JCI International Accreditation
We acknowledge and fulfill international safety and quality standards

HPA Magazine 11

One of the strategies adopted to improve quality, safety and productivity in health organisations is adherence to clinical accreditation processes. The HPA Health Group decided to invest in this improvement and last September saw its hospitals in Alvor and Gambelas being accredited by the Joint Commission International.
Experts from the most important international clinical audit institution have reviewed compliance with more than 300 standards of excellence and more than a thousand parameters related to patient safety and quality of care.
This international accreditation, now attributed to all the clinical and non-clinical services of the Hospitals of Alvor and Gambelas, recognises that our professionals and units are guided by the highest standards of safety and quality in areas such as infection control, reception, medical and surgical care, but also leadership and organisational management.
Integrating the group of the safest hospitals in the world, placing us in the most tourist region of Portugal, should be a source of pride for all, not only at the regional level, but also at the national level.

Dr João Bacalhau
Chairman of the Directors Board 

What was the key objective for the Hospitals of Alvor and Gambelas to apply for JCI accreditation?

Fundamentally know and increase our levels of quality and safety, but also standardise some of our practices. In addition, we believe that this experience has contributed to improve the culture focused on the quality and safety of patients.
Health organisations have as their main mission to offer diagnostic and therapeutic resources that enable their patients to restore their health as quickly as possible. This way, mechanisms and procedures are necessary to enable them to develop reliable work, supported by organisational and technical qualifications.
As health institutions carry out activities of high complexity, differentiation and responsibility, we believe that their standardisation facilitates the achievement of results and, above all, allows us to more effectively meet the needs of those who seek us.
An accreditation such as of JCI ensures that the structure promotes and develops conditions for performing clinical procedures and not only with safety, skill and excellence.

This accreditation was for some time an Administration project. Was this the right time?

Yes, it's true. We had been evaluating this possibility for some years. We thought this was the right time. We have acquired enough maturity to go for this challenge. We have solid teams, with a lot of experience, dedicated and exclusively working with us, that gave us the safety and the serenity to face this challenge.
I would like to underline that this experience was very interesting and enriching from the point of view of human resources management and leadership. I am referring to the commitment and motivation I have witnessed in many teams; everyone wanted to participate, everyone wanted to collaborate and above all, share their efforts and knowledge. I am sure that everyone has lived an enriching time of true teamwork.

Nurse Alexandre Gonçalinho
Quality Management

How do you organise and plan an accreditation process like JCI?

With a lot of time and especially with the great commitment of a vast group of people. Of course, there are ingredients that are also needed: having the right people, motivated people, and planning all activities in an organised manner.
The creation of a coordinating team was the first decision we had to make. Management quickly understood this need and offered all the conditions so that the team could start organising the whole process.
I cannot fail to mention, the fact that we already have ISO certifications in the scope of Quality and Environment for many years, has facilitated the dynamics and even the understanding of the normative. However, we also assumed that JCI's demanding clinical criteria, based on a US framework, forced us to do a lot of "new" work.
Regardless of the results achieved, which naturally leave us very satisfied, we believe that it is important to highlight that this experience has made us stronger and safer in our practices, as it has given us very important tools for daily practice: an analysis based on rigor and reflection that allow us to work at high levels of quality and safety.

Get two hospitals accredited, one after another, is a very rewarding but equally arduous task, and although there are many common processes, there are also some specificities

Yes, it was an arduous task. It was a couple of crazy weeks. It is true that there are many common requirements between the two units and, of course, when we moved on to the Gambelas Hospital in the 2nd week, we already had experience in order to know where we could do better.
But I prefer to say that there were two independent accreditations, because apart from having different services, there is the specificity of the facilities for example, and this was an aspect that was very strictly verified. The safety of installations and equipment is a requirement of great importance in JCI accreditation.
Another aspect relates to the specificity of services. For example, Hyperbaric Medicine only exists in Alvor, Maternity and Neonatology only exist in Gambelas, so these were processes built from scratch and individually, in the sense that they could not be shared.
But yes, it is true that we were very bold. Getting accreditation of two hospitals with the dimensions that ours have, was a great challenge, which was only possible to achieve, I repeat, with the right people and with great motivation and dedication. There was great effort of the teams in the systematisation of administrative tasks, in the scope of the creation of the normative. It was perhaps the heaviest area to meet.
But the truth is that we were congratulated by the auditors on the people. They came to confide that they had never met such motivated, proactive and available teams, and especially that showed they wanted to be audited. There was indeed a very interesting chain of enthusiasm, the teams wanted to truly know their levels of quality and safety. It was definitely very rewarding. 

