Accreditation support

Collaborate in the process of improving patient care through a combined strategy of training, guidance, and methodological support, with special emphasis on creating learning networks.

Promote the structuring of the improvement process using planned implementation strategies, considering barriers and facilitators of change.

Encourage monitoring of practice through the use of clinical indicators measured uniformly to facilitate comparison between centers.

The Avedis Donabedian Foundation has worked with this methodology in more than 15 areas or improvement topics in the hospital and social care field, including more than 300 teams and over 30,000 clinical professionals trained through e-learning strategies.

The reasons to select this model among existing external evaluation systems are many, but we can highlight:

• The reasons to select this model among existing external evaluation systems are many, but we can highlight:
• its extensive experience in the sector
• its strong driving force for improving centers

The Joint Commission International accreditation always covers the entire organization; it is not applied to areas or services independently, since it is a model that guarantees the quality of care for the person throughout the process. The accreditation model is based on the key functions of the organization, which are carried out across all areas. In each of these functions, key processes are identified and best practice standards are established.

Patient-centered

Promotes a culture of patient safety

Evaluates all aspects of management

Represents an important improvement tool for the organization

Provides international recognition for the care provided by the center

Hospitals

Primary care centers

Outpatient care centers

When a healthcare organization decides to seek external quality recognition through accreditation, an important internal process is initiated to ensure the center meets the standards’ requirements. This process usually involves implementing a set of coordinated and interrelated changes that help improve the center’s work systems, making it a highly motivating and enriching process. However, this process is not without challenges, as it requires designing and implementing work systems according to the highest quality standards, which is a significant challenge for professionals.

Having the collaboration of an external body such as the Avedis Donabedian University Institute to guide and advise throughout the process greatly facilitates the work, maximizing the professionals’ efforts.

The improvement project presented here is based on the model and accreditation standards of the Joint Commission International. The reasons to select this model among existing external evaluation systems are many, but we can highlight its specificity for the healthcare sector, its extensive experience in the sector, and its strong driving force for improving centers.

Train the organization’s professionals to understand the requirements of the reference model.

Identify aspects that the organization needs to improve.

Provide methodological and technical support for planning improvements and redesigning processes.

Guide the organization in implementing changes and evaluating the effectiveness of improvements.

Quality improvement projects in healthcare organizations are usually based on models that outline the areas to address, specific aspects to evaluate, and sometimes the expected level of compliance. Organizations can develop their own models or take existing ones as a reference. Among the most known and widely used external evaluation models, both nationally and internationally, are ISO standards, the EFQM Model (both generic and applicable to organizations of any type and sector), and accreditation (specific for healthcare organizations).

The improvement project presented here is based on the Joint Commission International accreditation model.

• The Joint Commission is currently the organization with the most experience in healthcare accreditation worldwide. It has been dedicated for over 50 years to improving quality and safety in healthcare and social care organizations. Currently, it accredits nearly 20,000 organizations globally. The information and experience obtained from evaluating these organizations are used to update the standards periodically, adapting them to changes in healthcare services.
• In 1996, the Joint Commission International (JCI) was created, a division of the Joint Commission aimed at improving care quality in the international community by providing accreditation services worldwide. To ensure international applicability of the standards, they are agreed upon by a group of experts and opinion leaders from all five continents. The JCI evaluation process is designed to adapt to the legal, religious, and cultural characteristics of each country.

The Joint Commission International accredits over 800 organizations worldwide.

Joint Commission International accreditation always covers the entire healthcare organization; it is not applied to areas or services independently, since it encompasses the organization as a whole. The Accreditation model is based on the key functions of the organization, carried out across all areas. In each of these functions, key processes are identified and best practice standards are established. Additionally, standards considered essential to guarantee patients’ and families’ rights, develop adequate care, and reduce risks in the care process are highlighted.

The model as a whole represents a compendium of good management practices for the entire center.

This system allows moving from structural and service-level evaluation to evaluation of care and management processes across the center.

Benefits

Choosing an improvement approach based on Joint Commission International accreditation provides the following benefits:

• Patient-centered: develops a care approach focused on the patient as the central element, requiring interdisciplinary care based on patient needs. Evaluates care quality throughout the process.
• Promotes patient safety culture: standards particularly emphasize content focused on patient safety and risk reduction in clinical and care processes.
• Evaluates all management aspects: guides all management phases toward efficiency and best practices, from leadership responsibilities to critical management and strategic planning processes.
• Represents an important improvement tool for the organization: the accreditation preparation process represents a common improvement project for managers and professionals, catalyzing internal changes.
• Provides international recognition for the care provided: Joint Commission International accreditation publicly demonstrates that the center meets the quality requirements of the sector’s most technically competent institution. This accreditation represents an indisputable international recognition of prestige.

The work plan to prepare a center for JCI accreditation usually consists of four phases, which gradually introduce the model into the organization and help generate changes in work systems to meet the standards’ requirements. These phases are:

• 1. Training
• 2. Situation diagnosis
• 3. Improvement planning
• 4. Implementation of the improvement project

Phases 3 and 4, focused on planning and implementing improvements, depend on the results of the diagnostic evaluation carried out in phase 2. Occasionally, it may be necessary to adjust the level of support in these phases after reviewing the diagnostic results, although the objectives and activities described for each phase remain stable.