International ACHE Profile:
Robert A. Kasworm
Q: Tell us briefly about your background in healthcare management.
Q: How did you arrive at your current position?
Q: What are your primary job responsibilities?
Q: What is the biggest challenge you face in your current position?
Q: What is the biggest reward?
Q: Briefly describe the overall healthcare atmosphere in Tanzania.
Q: How do you see healthcare management changing in the next five years?
Q: What advice can you offer for other international affiliates?
Best Practices for JCI Accreditation
When ACHE surveyed International Affiliates in Fall 2009 on what topics should be included in upcoming newsletters, Joint Commission International Accreditation was a popular response. An article in the Winter 2010 edition of this newsletter touched on the need for national and global accreditation standards. This is a follow up to that article.
Gaining JCI Accreditation (JCIA) is an important milestone that will instill pride in your staff, foster respect and collaboration among all levels of your organization, and identify your organization as a provider of world-class care.
But the process is a challenging one.
Below, healthcare executives from three organizations share best practices for achieving and maintaining accreditation and the benefits they achieved.
The Initial Accreditation Process
The accreditation process, from start to finish, can take from one to two years, depending on the current state of the organization in relation to the standards. Getting the entire hospital on board is an important first step. Steve Sobak was the chief operating officer for KK Women’s and Children’s Hospital in Singapore when it went through its initial accreditation in 2005. Getting the project off the ground took more than three years.
“The medical staff was not prepared to take on the challenge,” says Sobak. “Also, when raised initially, it came from the administrative side, which failed to generate the necessary commitment and support from the clinical side.” On the second pass, the idea was successfully introduced and promoted by clinicians who observed other local hospitals that embraced JCIA. These so called clinical champions drove the process.
Once you have buy-in from the staff, the next step is to develop a process that includes the entire organization. Getting physicians integrated in the process is critical. “They can’t just be available on the day of the survey,” says Nish Patel, CEO of Women’s Hospital in Doha, Qatar, who led the organization’s recent recertification efforts. “Get physician champions on your team.” These doctors will motivate other doctors.
Also, unlike the accreditation process for some organizations in the United States, the executive team will likely be more hands-on, at least for the first few cycles. “The JCI surveyors are going to come up to you and ask you,” Patel says. “We all had to step up and get familiar with our processes—how things worked down to the nitty gritty, not just the overview.”
Rather than delegate responsibilities to a specific JCI committee, Patel suggests you develop task forces with members throughout all levels of the organization to address each chapter of the standards, and make sure the teams meet regularly.
Before the first team meeting, necessary financial resources for the entire process need to be set aside—such as securing JCI consultants, investing in infrastructure changes to meet the standards and staff training. Medical staff members also have to reallocate their time to attend meetings and participate in the process.
Once you have everything in place, it is time to bring in JCI consultants to perform a mock survey and assess the progress of your organization with each standard. John Wocher, FACHE, executive vice president of the Kameda Medical Center, Kamogawa City, Chiba Prefecture, Japan, was the leader of Kameda’s reaccreditation process. He also recommends attending a JCI Practicum, designed specifically for those seeking to obtain JCI Accreditation. The practicum includes a review of the current standards, the opportunity to address solutions to specific challenges and a walk-through of a mock survey at a local hospital.
For the Women’s Hospital staff, understanding the standards was a challenge. “Of course, it’s written in almost legalese, and some of our staff are working off of third or fourth languages,” Patel says. Patel brought in translators to help get the team up to speed. Picking the right translators to ensure smooth communication when surveyors are on site is also critical, adds Wocher.
The efforts don’t stop once an organization receives accreditation. “There was a constant need to remind, refresh and keep the interest up so as not to fall back into old habits and relax in the reporting and compliance requirements,” Sobak says. Also, to keep your accreditation, your organization will be reevaluated every three years.
The Triennial Reaccreditation Process
Preparing for the triennial reaccreditation can take roughly a year and can be particularly tricky with standards regularly changing. Women’s Hospital in Qatar received its initial accreditation in 2006. When the team started preparing for reaccreditation in 2009, it had to rewrite the book; JCI had developed new standards on facility management and safety and risk assessment, among other changes.
“It was such a foreign issue for us that we had to go chapter by chapter and standard by standard to see what was required,” Patel says. “For the risk assessment, we had to evaluate the risks of the hospital, the department and the emergency room. It was the first time anyone had asked us what risk assessment means in our institution. It became a very tough standard to meet, simply because it was one that was not previously thought of here.”
To start preparing, Women’s Hospital brought in consultants from Joint Commission Resources in June 2008, one year prior to its reaccreditation deadline, to perform a mock survey. The team used the survey results to determine what processes needed to be changed and how.
As reaccreditation is triennial, Women’s Hospital will be reviewed again in 2012. JCI is scheduled to set new standards in 2011 that focus on following a patient’s journey through the hospital and after initial care, rather than looking at policy and procedure. “That’s the acid test, rather than just reviewing a record,” Patel says.
Indoctrinating new staff that came on board after the initial accreditation is also a critical step.
Benefits of JCI Accreditation
The JCI Accreditation is a true testament to the teamwork and dedication of the entire organization, and the benefits extend beyond the JCIA certificate.
“We want to be known as the benchmark for international standards,” Patel says. “When we look at mortality rates, our rates are lower than other hospitals in the States.”
For Kameda Medical Center in Japan, the JCI Accreditation generated positive media and medical tourism industry interest, according to Wocher. The corporate culture at the Kameda Medical Center improved as a result.
Patel says the JCI process was a powerful team-building experience and a source of pride for staff. “It wasn’t just the front line who participated but nurses, admitting clerks and medical records clerks, among others. They saw the accreditation process as an important test, and they took it to heart and became the champion.”
For KK Women’s and Children’s Hospital, the process facilitated new friendships. “It broke down barriers,” Sobak says. “It allowed the medical staff to understand and appreciate the administrative support and duties, as well as gave staff the opportunity to work together and develop new networks and professional respect.”
Below are new, timely ACHE resources such as books, study courses and Web sites to help you excel in your career.
Five Keys to Increase Your Organization’s Resilience in the Downturn
Leaders in every organization need to look for ways to be more productive, which usually means slashing costs while increasing efficiency (i.e., doing more with less). But at the same time, you can’t stop moving forward. You must also look for ways to invest time, energy and resources in innovation initiatives (i.e., doing more for better returns).
(1) Recognize the importance of balancing productivity and innovation.
(2) Overcome fear through reflection and renewal.
(3) Strategize to increase productivity and efficiency.
(4) Embed a formal innovation process into your organization.
(5) Provide emotional and cultural support for productivity and innovation.
Adapted from “Five Keys to Increase Your Organization’s Resilience in the Downturn,” a special report by Susan J. Bethanis, CEO/founder, Mariposa Leadership Inc. To request a full copy of this report, visit mariposaleadership.com.
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