It is common to say that the preparation for the re-accreditation process begins the day after accreditation

It is true. Easy understandable, these audits leave us with ideas and opportunities for improvement. In this aspect, the next day we should start thinking about how to operate them and achieve them.
In addition, having an international accreditation of this scope should translate into improvements in quality and performance indicators, and this should be the "next day" focus, the focus that will lay and bring a re-accreditation.

Nurse Luís Fernandes
Digital Platform Documentory Manager

Was one of those most involved in the accreditation process as it was Luis’s responsibility to devise and monitor all documents on the JCI digital platform, a tool that functions as the organization's DNA and is the basis of the Accreditation process.

He knows in detail all the regulations and, consequently, the entire documentary system that he has fundamentally shaped and is the "backbone" of Accreditation. How is this process set up and, above all, how is it monitored?

The first step was to read thorough the JCI Accreditation Standards Manual in order to have an overview of what was required. From then on we began by going through what we already had in practice, in terms of standards and procedures. New documents had to be created and alterations had to be made on existing ones, in order to standardize procedures in various areas such as: patient safety (with emphasis on the 6 international goals), clinical practice, safety and security and many others.
It became necessary to identify the person responsible for each department to whom tasks were given with a view of elaborate documents with the various norms related to each function carried out in their department. Once created these norms were distributed among each staff member working in the department and implemented by all concerned. The person responsible then had to make sure that all accreditation norms were adhered to by each staff member in his team. 

Did you encountered areas where it was more difficult to meet requirements and therefore create the necessary documentation?

A hospital is an "organization" of great complexity. There are not only clinical areas. There are areas such as engineering, infrastructure, environment, security ... To create all the necessary norms for the whole hospital on my own would have been and impossible task. Several interdepartmental meetings were necessary where I served as a link between the JCI Manuals and the various Department Heads, helping to interpret what was required and applying this to our Hospital. 

What was the biggest difficulty you experienced when having to meet requirements / organize information based on a North American concept?

The challenge was not only to shape the Portuguese concept into a North American context but also to comply with some of the most demanding norms. For each standard and measurable element when the JCI requirements were more demanding than the national legislation, it was necessary to transpose this into our existing norms.

Nurse Simão Martins
Director of the Risk Management Board

He is responsible for the Risk Management Board and the Patient Safety Committee. Considering that JCI Accreditation is based on the commitment of international patient safety goals, his area of intervention is transversal to this whole process.

In practice how does one monitor Risk Management and Safety and how do we lay down improvement criteria?

The Patient Safety and Risk Management Commission of the HPA Health Group were constituted by its Directors in mid-2017, with a well-defined mission regarding Patient Safety: to analyse the entire structure of the institution, all standard reference, as well as all the known weaknesses.
At the same time, the Commission was provided electronic means that permitted all employees, without exception, to participate actively in reporting incidents and adverse events occurring within the organisation. These indicators are analysed independently, classified according to Risk, and an action plan is subsequently elaborated, in order to mitigate the inherent risk.
As far as establishing improvement criteria, I believe that these are one of the functions of the Commission. That is, we started this process with a Reactive Risk Management model (analysis and action) and we then became more ambitious, investing at the same time in a more structured model with better defined objectives, that is, a Proactive model. Thus, in addition to maintaining the Incident Reporting System, we started to work on the next two years 2018-2019, on Risk Assessments in Services/Facilities, Audits and Monitoring of clinical indicators, working together with the Quality Control Department, procedure risk analysis and national benchmarking, such as the National Health Assessment System (SINAS).

