JCI-简介教学讲解课件

WhatisJCI?何谓JCI?

JCIisaninternationalaccreditationarmofJCAHO(JointCommissiononAccreditationofHealthCareOrganisations)JCI是JCAHO属下一个国际医疗机构素质认证的支部40hospitalsareaccreditedwithJCIacross11othercountries(1inThailand,1inPhilippines,1inChina)全球另有40间医院已受JCI认证，遍布11个国家(包括1间在泰国、1间在菲丽滨、1间在中国)5000UShospitals(96%ofbedcapacity)areaccreditedwithJCAHO五千间美国医院(96%的床位)已受JCAHO认证JCAHOisdedicatedtoimprovingclinicalqualityandpatientsafetyJCAHO意志改进医疗素质和病人安全水平WhatisJCI?JCIisaninternaJCIStandardHingesOn2BroadAreas:

JCI标准视以下两大方面而定:Equivalent&ComplementsISOstandards与ISO标准相似并互补Patient-centredStandards

以病人为中心的标准HealthOrganisationMgmtStandards

医疗机构管理的标准JCIStandardHingesOn2Broad368

Standards标准197

CoreStandards核心标准AboutJCIStandards有关JCI标准1032

MeasurableElements可衡量元素MustMeetallCoreStandards

必定要达到所有核心标准197AboutJCIStandards1032AboutJCIStandards有关JCI标准Patient-CenteredStandards以病人为中心的标准

Accesstocareandcontinuityof care(ACC)

能享有医护和连续性的医护

PatientandFamilyRights(PFR)

病人及家属的权利

AssessmentofPatient(AOP)

诊断病情

CareofPatients(COP)

医治及护理病人

PatientandFamilyEducation(PFE)

教育病人及家属HealthOrganizationMgmtStandards医疗机构管理的标准

Qualityimprovementandpatientsafety (QPS)

素质改进及病人安全

Preventionandcontrolofinfections(PCI)

预防及控制传染

Governance,leadership,anddirection (GLD)

管理、领导和引导方向

Facilitymanagementandsafety(FMS)

设施管理和安全

Staffqualificationsandeducation(SQE)

职员的资历和教育

Managementofinformation(MOI)

咨汛管理AboutJCIStandardsPatient-CWhyJCIforNUH?

为什么本院追求JCI品质认证?CommitmentToEnhance:承诺加强:PatientSafety病人的安全Co-ordinationofCare护理的协调WhyJCIforNUH?

为什么本院追求JCI品质认ContinuityofCare连续性的医护Patient&FamilyRights病人及家属的权利Patient&FamilyEducation教育病人及家属QualityImprovement&PatientSafety素质改进及病人安全Prevention&ControlofInfections预防及控制传染ManagementofInformation咨汛管理StaffQualifications&Education职员的资历和教育FacilityManagement&Safety设施管理和安全Governance,Leadership&Direction管理、领导和引导方向UsingJCItoManage&ImproveClinicalCare利用JCI标准来管理和改善医疗护理AssessmentofPatients诊断病情CareofPatients医治及护理病人AccesstoCare能享有医护Billing&Discharge开给账单和出院Clinical医护Medical医疗Nursing护理ClinicalSupport医护辅助Services服务PatientServices病人服务FinancialServices财务服务EnvironmentalServices环境设备服务FoodServices膳食服务PatientServices病人服务FinancialServices财务服务Patient-CenteredStandards以病人为中心的标准HealthCareOrganizationManagementStandards医疗机构管理的标准Appointment预约Marketing促销Registration登记Admission入院UsingJCItoManage&ImproveJCIProvidesAFramework…

JCI提供一个结构框架…JCIrequirementsprovidetheframeworktostrengthenpatientcareprocessesandthemanagementstructurerequiredtosustainexcellenceinstandardsofcare.JCI的要求为加强病患护理的程序及维持管理架构所需的杰出护理标准提供基础框架。JCIProvidesAFramework…

JCIHowJCIsitsinNUH’soverallFramework?

