resources– We are looking for failures that are most
severe, occur often, and are hard to detect.
Failure ModeWhat you observe when a failure occurs
Used felt pen on form X
Non-formulary drug ordered
Soda opened and left out
Look alike drug name ordered 360
168
RPN
54
210
1
3
Rank
4
2
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Exercise: RPNs and Rankings
– Use the scores you created to determine Risk Priority Numbers (RPNs).
– Use the RPNs to determine rank
RPN=Severity x Occurrence x Detectability
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No soda served Customer leaves venue to find unopened soda Distributor did not deliver soda
Soda not ordered from distributor
Soda sent to the wrong room
Soda too warm to serve
Staff forgot to deliver soda
Soda opened and left out Customer drinks “flat” soda Soda decarbonation
Customer avoids soda-remains thirsty Soda decarbonation
Customer bumps table and spills open soda Soda decarbonation
Shaky table
Customer thinks open sodas belong to others Soda decarbonation
Customer leaves venue to find unopened soda Soda decarbonation
Soda served warm Customer avoids soda-remains thirsty Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
Customer leaves venue to find cold soda Refrigerator broken
Not enough time to cool soda post delivery
Cold soda left out too long
No ice available
5555777745884777777
1463146388838813724
98389838999399101279
4516090120632241261682883605767228850470219898252
18914111771084311542161912126
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Step 6: Redesign the process/design controls
– Brainstorm actions that could address the failure modes with the highest Risk Priority Number (RPN)– Eliminate risk if possible– Minimize/mitigate risk if it cannot be
eliminated– Look for opportunities to “failure proof”
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Prioritized Potential Failure Modes
0
100
200
300
400
500
600
700
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
– All failure modes are important
– Some Failure Modes will be clear targets
Ris
k Pr
iorit
y N
umbe
r
Failure Modes
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How can we Reduce Risk?– One way to reduce risk is to reduce
the Risk Priority Number– Can I make this failure less severe?– Can I make this failure occur less often?– Can I make this failure easier to detect?
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7. Analyze and Test the New Process
– One the new process has been developed, conduct another FMEA, examining the potential risks.
– For failure modes with high RPNs, look for additional ways to eliminate or mitigate risk
166
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8. Implement and Monitor New Process
– Repeat several times, after elimination of each Failure Mode
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Summary– Failure Mode Effects Analysis
(FMEA) is an effective proactive risk reduction technique
– Doing it right– requires a well functioning team– requires resources in time and talent– results in reducing patient harm and
improving patient outcomes
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Filling out an FMEA: Words first
What is the first Failure Mode?
1What is the first effect of that Failure Mode?
2What is the most likely cause of the failure that produces this effect?
3
What is the next most likely cause of the failure? Enter causes until you run out.
4
When you run out of causes for the effect your working on, move on to another effect.
5Enter causes for this effect until you run out.
6
When you run out of effects, move on to another Failure Mode.
7
167
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Filling out an FMEA: Numbers last
8
Fill in all of the severity ratings 9
10
11
12
13
14
15
16
17
18
19
Then, fill in all of the occurrence ratings
Then, fill in all of the detectabilityratings
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Tips for Filling out an FMEA– Words first (Failure Mode, Effect,
Cause)– Number second (Severity,
Occurrence, Detectability)– The numbers are relative values—they
only mean something ranked against each other
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66Next Presentation
168
Failure Mode Effect Potential Cause RPN RankWhat you observed when a failure occurs How the failure impacts the
customerThe most likely causes of the failure--this line must always be filled in
How severe is the effect to the customer?Severity Occurrence Detectability
How likely are we to be able to detect the failure or cause?
Failure Mode Effects Analysis
How often does the cause or Failure Mode occur?
Worksheet
10 5 110 5 1
RareCommon
10 5 1
RareCommon
10 5 1 5 1
LikelyUnlikely
10 5 1
LikelyUnlikely LikelyUnlikely
10
31 2 64 5 87
169
Failure Mode Effect Potential Cause RPN RankWhat you observed when a failure occurs How the failure impacts the
customerThe most likely causes of the failure--this line must always be filled in
How severe is the effect to the customer?Severity Occurrence Detectability
How likely are we to be able to detect the failure or cause?
Failure Mode Effects Analysis
How often does the cause or Failure Mode occur?
Worksheet
10 5 110 5 1
RareCommon
10 5 1
RareCommon
10 5 1 5 1
LikelyUnlikely
10 5 1
LikelyUnlikely LikelyUnlikely
10
31 2 64 5 87
170
Failure Mode Effect Potential Cause RPN RankWhat you observed when a failure occurs How the failure impacts the
customerThe most likely causes of the failure--this line must always be filled in
How severe is the effect to the customer?Severity Occurrence Detectability
How likely are we to be able to detect the failure or cause?