What is your opinion how has the organizational culture changed regarding Risk & Safety in the past year?

At this moment we can say that the HPA Health Group has become increasingly aware of this subject and is incessantly searching for Safety and Excellence in the care it provides. 
Everyone has become more reflexive, looking for problems and solutions in each internal process but above all, with the involvement of all employees.
A concrete example of this paradigm was the result obtained from the questionnaire put to all staff, where the goal was to analyse the existing culture on internal security. The results reflected the evolution and involvement of everyone, and it can be highlighted that approximately 60% of employees rate their unit / service as "Excellent" and "Very Good" as far as patient safety is concerned. Likewise, in comparison with the national benchmark our rating was also very positive.

In the international ranking (considering that the JCI Accreditation is an international accreditation) how do we position ourselves in relation to risk and safety?

It's a difficult answer to translate into numbers or rankings. However, it is with pride that we can say that our two Hospitals now comply with all international standards recommended by Joint Commission International.
This audit confirmed everything that I mentioned above. Changes can be observed, we can see an improvement in quality and an increase in patient safety. The JCI evaluation was for us the culmination of months of preparation and transformation and, above all, a reward for the HPA Health Group, for its good practices which are clearly defined, fulfilling the "6 International Patient Safety Goals".
The next few years will be a major challenge, since in addition to being able to join national campaigns and programs directed at patient quality and safety, we can enjoy the credit of being recognised as an entity with an international accreditation, that strictly regulates its health practices.

Nurse Paulo Silva
Resuscitation Training Coordenador 

Paulo has an in-depth knowledge on resuscitation training and is one a core member of the Training Department on Resuscitation Training. For JCI, it is fundamental that all healthcare professionals be trained in resuscitation.

Before we began the JCI accreditation process, we already had a resuscitation training program in progress. What changed with the JCI accreditation?

When the HPA Group's Resuscitation Training Program was designed, accreditation was already a reality for the Group, so all that had to be done was to redesign the existing program bearing in mind JCI requirements.
Once accredited, a hospital has to ensure the continuation of policies and aim to fully comply with the accreditation norms.
The only change was an increased commitment on behalf of the organization, fortifying the already existing resuscitation program transversally to all its employees, resulting in a continuous improvement of the training course provided for the benefit of its patients.

What other areas needed fortifying as an accreditation requirement?

Safety and security, and in particular fire safety, is a very important chapter of the accreditation manual.
Safe infrastructures are an integral part of the Patient Safety policy, as well as a fundamental contribution to the Health and Safety Work policy.

Nurse Luciana Matos & Nurse Catarina Bentes
Both Responsible for the Infection Control Commission 

They are both responsible for the Infection Control of the Group. As far as accreditation is concerned International Patient Safety Goals is another of the most demanding procedures of the certification. A lot had already been done by the Commission in terms of documented procedures and also in terms of the results achieved. However, with the implementation of JCI Accreditation there was a need to change its functioning paradigm and rethink various development strategies.