JCI

如何融入本院的整体结构框架?SystemsFramework体系框架ContinualImprovement持续改进ImproveCare&LowerCosts改进护理并减低成本Quality素质认证ISO9001Health&Safety卫生和安全素质认证OHSAS18001People人力资源素质认证PDS&PeopleExcellenceReduceHealth&SafetyRisks减低对健康及安全的威胁SingaporeQualityFramework新加坡素质认证框架S’poreQualityClass新加坡素质认证等级COREVALUES核心价值观Clinical,Process&ServiceExcellence卓越的医疗护理、流程及服务BalancedScorecard平衡记分卡HighLevelOutcomes高层绩效OrganisationalExcellence机构优异表现Environment环境素质认证ISO14001CPIP,6Sigma&IQCProjectsCPIP,6Sigma&IQC项目Learning&Growth学习与成长Service服务Process流程Clinical医疗护理Quality,Environmental,Health&SafetyManagementSystemsCulture,Systems&Tools素质，环境，健康和安全管理系统文化，体系及工具JCIAccreditationJCI素质认证MISSION&VISION使命及远景PeopleExcellence杰出人力资源LearningEnvironment学习环境Quality&Cost-EffectiveCare&Service优质及经济效益的护理和服务SocialResponsibilitytoEnvironment&Community对环境及社区承担的社会责任SafeWorkEnvironmentforStaff&Patients为员工和病人提供安全的工作环境Reduce,Reuse&RecycleResources&Waste减少、再用和再循环资源及废弃物HowJCIsitsinNUH’soverallOurJCIJourney

我们迈向JCI的历程JCI专家到访20032004Publicise,Awareness,Documentation&Implementation宣传，提高意识,文件笔录及贯彻完成Phase1第一阶段Phase2第二阶段Phase3第三阶段OctoberNovemberDecemberJanuaryFebruaryMarchtoAprilMaytoJuneJuly十月十一月十二月一月二月三至四月

五至六月

七月RoadShows路展NewMOs新的医疗人员SelfAssessmentIdentifyGapsBridgeGapsJCIExpertVisitJCI专家到访SelfAudit,Review&ImplementationRoadshows路展Survey自我评估认识差距弥补差距自我审计、评审及贯彻完成调查Workshop&MockSurveyCompletionofDocumentation实习班及模拟调查完成文件的纪录OurJCIJourney

我们迈向JCI的历程JCIOverviewofJCISurveyProcess

纵观JCI评审调查过程ContinuousQualityImprovement持续的素质改进InitialReviewofCoreStandards初始评审核心标准IdentifyGaps辨别差距CloseGapswithInputsfromJCIChampions从JCI得主吸取经验弥补差距RepeatReviewofCoreStandards多次评审核心标准ImplementStrategiestoImproveWorkProcess实行策略改进工作程序OverviewofJCISurveyProcessQualityImprovementFramework

素质改进的结构框架SentinelEventsegsurgicalmishaps,ADEsFrequentAdverseEventsegTransfusionreactions,nosocomialinfections,falls,medicationerrors,pressureulcersNearMissesegmislabelling,prescription&administrationofdrugsUnderuse,Overuse,MisuseSentinelEventReview/RootCauseAnalysisDETECTION觉察IMPROVEMENT改进ReviewbyQA/PeerReviewCommittees(egInfectionControl&BloodTransfusionCommittees)ANALYSIS分析MonitorandEvaluateChange No-faultreporting(eHOR) ClinicalReviewProgram (Chartreviews) PatientFeedback/Survey CasemixData ClinicalAuditStrategiesforImprovement

ClinicalPracticeImprovementProgramme(CPIP)CollaborativeProjects(egVentilatorBundles)QAProgrammes(egQIP&ACHSIndicators)ProcessImprovements(egQualityCircles,6Sigma,WorkRedesign)REPORT&SPREADCHANGEMANAGEMENT改变管理ClinicalOutcomesTrackingSystem

NHG2004Annex2(RefertoNUH-HAP-QIU-003–NUHQI&PSPlanAnnex2)QualityImprovementFramework

ExamplesofJCIInitiatives

提倡JCI措施的例子ExamplesofJCIInitiatives

提倡PatientInfoBrochure

病人讯息小册子PatientRights&ResponsibilitiesLeafletavailableatallSOCs,WardsandEMD在所有诊所、病房和急诊部展放有关病人权利和责任的小册子PatientInfoBrochure