Failure Mode Effects Analysis
How often does the cause or Failure Mode occur?
Worksheet
10 5 110 5 1
RareCommon
10 5 1
RareCommon
10 5 1 5 1
LikelyUnlikely
10 5 1
LikelyUnlikely LikelyUnlikely
10
31 2 64 5 87
171
Failure Mode Effect Potential Cause RPN RankWhat you observed when a failure occurs How the failure impacts the
customerThe most likely causes of the failure--this line must always be filled in
How severe is the effect to the customer?Severity Occurrence Detectability
How likely are we to be able to detect the failure or cause?
Failure Mode Effects Analysis
How often does the cause or Failure Mode occur?
Worksheet
10 5 110 5 1
RareCommon
10 5 1
RareCommon
10 5 1 5 1
LikelyUnlikely
10 5 1
LikelyUnlikely LikelyUnlikely
10
31 2 64 5 87
172
Failure Mode Effect Potential Cause RPN RankWhat you observed when a failure occurs How the failure impacts the
customerThe most likely causes of the failure--this line must always be filled in
How severe is the effect to the customer?Severity Occurrence Detectability
How likely are we to be able to detect the failure or cause?
Failure Mode Effects Analysis
How often does the cause or Failure Mode occur?
Worksheet
10 5 110 5 1
RareCommon
10 5 1
RareCommon
10 5 1 5 1
LikelyUnlikely
10 5 1
LikelyUnlikely LikelyUnlikely
10
31 2 64 5 87
173
Failure Mode Effect Potential Cause RPN RankWhat you observed when a failure occurs How the failure impacts the
customerThe most likely causes of the failure--this line must always be filled in
How severe is the effect to the customer?Severity Occurrence Detectability
How likely are we to be able to detect the failure or cause?
Failure Mode Effects Analysis
How often does the cause or Failure Mode occur?
Worksheet
10 5 110 5 1
RareCommon
10 5 1
RareCommon
10 5 1 5 1
LikelyUnlikely
10 5 1
LikelyUnlikely LikelyUnlikely
10
31 2 64 5 87
174
Failure Mode Effect Potential Cause RPN RankWhat you observed when a failure occurs How the failure impacts the
customerThe most likely causes of the failure--this line must always be filled in
How severe is the effect to the customer?Severity Occurrence Detectability
How likely are we to be able to detect the failure or cause?
Failure Mode Effects Analysis
How often does the cause or Failure Mode occur?
Worksheet
10 5 110 5 1
RareCommon
10 5 1
RareCommon
10 5 1 5 1
LikelyUnlikely
10 5 1
LikelyUnlikely LikelyUnlikely
10
31 2 64 5 87
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Day 4: The Survey and International Patient Safety Goals
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Last Survey Simulation Discussion and Reflective
Learning
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Discussion Questions– What differences did you notice
between the approaches that your two surveyors used?
– What do these differences mean for how you will prepare for your survey?
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Discussion Questions– What surprised you the most about
the tracer process?
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Discussion Questions– What are three most important things
that you have learned about the tracer process?
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Discussion Questions– What are the three most important
pieces of advice that you would give to a staff members who must conduct their first tracer?
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Four Steps for Continual Improvement
It’s not where you’ve been—it’s where you’re going.
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The Mindset
Accreditation is a milestone on the continuous journey of improvement
The effort is for your patients, not the certificate
Three years fly by quickly, staying ready is easier than getting ready
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The ToolsAccreditation Standards provide a common quality language and common set of expectations to point the way forward
Motivational Goals bring collective energy and ideas to priority topics
Credible Data guide individual decisions and overall strategic direction
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The ChallengeSustaining improvement requires establishing an organizational culture of safe, quality care
Individual behaviors must change one person at a time.
