Preparing for the JCI quality system

Our most important quality improvement project in 2019 was preparing for acquiring an international quality system compliant with the criteria of Joint Commission International (JCI).

JCI is a quality system covering the entire hospital, all functions and occupational groups, and provides a platform for self-monitoring. JCI is the world’s largest hospital accreditation system. A hospital must fulfil certain quality criteria in order to pass the accreditation audit. It is our goal for six of our divisions to pass the accreditation audit in 2021.

The first phase of the JCI project involves: Children and Adolescents; Perioperative, Intensive Care and Pain Medicine; Gynecology and Obstetrics; Psychiatry; the Head and Neck Center; and the Comprehensive Cancer Center. Representatives of support services are also widely involved, since the JCI quality criteria apply to all functions and all occupational groups. The system will gradually be extended to cover all of HUS.

The JCI project is coordinated by the Quality and Patient Safety (LAAPO) unit in the Joint Authority Administration, headed by the Chief Quality Officer.

In August 2019, we signed a cooperation agreement with Mount Sinai Hospital (MSI). Mount Sinai sent 12 employees to inspect the quality of our six JCI departments. After their one-week visit, they returned a detailed report of how they estimated we need to improve our quality in order to pass the accreditation audit. This report is an important quality tool.

Having an international quality system improves the quality of an organization not just through quality criteria but also with metrics and auditing. We have set up multidiscipline working groups for reviewing the JCI quality criteria and have devised a set of indicators to measure the eight dimensions of quality. The basic concept with quality indicators is that there should be as few indicators as possible, they should be monitored frequently, and above all action should be taken to improve the metrics. There is a monitoring method associated with JCI auditing, known as Tracer methodology, which we will be using for self-monitoring of quality. Instructors from the JCI organization trained 37 employees in the use of the methodology on the Meilahti campus. They are now able to conduct evaluation rounds in units and work with unit personnel to find ways to improve quality. These evaluation rounds are good practice for the actual quality audits.