病人讯息小册子PPatientEducation教育病人A

healthinformationandresourcecentreforpatientsandvisitors…OurPatientEducationHub医学健康常识中心–

为病人和访客提供健康资讯和常识PatientEducationAhealthinfoWeCareForOurPatients…Aspartofourpatienteducationefforts,posterson‘5StepsToSaferHealthcare’aredisplayedinourliftnoticeboards,wardsandclinics/centres.Throughthis,wekeepourpatientsinformedoftheirrolesinhelpingtoachievethesafestandbestpossiblemedicalcareandtreatment.AJCIInitiative在电梯里，病房里和诊所里的布告版占卦教育病人的“五步安全医护”海报，借此灌输病人如何协助达到最安全和最佳的医护和医疗。WeCareForOurPatients…AspaWritingnamesofdrugscorrectlyforpatientsafety使用正确的药物名称，提高病人安全水准。WritingnamesAttentionallHealthcareProfessionals!PUTONPROTECTIVEBARRIERS,MINIMISEYOURRISKOFINFECTION!ShortcutstoSAFETYcancutshortyourlife!PutonappropriateprotectivebarriersinaccordancetotheSARSAlertLevelsorInfectionControlGuidelinesandwhenthereiscontactorriskofcontactwithbloodorbodyfluids.Protectivebarriersreducetheriskofexposuretopotentiallyinfectivematerial.

Youshouldwear:Gloves

toprotectskinonhandsMask

toprotecttheskinandmucosaonthefaceandtoreduceriskduetoinhalationofinfectivematerialGogglesorface-shield

toprotectskin,eyesand/ormucosaonthefaceGownand/orplasticapron

whensplashesarelikelytooccur.减少感染，工作时应穿戴适当的保护装备如：手套、面罩、眼罩和外套！AttentionallHealthcareProfeAttentionallHealthcareProfessionals!MINIMISEYOURRISKOFINFECTIONOnesharpinjurycouldchangeyourlife.Preventthisfromhappeningto

YOU!DonotrecapneedlesDiscardsharpsintothe“Sharp”boxpersonally

Maintainasafeworkingdistancewhenyour colleagueishandlingsharpsDonotpasssharpsfromhandtohand减少感染，小心和适当的处理针头！减少感染，小心和适当的处理针头！AttentionallHealthcareProfePainAssessment疼痛评估 Allpatientswillbe assessedforpain

为所有病人进行疼痛评估

Assessmentwillbedone everyshift/asandwhen required

在每个轮班或有需要时才 进行 Informdoctorsif patient complainsofpain

通知医生如果病人告知身体 疼痛

Findingswillbemonitoredas5thvitalsign intheclinicalchart调查结果将列为第五个至关重要的标志，在临床图表上观察。PainAssessment疼痛评估 AllpatiStaffEmergencyInfoCard

职员的紧急意外电话号码卡AllstaffcarryanEmergencyInformationCardwithimportantnumberstocallforvariousemergencies.所有职员都携带一张紧急意外电话号码卡Front前Back后StaffEmergencyInfoCard

职员的紧ClinicalPracticeImprovementProgram–

AModelforImprovement

临床实践改进项目模式Act行动Plan策划Study研究Do实践Whatarewetryingtoaccomplish?Howwillweknowthatachangeisanimprovement?Whatchangescanwemakethatwillresultinanimprovement?CliniciansdrivingimprovementprojectstoimproveClinicalProcesses&Outcomes医疗人员推行改进项目为改善临床程序和效果ClinicalPracticeImprovementJCIAccreditationinvolveshardwork,sweat,arguments,toughdecisions…ButitisWORTHIT!取得JCI品质认证需要勤劳地工作、汗水、探讨、坚强的意志…但这些都是值得的!JCIAccreditationinvolveshar

Ajourneytakentogether一个共同奋斗的历程Betweenprofessionalgroups专业小组之间Amongprofessionals专家之间