Organizational cultures can change at a moments notice
Sentinel events or leadership changes can alter culture immediately.Frequently measure the direction and rate of progress
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Four Steps To Success1.1. Keep things simple and clearKeep things simple and clear
2. Consider data your best friend2. Consider data your best friend
3. Presume change and manage it3. Presume change and manage it
4. Practice the process 4. Practice the process
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Success Step #1: Keep Things Simple and Clear
Policies and Procedures:As few as practicalShortSimple languageReadily accessible for those who need themKept up-to-date
A strong quality culture in an organization is sustained by leadership not policiesIndividual behaviors are shaped best by mentors and role models not policies
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Find simple and effective ways to communicate essential quality and safety information to all parties – governance, leaders, staff, patients
A brief communication about quality once a week is better than a big document once a month
Success Step #1: Keep Things Simple and Clear
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Success Step #2: Consider Data Your Best Friend
Consider how key points can be made more effective with data - a graph is worth a thousand words
Motivate governance, management, professional staff and patients with data
Post infection rates all over the hospital
Post average length of stay for procedures on the door of the staff lounge
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Success Step #2: Consider Data Your Best Friend
Do not try to interpret all the data--let the data owners do so
Let the orthopedic surgeons explain why the complication rate for hip replacements is drifting upward for the last 2 quarters
Data owners must also own the actions for improvement and claim success for sustained improvements
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Success Step #2: Consider Data Your Best Friend
Continue to refine and mature your data systems
Create data collection tools that people want to use Create event reporting processes that everyone uses
Strengthen the data analysis process so that it becomes more rapid and comprehensive
Demonstrate data use and how it contributes to understanding all aspects of your organization
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Success Step #3:Presume Change and Manage It
Catalogue the changes occurring in your organization:
Leadership changesClinical services New/renovated buildings, facilitiesNew staff (including contract workers)Changes in the patient populationClinical and management activities
Consider how they should be managed
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Success Step #3:Presume Change and Manage It
Ensure that standards are met as changes occur
Training for staff as they are hired
Fire safety in new facilities and during renovations
Build quality into all contracts for services
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Success Step #4:Practice the Process
Do patient and system tracerscomplete at least one a month to be ready for survey or resurvey
Continually evaluate patient records to ensure they tell the entire “story” of the patient
Do exercises that “break” high-risk processes to see if adverse events can sneak though
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Success Step #4:Practice the Process
Practice the group interviews of leaders
Practice using interpreters to ensure the comfort level of staff
Check the track record for all documentation
4 months for an initial survey12 months for a triennial survey
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Some Final Tips
The accreditation survey is also a learning process—there is something new to learn every time you go through it.As you prepare for an accreditation survey or maintain continued readiness for survey, your quality and patient safety capabilities should and will growKeep quality and safety as an integrated activity
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Some Final Tips
Quality and safety everyone’s job.
The quality department/unit is primarily for coordination and facilitation of quality with leaders setting priorities and all staff participating in monitoring and improving quality and safety.
Avoid the “it’s the quality department’s job”syndrome.
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Some Final Tips
Continue to celebrate your successes as
you continue to improve.
Constant, incremental improvement can
have a profound impact on patient safety.
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Step 5?– For those that are preparing for
reaccreditation, what practices have helped you?
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Questions-Discussion
www.jointcommissioninternational.org
Next Presentation
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Day 5: Tools and Techniques
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Communication Between Hospital Staff and Patients and Families:
Skills to Improve Patient Safety and Build Trust and Confidence
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To improve the safety and quality of care in the international community
through the provision of education, publications, consultation, evaluation, and accreditation services
Mission of Joint Commission International
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The Importance of Communication to Medical
Errors– Poor communication among health
care providers places patients at risk
– Poor communication with patients and families destroys trust and confidence in providers and the health care system
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Sentinel Event Experience to Date Provides the Evidence
531 events of wrong site surgery
520 inpatient suicides488 operative/post op
complications385 events relating to
medication errors302 deaths related to delay in treatment224 patient falls153 deaths of patients in
restraints138 assault/rape/homicide
Of 4064 sentinel events reviewed by the Joint Commission, January 1995 through December 2006:
= 4064 RCAs
125 perinatal death/injury94 transfusion-related
events85 infection-related events72 deaths following
elopement66 fires67 anesthesia-related events51 retained foreign objects
763 “other”
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Root Causes of Sentinel Events
0 10 20 30 40 50 60 70 80 90 100
Organization culture
Care planning
Continuum of care
LeadershipEnviron. safety / security
Procedural compliance
Competency/credentialing
Availability of infoStaffing
Patient assessment
Orientation/training
Communication
(All categories; 1995-2004)
Percent of 2966 events
Average number of root causes cited per
RCA = 3.1
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Root Causes of Sentinel Events
0 10 20 30 40 50 60 70 80 90 100
Organization culture
Care planning
Continuum of care
Leadership
Environ. safety / security
Procedural compliance
Competency/credentialing
Availability of info
Staffing
Patient assessment
Orientation/training
Communication
(All categories; 2005)
Percent of 582 events
Average number of root causes cited
per RCA = 3.8
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Root Causes of Sentinel Events
0 10 20 30 40 50 60 70 80 90 100
Organization culture
Care planningContinuum of care
Leadership
Environ. safety / security
Procedural compliance
Competency/credentialing
Availability of info
Staffing
Patient assessment
Orientation/training
Communication(All categories; 2006)
Percent of 516 events
Average number of root causes cited
per RCA = 5.3
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Why Communication Breaks Down
– Organizations and health care providers do not have the two way “conversations” with patients to build a trusting relationship.– Example: patients are asked questions
by health care providers and not permitted to tell their story on an initial assessment. Average patient is interrupted by the provider within 20 seconds when explaining why they are seeking care.
