Quality should always be manifestly visible in everyone’s work at a hospital. The JCI quality system makes it visible.

HUS is currently preparing for JCI accreditation. This means adopting the international JCI quality system and having an external party conduct a systematic evaluation of whether HUS fulfils international quality requirements.

“The JCI quality standards apply to all functions and all occupational groups at HUS hospitals, including research and teaching,” says Chief Quality Officer Sanna-Maria Kivivuori.

Now six departments are applying for quality accreditation. The core of quality improvement is formed by two quality officers in each unit, one physician and one nurse. The duties of these quality officers were written up in the year under review. In practice, this involves normal work duties that have now simply been formalized in writing.

One of the quality officers is Anneli Övermark, Nurse Manager of intensive care unit 20. She and the other quality officers have the task of applying quality standards to practical work. She notes that the quality effort is about things that must be done in any case, but JCI provides a good frame of reference and encouragement.

“We have had a lot of discussions with employees about what JCI is and why we’re doing this. Good quality adds to job satisfaction and pride in their work,” says Övermark.

Good care for all

The patient and the patient’s best interests are always in the focus in the JCI quality system. Improving quality is above all about improving patient equality by consolidating treatments and practices. Systematic and anticipatory quality efforts also improve patient safety.

“Engagement is also important for quality: how do I engage with a patient, and what is the impression left with the patient,” says Kivivuori.

Quality must always be manifested in everyone’s work .

“Quality means that regardless of who is giving care to any given patient, all patients receive equally good care,” says Övermark.

Equality also applies to personnel, because the quality system ensures that every job is equally valuable regardless of where a person is stationed.

“It is good for employees to have clear and agreed basic procedures. That frees up time for difficult cases and extraordinary situations,” says Kivivuori.

Good results are motivating

In intensive care, quality work has involved identifying risky medications and improving pharmaceutical safety. The Clinic Senior Pharmacist has assisted in this, preparing a medication safety evaluation in the department.

In intensive care, every employee must undergo fire training, be familiar with the contents of the disaster folder, obtain an official ID card and perform a safety task. There is a list on the ward bulletin board on which everyone must sign off on the completions required.

“Everyone must also know the infection instructions. We have a board showing hospital infections, hand sanitizer uses and hand sanitizer observations. These are practically the only indicators for measuring hospital hygiene,” says Övermark.

It is important to share and be happy about good results. Övermark reports that recently the ward celebrated a significant decrease in pressure ulcers thanks to the Lean project.

“This is exactly what we mean when we talk about patient safety and quality,” says Övermark.

What is JCI?

JCI (Joint Commission International) is the world’s most widespread hospital quality system. The purpose of the accreditation process is to evaluate whether a hospital fulfils certain quality criteria. Every hospital may decide on its own quality indicators, but they must monitor those indicators and take action to improve their results.

Six HUS departments will be applying for JCI accreditation at the beginning of 2021: Perioperative, Intensive Care and Pain Medicine; Children and Adolescents; Gynecology and Obstetrics; the Head and Neck Center; Psychiatry; and the Comprehensive Cancer Center. These cover one third of all HUS activities and have about 8,000 employees combined.

The article was originally published in Husari 6/2019.