Cross-learning/dialogue相互学习/对话

Workingasateamforpatients’interest发挥团队精神，以病人的利益为主ValueofJCIJCI的价值观AjourneytakentogetherValueTopleadershipcommitment(CEO&CMB)-MustBelieveInIt!高层领导者的承诺(CEO&CMB)-坚定的信念!Leader-driven(esp.Clinician&Nursing)领导带头(尤其是医师及护理人员)Activeinvolvementofdoctors/nursesthroughJCIClinicianCoreGroup&NursingChampions通过JCI临床核心组及看护得主让医生/护士积极参与

Awareness&Communication(handbook,emails,intranet,posters,briefings,dailylogons)意识及沟通(笔记、电邮、企业网、海报、会议、‘电脑讯息’)JustdoIT!(Fightagainsttemptationtoprocrastinate…)现在就做!(决不拖延…)Persevere….坚持….SomeLessons…经验之谈…Topleadershipcommitment(CE

JCIAccreditationisnotanendnorastatementthatanorganisationhasarrived!JCI品质认证对一个机构而言既不是终点也不是一份声明！

ItisthebeginningofacommitmenttomakehealthcareSAFER,Better,Faster&Cheaper…它是对更安全、优质、快捷及经济的医疗护理的承诺的一个开始…Itisanon-goingjourney….这是一个持续不断的旅程….Conclusion总结JCIAccreditationisnotaneMeasurableOutcomes能衡量的结果Clinicaloutcomes临床效果$$$$$$PatientSatisfaction病人满意指数MeasurableOutcomesClinicalouThankYou谢谢ThankYouWhatisJCI?何谓JCI?

JCIisaninternationalaccreditationarmofJCAHO(JointCommissiononAccreditationofHealthCareOrganisations)JCI是JCAHO属下一个国际医疗机构素质认证的支部40hospitalsareaccreditedwithJCIacross11othercountries(1inThailand,1inPhilippines,1inChina)全球另有40间医院已受JCI认证，遍布11个国家(包括1间在泰国、1间在菲丽滨、1间在中国)5000UShospitals(96%ofbedcapacity)areaccreditedwithJCAHO五千间美国医院(96%的床位)已受JCAHO认证JCAHOisdedicatedtoimprovingclinicalqualityandpatientsafetyJCAHO意志改进医疗素质和病人安全水平WhatisJCI?JCIisaninternaJCIStandardHingesOn2BroadAreas:

JCI标准视以下两大方面而定:Equivalent&ComplementsISOstandards与ISO标准相似并互补Patient-centredStandards

以病人为中心的标准HealthOrganisationMgmtStandards

医疗机构管理的标准JCIStandardHingesOn2Broad368

Standards标准197

CoreStandards核心标准AboutJCIStandards有关JCI标准1032

MeasurableElements可衡量元素MustMeetallCoreStandards

必定要达到所有核心标准197AboutJCIStandards1032AboutJCIStandards有关JCI标准Patient-CenteredStandards以病人为中心的标准

Accesstocareandcontinuityof care(ACC)

能享有医护和连续性的医护

PatientandFamilyRights(PFR)

病人及家属的权利

AssessmentofPatient(AOP)

诊断病情

CareofPatients(COP)

医治及护理病人

PatientandFamilyEducation(PFE)

教育病人及家属HealthOrganizationMgmtStandards医疗机构管理的标准

Qualityimprovementandpatientsafety (QPS)

素质改进及病人安全

Preventionandcontrolofinfections(PCI)

预防及控制传染

Governance,leadership,anddirection (GLD)

管理、领导和引导方向

Facilitymanagementandsafety(FMS)

设施管理和安全

Staffqualificationsandeducation(SQE)

职员的资历和教育

Managementofinformation(MOI)

咨汛管理AboutJCIStandardsPatient-CWhyJCIforNUH?

为什么本院追求JCI品质认证?CommitmentToEnhance:承诺加强:PatientSafety病人的安全Co-ordinationofCare护理的协调WhyJCIforNUH?