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Why Communication Breaks Down
– Communication is not standardized– Professional jargon used by all groups
of health care providers– Abbreviations and short hand notes
seem to be a personal preference not an organization policy
– Information is a mixture of electronic, verbal and paper in most organizations thus no single source captures everything
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Why Communication Breaks Down
– Health care is complex and delivered across a continuum of acute care and community settings– The hand off of information from shift to
shift and from setting to setting is poor and even critical information can fall between the cracks for example, medications the patient is or should be taking
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Why Communication Breaks Down
– The “culture” within and between professional groups is often a barrier– Nurses hesitate to challenge physicians
even when they sense an error is about to be made
– Admitting errors is not viewed as an opportunity to learn rather, they are covered up to save face
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The Human Side of Errors– “By focusing on the human
consequences of medical errors, they (advocacy groups) force care givers to confront our inadequacies in communicating with patients and families when things go wrong”
– Lucian L. Leape, M.D.– Adjunct Professor of Health Policy – Harvard School of Public Health
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JCI Standards and Accreditation Support Good
Communication– Patients have access to a quality focused
organization– Patient and family rights are respected and
protected– Education and communication is understandable– Satisfaction is seriously evaluated– Involvement in care decisions and care process
is welcomed– Kept informed of care process and when
unexpected errors and complications occur
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JCI Standards and Accreditation Support Good Communication
– Family valued in the care process and part of all communication
– End of life care and pain management respect personal preferences and maintain dignity
– There are clear processes to resolve care issues or address complaints
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Disclosing Medical Errors– Approach patients’ and their families’
need for communication and information with an attitude of understanding and respect.
– Tell patients and their families what went wrong as soon as it is known.
– Sincerely apologize.– Tell patients and their families how
such errors will be prevented in the future.
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Internal Processes Related to Medical Errors
– Identify the individuals or departments who should be notified of an incident.
– Specify how the incident should be reported.
– Define who is responsible for reporting.– Define the process for the events that
follow reporting the incident.– Report errors promptly to supervisors,
risk managers, and others.
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Apology and Litigation– University of Michigan Health System
– A new policy on handling medical malpractice claims was based on three principles:– a) When we hurt someone through
unreasonable medical care we ought to make it right
– b) We ask the staff to do hard work. When the care they provide is reasonable, we need to support them even when something goes awry.
– c) We need to learn something from medical errors and patients’ experiences.
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Apology and Litigation– Results of an open disclosure policy
– August 2001 – 262 claims and suits– May 2006 – 93 claims and suits
– Before the policy - $48,000 average claim
– Since policy - $21,000 average claim
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Patients as Partners:Involving Patients and
Families
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FACT– Patients as respected partners in
health care– Feel free to ask questions until they
understand the answers– Feel empowered to challenge a
physician or nurse about some aspect of treatment
– Feel support from the entire organization
– Are more likely to comply with treatment
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FACT– Have better outcomes– Are less likely to bring legal action if
things go wrong– Often identify potential medical errors
that hospital staff are overlooking
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Reality– In most organizations patients are
not serious partners– They are only seriously listened too when a
bad event occurs– Making patients into partners takes change
that most organizations are reluctant to make– Creating a new culture takes leadership that is
often missing– Changing philosophy, attitudes and behaviors
is not easy
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Brochures can be ordered that have a blank panel to allow for information about the organization, its commitment to patient safety, and the organization logo.
Organizations can order campaign buttons that can be worn by staff.