As far as the Infection Control Commission is concerned, the JCI Accreditation process has proven to be a demanding, labor-intensive but very productive process.
The Infection Control Commission, as it was initially called, already existed in the hospital, albeit timidly. It is now known as the Grupo Coordenador Local para a Prevenção e Controlo de Infeção e Resistência aos Antimicrobianos (GCLPPCIRA). 
We were responding to requests of the Group and creating internal norms based on national legislation meeting each need as it arose which served the purpose. That is, our response was that of a reactive commission rather than a preventive commission. Over the years it was not just the denomination of the name that complicated matters, but we also realized that the response we were giving would have to integrate the various units of the Group and be proactive.
We already had a plan in mind, on how we wanted to develop GCLPPCIRA, but it was with the help of the JCI standards that we learned how to structure our thoughts and began to better setup what is now the GCLPPCIRA of the HPA Health Group.
We structured our thoughts transversally according to  JCI standards, informing all professional staff on the various procedures. This made our communication with management and employees much easier as both had to comply with the established standardized norms.
We gained something of utmost importance from JCI: the need for everyone to remain focused on the same path and follow the same code. For us this was a tool that brought teams closer, working together towards the same goal.
Analyzing all the regulations set up during the past eighteen months, we believe that the most difficult to implement although seeming to be the simplest, were hospital hygiene procedures. Denominations, detergents and disinfectants we changed, but we believe that the greatest difficulty was involving all health professionals in the responsibility of maintaining a safe environment for patients, families and staff, as this is not the exclusive role hospital auxiliaries.
Regulations were created to be dynamic and adaptable to the various services, to solve difficulties encountered. They contemplated not only infrastructures but also equipment. We are the first hospital to carry out high-level disinfection of semi-critical instruments, such as the catheters used in gynecology. 
It is a fact that GCLPPCIRA went through considerable growth and structuring over the past year. The people who were responsible for creating and altering existing norms contributed greatly towards the whole certification process, they led the internal training process and discussed the many changes that has to take place and "sweated" throughout the whole procedure. However, we have to thank those that believed that it was possible to achieve our goal, helped us to improve procedures or alter them, challenging us to continuously do better. These people were and are essential for our continued growth and improvement. 
The success of this process undoubtedly reflects the commitment of all the professionals of the HPA Health Group, to whom we wish to express our sincere gratitude and a special request to continue their excellent work and involvement. As far as we are concerned we will continue our commitment to the certification process. 

As this accreditation is fundamentally clinical, we were curious to find out the opinion and vision of our Medical Directors. We decided to ask each one the same questions.

I) From a clinical point of view, what would be the advantages of this accreditation? and II) How do you think we can motivate everyone, to alter long-established attitudes and practices, for example? 

Dr. Carlos Glória
Medical Director of the HPA Alvor

I) The HPA Health Group has had since its foundation a project of quality health care. We were certified years ago by the Quality and Environment Control Standards ISO 9001 and ISO 14001. However it was our wish to go further as we knew that we could always achieve more and better. It was with this in mind that we embarked on this process of Clinical Accreditation which would allow us to reach the safety standers comparable to the best international hospital anywhere in the world. In addition to helping us consolidate and improve the structure of the entire existing procedures (infection control, safe surgery, fall risk prevention, etc.), JCI has enabled us to evolve into advanced monitoring processes in all areas and groups of the hospital. The clinical and nursing processes were also audited and improved, with more detailed and precise clinical information. All areas of the hospital that could represent any kind of risk to patients were monitored (medication, diagnostic exams, medical equipment, etc.) were also tested and standardized according to set standards. The result is a Hospital Group with medical care based on extremely high safety and quality standards.
II) Initially, professionals showed some concern on taking on a quality control project with the expectancy level of JCI. In the initial stages there was some anxiety concerning the immensity of the organisational task ahead in the necessity of reviewing and implementing hundreds of rules and requirements, but I never found motivation to be a problem. The culture of our Hospital Group has always been focused on quality and safety. Basically the procedures remained the same but were now based on standards of excellence. When people are challenged to be excellent, we find that they adhere naturally. At the end we won the prize and everyone is proud to say: I work in the HPA Health Group!

Dr. Paulo Sousa 
Medical Director of the HPA Gambelas

I) I believe that JCI Accreditation has brought a new perspective to the way we practice medicine in the HPA Health Group.
By improving patient safety the quality of medical acts are enhanced. The interaction that was created between the various professional groups has reduced medical error in clinical practice. We can say that we have a hospital that continues to provide excellence services with an above-average level of patient safety.
II) Let’s start with the difficulties. I think the biggest was for the professional staff to adhere to the various norms. Doctors and nurses including other staff are people with habits and changing these habits is an arduous task.
The time that it takes to comply with all the standards also generated some discomfort.
The most positive aspects of the JCI accreditation are patient safety, the transparency of the medical act and risk sharing with all involved, including the patient.
We are a more conscious organisation and the fact that to maintain this accreditation we are evaluated periodically will force everyone to remain faithful to this philosophy.