为什么本院追求JCI品质认ContinuityofCare连续性的医护Patient&FamilyRights病人及家属的权利Patient&FamilyEducation教育病人及家属QualityImprovement&PatientSafety素质改进及病人安全Prevention&ControlofInfections预防及控制传染ManagementofInformation咨汛管理StaffQualifications&Education职员的资历和教育FacilityManagement&Safety设施管理和安全Governance,Leadership&Direction管理、领导和引导方向UsingJCItoManage&ImproveClinicalCare利用JCI标准来管理和改善医疗护理AssessmentofPatients诊断病情CareofPatients医治及护理病人AccesstoCare能享有医护Billing&Discharge开给账单和出院Clinical医护Medical医疗Nursing护理ClinicalSupport医护辅助Services服务PatientServices病人服务FinancialServices财务服务EnvironmentalServices环境设备服务FoodServices膳食服务PatientServices病人服务FinancialServices财务服务Patient-CenteredStandards以病人为中心的标准HealthCareOrganizationManagementStandards医疗机构管理的标准Appointment预约Marketing促销Registration登记Admission入院UsingJCItoManage&ImproveJCIProvidesAFramework…

JCI提供一个结构框架…JCIrequirementsprovidetheframeworktostrengthenpatientcareprocessesandthemanagementstructurerequiredtosustainexcellenceinstandardsofcare.JCI的要求为加强病患护理的程序及维持管理架构所需的杰出护理标准提供基础框架。JCIProvidesAFramework…

JCIHowJCIsitsinNUH’soverallFramework?

JCI

如何融入本院的整体结构框架?SystemsFramework体系框架ContinualImprovement持续改进ImproveCare&LowerCosts改进护理并减低成本Quality素质认证ISO9001Health&Safety卫生和安全素质认证OHSAS18001People人力资源素质认证PDS&PeopleExcellenceReduceHealth&SafetyRisks减低对健康及安全的威胁SingaporeQualityFramework新加坡素质认证框架S’poreQualityClass新加坡素质认证等级COREVALUES核心价值观Clinical,Process&ServiceExcellence卓越的医疗护理、流程及服务BalancedScorecard平衡记分卡HighLevelOutcomes高层绩效OrganisationalExcellence机构优异表现Environment环境素质认证ISO14001CPIP,6Sigma&IQCProjectsCPIP,6Sigma&IQC项目Learning&Growth学习与成长Service服务Process流程Clinical医疗护理Quality,Environmental,Health&SafetyManagementSystemsCulture,Systems&Tools素质，环境，健康和安全管理系统文化，体系及工具JCIAccreditationJCI素质认证MISSION&VISION使命及远景PeopleExcellence杰出人力资源LearningEnvironment学习环境Quality&Cost-EffectiveCare&Service优质及经济效益的护理和服务SocialResponsibilitytoEnvironment&Community对环境及社区承担的社会责任SafeWorkEnvironmentforStaff&Patients为员工和病人提供安全的工作环境Reduce,Reuse&RecycleResources&Waste减少、再用和再循环资源及废弃物HowJCIsitsinNUH’soverallOurJCIJourney

我们迈向JCI的历程JCI专家到访20032004Publicise,Awareness,Documentation&Implementation宣传，提高意识,文件笔录及贯彻完成Phase1第一阶段Phase2第二阶段Phase3第三阶段OctoberNovemberDecemberJanuaryFebruaryMarchtoAprilMaytoJuneJuly十月十一月十二月一月二月三至四月

五至六月

七月RoadShows路展NewMOs新的医疗人员SelfAssessmentIdentifyGapsBridgeGapsJCIExpertVisitJCI专家到访SelfAudit,Review&ImplementationRoadshows路展Survey自我评估认识差距弥补差距自我审计、评审及贯彻完成调查Workshop&MockSurveyCompletionofDocumentation实习班及模拟调查完成文件的纪录OurJCIJourney

我们迈向JCI的历程JCIOverviewofJCISurveyProcess

纵观JCI评审调查过程ContinuousQualityImprovement持续的素质改进InitialReviewofCoreStandards初始评审核心标准IdentifyGaps辨别差距CloseGapswithInputsfromJCIChampions从JCI得主吸取经验弥补差距RepeatReviewofCoreStandards多次评审核心标准ImplementStrategiestoImproveWorkProcess实行策略改进工作程序OverviewofJCISurveyProcessQualityImprovementFramework