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SpeakUP Initiatives
– Speak Up: Help Prevent Errors In Your Care
– Universal Protocol: Wrong Site Surgery
– Three Things You Can Do To Prevent Infection
– Tips To Prevent Medication Mistakes
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Communication is Critical– Have a conversation with a patient not just talk at
them– Make sure they understand all portions of a
consent form– Involve the patient and their family in care
decisions to the extent they want to be involved– Make sure patient rights are known by patients
and staff– Say you are “sorry” if something unexpected and
adverse happens– Communicate in a language and style the patient
understands
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Some Tips– Post signs urging patients and families to ask
questions
– Develop a fact sheet with advice and questions that make patient and family participation easier
– Create a patient and family advisory council
– Find ways to ensure that patients understand the education you provide to them and their families
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Advice to a Parent– “Every child is different, every parent
is different, every illness or behavior is somewhat different from any other……….Remember that you know a lot about your child and I
don’t know anything”– Benjamin Spock, M.D.– Baby and Child Care
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www.JointCommissionInternational.org
THANK YOU For more information
please visit our website:
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International Patient Safety Goals (IPSG)
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Evolution of the International Patient Safety Goals
2005 Announcement of the JCI International Patient Safety Goals (IPSG)
2006 Pilot testing of the JCI IPSG– Results did not impact accreditation
decision
2007 Implementation of IPSG as requirements for International accreditation of hospitals
2008 IPSG as part of published 3rd Edition of JCI Standards for hospitals, effective January 2008
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Implementation of IPSG….
Represents proactive strategies to reduce risk of medical error and reflect good practices proposed by leading patient safety experts
Incorporating these new tools into our accreditation requirements is a significant step
Organizations taking responsibility for using the IPSG to foster an atmosphere of continuous improvement is even more important
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2008 International Patient Safety Goals
IPSG 1 Identify Patients CorrectlyIPSG 2 Improve Effective CommunicationIPSG 3 Improve the Safety of High-Alert
MedicationsIPSG 4 Ensure Correct-Site, Correct-Procedure,
Correct-Patient SurgeryIPSG 5 Reduce the Risk of Health Care
Associated InfectionsIPSG 6 Reduce the Risk of Patient Harm
Resulting from Falls
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IPSG.1Identify Patients Correctly
A collaborative process is used to develop policies and/or procedures that address the accuracy of patient identification
Use at least two (2) ways to identify a patient:
• giving medications• giving blood and blood products• taking blood samples• taking other samples for clinical testing• providing treatment or procedure
The patient’s Room Number cannot be used as an identifier
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A collaborative process is used to develop policies and/or procedures that address the accuracy of verbal and telephone communications
IPSG 2: Improve Effective Communication
Person receiving the following:
• Verbal order• Telephone order• Reporting of critical test results
Must use a verification “read back” of complete order or test result
The order or test result is confirmed by the individual who gave the order or test result
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Critical Test Results
– Ensure that there is collaborative process to determine what they are– Clinical Laboratories
– Bedside testing– Imaging Studies– Electrocardiogram– Pulmonary Function Testing– other
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A collaborative process is used to develop policies and/or procedures that address the location, labeling and storage of concentrated electrolytesConcentrated electrolytes are not present in patient care units unless clinically necessary and actions are taken to prevent inadvertent administration in those areas where permitted by policy
IPSG 3: Improve Safety of High Alert Medications
Remove concentrated electrolytes from patient care units, including, but not limited to, the following:
• Potassium Chloride• Potassium Phosphate• Sodium Chloride > 0.9%
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Clinical Necessity
– Has to be supported by evidence– Is the substance really needed very
quickly?– If it is used to dilute, is the diluted
solution not available?
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IPSG 4: Ensure Correct-site, Correct-procedure, Correct-patient Surgery
Collaborative process used to develop PP
Mark the precise site in clearly understood way and involve patient in doing thisDevelop process or checklist to verify correct documents and functioning equipment
Use a Checklist including “Time-Out” just before surgical procedure
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Universal Protocol
CORRECTSURGERYSITE
DOCUMENTS
EQUIPMENT
BODY PARTPROCEDURE
PATIENT
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UniversalProtocol
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A collaborative process is used to develop PP that address reducing the risk of health care–associated infections
IPSG 5: Reduce the Risk of Health Care-Associated Infections
The hospital has adopted or adapted currently published and generally accepted hand hygiene guidelines (can be national or international)
The hospital implements an effective hand hygiene program
Need data to demonstrate effectiveness
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IPSG 6: Reduce the Risk of Patient Harm resulting from Falls
Develop PP using collaborative process Assess and periodically Reassesseach patient’s risk for falling, including the potential risk associated with the patient’s medication regime, Take action to decrease or eliminate any identified risks.
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How to Get Started with JCI Accreditation
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The Accreditation Journey:The Basics
Evaluate the commitment of leadership (Board, CEO, and clinical leaders) to a never ending journey.Assess the purity of purpose: to be a safe, high quality organization. Set a clear understanding that the process will require significant leader time. Assigning accreditation only to the quality department will not work.
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The Accreditation Journey List all barriers and strengths to success and plan strategies for each.
Understand implications for financial and human resources. These may include facility enhancement, training, recruitment of new staff, and redesign of systems.
Set a realistic timeframe for preparation. Average preparation time?
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The Accreditation Journey:JCI Resources
• JCI International Standards for Hospitals, 3nd
Edition• Hospital Survey Process Guide• Web-based training on introduction to the
international accreditation process• ISAS – International Self Assessment System• Newsletters and publications, both print and
electronic• JCI Practicum – Several locations worldwide• JCI Executive Briefings
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The Accreditation Journey:Continual Education
Provide education for organizational leaders and managersand then progressively for all staff. Re-educate frequently.Include:
Introduction to accreditation philosophy and approachDiscussion of accreditation as a patient-focused quality improvement and risk reduction strategyReview of the standards and measurable elementsDiscussion of the survey process and what to expectProject planning and next steps
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The Accreditation Journey:Baseline Assessment
Determine the organization’s current adherence to thestandards and each measurable element.
Use knowledgeable and credible evaluators (either internal or external consultants) who will critically and objectively assess each area.Score as Met, Partially Met, or Not Met and cite specific findings and recommendations. Include all areas of the organization in the assessment.Consider an assessment of organizational “culture”related to quality and patient safety.
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The Accreditation Journey:Baseline Assessment
In addition to addressing standards adherence, analyze and collect available baseline quality data as required by the quality monitoring standards (QPS).
More data and data sources may be available than you first realize.
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The Accreditation Journey:Baseline Assessment
Begin to combine activities of risk-management, quality management, facility safety, etc. into one comprehensive data set.
Examples: medication errors, hospital-associated infection rates, antibiotic usage, falls, hazardous material spills, surgical complications, etc.
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The Accreditation Journey:Action Planning
Using the findings of the baseline assessment, develop a detailed project plan with assigned responsibilities, deliverables, and timeframes.
Example: Revise informed consent policy, develop a new informed consent statement, educate staff by 30 August. Responsibility: One PersonIf available, use a software program such as MS Project or Excel to confirm project plan in writing.Hold leaders and staff accountable to plan.
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The Accreditation Journey:Action Planning Tips
Think structure-process-outcome in the implementation sequence, in other words develop polices first. Expectation required actions result
Implement those requirements that will take the longest to make fully functional such as the quality monitoring system for the QPS indicators.
Do not forget the “track record” requirement = 4 months a first survey.
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The Accreditation Journey:Team Approach
Assign oversight of each chapter of standards to a respected champion or leader who will select team members from throughout the hospital.Tip: Involve those who may be skeptical of the process. Look for good people skills, time management skills, and consensus building skills.Be prepared to change assignments as new champions emerge and some leaders drop out.
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The Accreditation Journey:Policies and Procedures
In addition to an overall project plan, it is often helpful to compile a list of all required policies and procedures that will need development or revision.
It may take more time than you think to write, have organizational review, and get final approval on policies.Be certain that your policy reflects your actual practice. This is how surveyors will evaluate your organization.Plan time for education of new policies. Test understanding and compliance.Create, refine and/or test your document management system. (Policy on Policies)
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The Accreditation Journey:Mid-Point Strategies
Continue to monitor your progress in meeting the standards; do a mini-evaluation of each chapter at regular intervals.
It is not a setback to adjust your project plan if necessary. Changes in processes often take longer than expected.
Continue to involve as many staff as possible in the process. Make accreditation an organizational quality goal that you are striving to achieve together.
Keep staff motivated.
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Successful Strategies:Physician Perspective
Physician commitment to the accreditation process iscritical to success.
Physicians must see accreditation standards as a framework by which organizational processes will be improved in order to support good medical care.Accreditation is not a peer review process as many physicians suspect.Accreditation supports the use of good clinical science and best practices.
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Suggested Strategies– Educate, Educate, Educate– Develop/revise P/P and forms based upon the
standards and MEs– Involve all staff including leaders on a regular
basis– Conduct monthly patient tracers and system
tracers– Focus the tracer, educate on standards and develop
interviewer skills– Practice questions in different ways with various
ways for staff to show evidence of compliance– Practice tracers with staff – not management
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Suggested Strategies– Conduct open medical record reviews
– Have staff involved in medical record reviews – Use MR evidence while conducting the tracers– Use the internal audit data to show progress or
areas of focus
– Train staff in care processes, P/P, and documentation expectations
– Educate, re-educate, re-educate
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Successful Strategies Learn from what others have done well and adapt the experience to the needs of your organization.
Ask JCI for assistance and clarification with standards interpretation. Don’t waste time going down the wrong path.
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Pitfalls To Avoid: Be AwareTop leaders give “lip service” to the process, but are unrealistic in what it will take to achieve accreditation in terms of time and resources.
Staff end up feeling that accreditation is extra work for which they are not rewarded or recognized.