素质改进的结构框架SentinelEventsegsurgicalmishaps,ADEsFrequentAdverseEventsegTransfusionreactions,nosocomialinfections,falls,medicationerrors,pressureulcersNearMissesegmislabelling,prescription&administrationofdrugsUnderuse,Overuse,MisuseSentinelEventReview/RootCauseAnalysisDETECTION觉察IMPROVEMENT改进ReviewbyQA/PeerReviewCommittees(egInfectionControl&BloodTransfusionCommittees)ANALYSIS分析MonitorandEvaluateChange No-faultreporting(eHOR) ClinicalReviewProgram (Chartreviews) PatientFeedback/Survey CasemixData ClinicalAuditStrategiesforImprovement

ClinicalPracticeImprovementProgramme(CPIP)CollaborativeProjects(egVentilatorBundles)QAProgrammes(egQIP&ACHSIndicators)ProcessImprovements(egQualityCircles,6Sigma,WorkRedesign)REPORT&SPREADCHANGEMANAGEMENT改变管理ClinicalOutcomesTrackingSystem

NHG2004Annex2(RefertoNUH-HAP-QIU-003–NUHQI&PSPlanAnnex2)QualityImprovementFramework

ExamplesofJCIInitiatives

提倡JCI措施的例子ExamplesofJCIInitiatives

提倡PatientInfoBrochure

病人讯息小册子PatientRights&ResponsibilitiesLeafletavailableatallSOCs,WardsandEMD在所有诊所、病房和急诊部展放有关病人权利和责任的小册子PatientInfoBrochure

病人讯息小册子PPatientEducation教育病人A

healthinformationandresourcecentreforpatientsandvisitors…OurPatientEducationHub医学健康常识中心–

为病人和访客提供健康资讯和常识PatientEducationAhealthinfoWeCareForOurPatients…Aspartofourpatienteducationefforts,posterson‘5StepsToSaferHealthcare’aredisplayedinourliftnoticeboards,wardsandclinics/centres.Throughthis,wekeepourpatientsinformedoftheirrolesinhelpingtoachievethesafestandbestpossiblemedicalcareandtreatment.AJCIInitiative在电梯里，病房里和诊所里的布告版占卦教育病人的“五步安全医护”海报，借此灌输病人如何协助达到最安全和最佳的医护和医疗。WeCareForOurPatients…AspaWritingnamesofdrugscorrectlyforpatientsafety使用正确的药物名称，提高病人安全水准。WritingnamesAttentionallHealthcareProfessionals!PUTONPROTECTIVEBARRIERS,MINIMISEYOURRISKOFINFECTION!ShortcutstoSAFETYcancutshortyourlife!PutonappropriateprotectivebarriersinaccordancetotheSARSAlertLevelsorInfectionControlGuidelinesandwhenthereiscontactorriskofcontactwithbloodorbodyfluids.Protectivebarriersreducetheriskofexposuretopotentiallyinfectivematerial.

Youshouldwear:Gloves

toprotectskinonhandsMask

toprotecttheskinandmucosaonthefaceandtoreduceriskduetoinhalationofinfectivematerialGogglesorface-shield

toprotectskin,eyesand/ormucosaonthefaceGownand/orplasticapron

whensplashesarelikelytooccur.减少感染，工作时应穿戴适当的保护装备如：手套、面罩、眼罩和外套！AttentionallHealthcareProfeAttentionallHealthcareProfessionals!MINIMISEYOURRISKOFINFECTIONOnesharpinjurycouldchangeyourlife.Preventthisfromhappeningto

YOU!DonotrecapneedlesDiscardsharpsintothe“Sharp”boxpersonally

Maintainasafeworkingdistancewhenyour colleagueishandlingsharpsDonotpasssharpsfromhandtohand减少感染，小心和适当的处理针头！减少感染，小心和适当的处理针头！AttentionallHealthcareProfePainAssessment疼痛评估 Allpatientswillbe assessedforpain

为所有病人进行疼痛评估

Assessmentwillbedone everyshift/asandwhen required

在每个轮班或有需要时才 进行 Informdoctorsif patient complainsofpain

通知医生如果病人告知身体 疼痛

Findingswillbemonitoredas5thvitalsign intheclinicalchart调查结果将列为第五