Over-eager managers make the entire accreditation process feel punitive and inspecting rather than motivating.
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Final Mock SurveyPlan for a final “mock survey” at least 6 months in advance of the target date of your actual accreditation survey.
Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation. They will look at the organization with more objectivity. If using internal evaluators, mix disciplines and locations.
Plan revisions and corrections based on the findings of the mock survey. Educate.
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The Accreditation SurveyRequest an application from JCI at least 6 months or longer in advance of target dates for survey.
Once your application is completed, a surveyor team will be assigned and dates confirmed.
A survey team leader will be in contact to coordinate an agenda and plans for the survey.
Support staff in doing the work they routinely do so the survey does not cause undue anxiety and fear.
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After the SurveyCelebrate your success!
If there are areas for improvement, you may need to submit documentation or a follow-up progress report to JCI.
Maintain the momentum from your preparation and survey. Establish a system and process for ongoing standards compliance and survey readiness.
Continue education.
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Questions?
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Appendix
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Tracer Activity Data Collection Tool
Clinical Service:______________________________ Patient ID Number:____________ Focus Areas: Date of Tracer:________________ 1. _________________________________________ 3.___________________________________ 2. _________________________________________ 4.___________________________________
Unit / Department
Individuals Providing
Care
Issues Standards Focus Areas
©JCR, Inc. 2003 227
Tracer Activity Data Collection Tool
Clinical Service:______________________________ Patient ID Number:____________ Focus Areas: Date of Tracer:________________ 1. _________________________________________ 3.___________________________________ 2. _________________________________________ 4.___________________________________
Unit / Department
Individuals Providing
Care
Issues Standards Focus Areas
©JCR, Inc. 2003 228
Tracer Activity Data Collection Tool
Clinical Service:______________________________ Patient ID Number:____________ Focus Areas: Date of Tracer:________________ 1. _________________________________________ 3.___________________________________ 2. _________________________________________ 4.___________________________________
Unit / Department
Individuals Providing
Care
Issues Standards Focus Areas
©JCR, Inc. 2003 229
Tracer Activity Data Collection Tool
Clinical Service:______________________________ Patient ID Number:____________ Focus Areas: Date of Tracer:________________ 1. _________________________________________ 3.___________________________________ 2. _________________________________________ 4.___________________________________
Unit / Department
Individuals Providing
Care
Issues Standards Focus Areas
©JCR, Inc. 2003 230
Tracer Activity Data Collection Tool
Clinical Service:______________________________ Patient ID Number:____________ Focus Areas: Date of Tracer:________________ 1. _________________________________________ 3.___________________________________ 2. _________________________________________ 4.___________________________________
Unit / Department
Individuals Providing
Care
Issues Standards Focus Areas
©JCR, Inc. 2003 231
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Zakaria Zaki Alattal, MSN Consultant, Joint Commission International Zakaria Zaki Alattal has more than 15 years of experience in management and training health care providers in various areas. His expertise includes utilizing Joint Commission International (JCI) standards to build quality systems in hospitals and health care organizations. Through management of the unique challenges facing each organization, he is able to identify quality concepts and enhance the quality of health care services. Dr. Alattal serves as a professional trainer for health care providers and health administrators on quality and management competencies at the Wollongong University Dubai, as well as providing on-the-job training for health care staff in Saudi Arabia, Yemen, Jordan, Egypt and the United Arab Emirates. He consults for hospitals in the Middle East on subjects related to quality and patient safety, but is also knowledgeable of the United States health care standards. He also lectures on patient safety quality management, performance management, and health management. Dr. Alattal holds an honor’s master’s degree in quality management and a master’s degree in nursing. He received the Dubai Quality Group Award as the top graduate of Wollongong University in 2003. He is currently conducting his PhD research at the University of Salford – Manchester in the UK on factors affecting the implementation of the JCI standards in UAE hospitals. Dr. Alattal is a certified senior assessor for Dubai Quality and EFQM (European Quality Award) as well as an ISO certified assessor. He is also a Certified Professional in Healthcare Quality (CPHQ) and National Association for Healthcare Quality (NAHQ).
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Ashraf Ismail, MD, MPH, CPHQ Managing Director, Middle East International Office
Joint Commission International
In March 2009, JCI appointed Dr. Ismail as the managing director of its Middle East office located in Dubai. Dr. Ismail is a physician with 20 years of international experience in hospital accreditation, healthcare quality management, performance improvement and development of human resources for health. His contributions in postgraduate quality education and training are well recognized. As an adjunct professor at George Mason University, School of Health and Human Services, he teaches a variety of quality courses for the certificate in quality and outcomes management. Dr. Ismail is a WHO consultant in accreditation and health care quality. In 2006, he was appointed as Strategic Planning Advisor to the Minister of Health in UAE to develop the new strategy of the health sector. As a quality consultant, he assists healthcare facilities through the accreditation process. His experience in these areas has extended from USA to the Middle East. For four years, he was as a quality consultant to Inova Health System, the largest health system in Northern Virginia. As a faculty at Johns Hopkins University and Director of JHPIEGO’s Asia/Near East/Europe Regional office. While he was employed with USAID in Cairo, Egypt, he implemented the first National Quality Improvement Program in the Family Planning Clinics in Egypt
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Suhail Kady, MD, MPH, CPE, CPHQ Consultant, Joint Commission International Suhail Kady is a certified physician executive with over 15 years of experience in health care, including expertise in medical management, medical staff leadership, performance improvement, staff credentialing and education of staff in leadership and quality improvement areas. Dr. Kady’s broad background includes teaching in a residency program, serving as both an assistant medical director and a medical director domestically and internationally. His consulting expertise includes operational management of health care delivery systems, quality measurement and management, hospital/physician relations, patient and family education, patient safety, medication management systems and credentialing. Dr. Kady has provided educational programs and international consulting services to organizations in UAE, Saudi Arabia, Ireland, Qatar, Lebanon, Turkey, South Korea, Singapore, Belgium and Thailand. Some of Dr. Kady’s experience with health care and acute hospitals includes serving as an attending physician at Generations+ Northern Manhattan Health Network, in New York, an Assistant Professor of Clinical Medicine at New York Medical College, in Valhalla, New York and a Senior Consultant\ Medical Director at Al Rahba Hospital in Abu Dhabi, UAE. Dr. Kady’s professional affiliations include a Certified Physician Executive at the American College of Health Care Executives and a Diplomate of the American Board of Internal Medicine. He received his doctor of medicine degree from Jordan University, in Amman, Jordan, and Master in Public Health (MPH) from New York Medical College, where he also completed his internal medicine residency.
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Sherry Kaufield, MA, FACHE, Executive Director, International Services
Ms. Kaufield joined Joint Commission Resources in 2004 with over 30 years of experience in health care. Sherry oversees JCI international consulting and education services in over 80 countries, collaborating regularly with JCI Regional Managing Directors in Singapore, Dubai, Milan, and Ferney-Voltaire, France.
Sherry has advised both domestic and international healthcare organizations in the areas of standards compliance, accreditation readiness and patient safety and quality improvement. She has traveled extensively and worked with multiple clients in Europe, the Middle East, Asia, and Latin America. Clients include individual organizations, healthcare systems, Ministries of Health, health authorities, third party payors and other government bodies. Sherry regularly serves as a faculty member at international practica and other educational events. She is a consulting editor and contributor for the publication, "Joint Commission International Accreditation: Getting Started" and many other publications.
As a former Chief Operating Officer and Corporate Compliance Officer of a 400 bed tertiary Medical Center and Level I trauma center, Sherry has expertise in operations, business development, public relations and marketing, and in the development and implementation of multi-hospital performance improvement and strategic planning initiatives. Her background also includes consultation to non-profit healthcare and other organizations in the areas of board leadership and development.
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Lynda E. Mikalauskas, BScN, MBA Consultant, Joint Commission International Lynda Mikalauskas has over 25 years of experience in health care and over 15 years of experience in international management and speaks fluent French, Turkish and English. Ms. Mikalauskas brings demonstrated expertise in nursing and administrative leadership to her role as a consultant for Joint Commission International, Inc. She specializes in organizational improvement and management and motivation of professional teams. She has adapted to multiple cultural diversities having worked in Saudi Arabia, Turkey, Canada and other parts of Europe and has consulted throughout Europe, Asia, and the Middle East. Ms. Mikalauskas’ consulting expertise includes operational assessment; patient safety assessment; medication management; infection prevention and control; environment of care; executive leadership and governing bodies; performance improvement; and incorporating tracer methodology and the periodic performance review as management tools. Ms. Mikalauskas’ experience with acute care hospitals and health care includes Associate Director, Joint Commission International, at the Europe Office, in Ferney-Voltaire, France; and Patient Care Services Group Manager and Director of Nursing, at V.K.V. American Hospital, in Istanbul, Turkey. Ms. Mikalauskas is professionally affiliated with the American College of Health Care Executives, the American Association of Nurse Executives and the International Society of Quality. She received her MBA from the University of Colorado in Boulder, Colorado and her BScN in Nursing from the University of Montreal in Montreal, Canada.
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