Eoin McGrath

1
The nursing role in JACIE

• Eoin McGrath
• JACIE Executive Officer
• Salon Pasteur, EBMT Annual Meeting,
• 13.30-15.00 March 26th 2007

2
Aims and objectives

• To identify the benefits of JACIE to patient care
• To develop a better understanding of the JACIE
  accreditation process
• To identify ways to support and collaborate with
  other groups
• To explore the nurses and allied health care
  professionals role in the JACIE process

3
JACIE! JACIE! JACIE!
4
JACIE CAN INSPIRE DIFFERENT REACTIONS
5
So two questions to start

• What does JACIE mean to you?
• What do you want to get from todays session?

6
JACIE Standards

• Brief summary

7
The JACIE Standards 3rd edition (Feb 2007)

8
Some context...
9
QUALITY OF CARE
BMT Unit
EU
10
JACIE since 2003

• Centres registered 107
• Centres in progress 46
• Centres inspected 61
• Facilities accredited 36
• Countries 13

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Applications
Registered 107 (Accredited 36)
FI 3 (2)
Total107 In preparation46 Inspected61 Accredite
d 36
BE 3
PL 1
NL 14 (5)
CZ 2
D 29
AT 2 (2)
UK 21 (11)
FR 15 (6)
ES 2
CH 10 (9)
IT 6 (1)
TR 1
12
Some terms

• QUALITY
• QUALITY MANAGEMENT
• QUALITY IMPROVEMENT
• ACCREDITATION

13
Quality

• All those features of a product (or service)
  which are required by the patient.

14
Quality management

• What the organization does to
• ensure that its products or services satisfy the
  patient's quality requirements and
• comply with any regulations applicable to those
  products or services.
• enhance patient satisfaction, and
• achieve continual improvement of its performance.

15
Quality Programme

• The set of activities, including
• Management review
• Training
• Audits
• Corrective and preventive actions that represent
  a commitment by an establishment to the quality
  of its products.

16
Quality management systems

• What the organization does to manage its
  processes, or activities in order that
• its services meet the organizations objectives,
  such as
• satisfying the patient's quality requirements,
• complying with regulations

17
Quality management systems

• Systemizing way of doing things
• Step-by-step
• Everyone is clear about who is responsible for
  doing what, when, how, why and where.
• Management system standards provide the
  organization with an international,
  state-of-the-art model to follow.

18
Quality Improvement

• The combined and unceasing efforts of
  everyonehealthcare professionals, patients and
  their families, researchers, payers, planners and
  educatorsto make the changes that will lead to
  better patient outcomes (health), better system
  performance (care) and better professional
  development
• What is "quality improvement" and how can it
  transform healthcare? Paul B Batalden and Frank
  Davidoff. Quality and Safety in Health Care
  2007162-3 doi10.1136/qshc.2006.022046

19
Accreditation

• Accreditation is a process in which certification
  of competency, authority, or credibility is
  presented.

20
Why would you want accreditation?

• You have to have it (Law? Social security?
  Insurance companies?)
• Patients look for it
• Forms part of a risk management programme
• Motivates staff by setting a clear goal

21
Benefits

• International, expert consensus on
  state-of-the-art practices for quality
  management.
• Common language
• Increase efficiency and effectiveness.
• Model for continual improvement.

22
Benefits (cont.)

• Model for satisfying patients and other
  stakeholders.
• Build quality into products and services from
  design onwards.
• Comply with government regulations

23
Experience of quality improvement assessment

• Joint Accreditation Commission (JCAHO)
• Evaluates and accredits nearly 15,000 health care
  organizations and programs in the United States

24
Report

• "Improving America's Hospitals A Report on
  Quality and Safety" released 20/3/07
• Findings
• Quality and safety improvement in hospitals
  contributes to
• saved lives
• better health and quality of life for many
  patients
• lower health care costs.

25
On the other hand...

• When hospitals do not consistently provide
  standard evidence-based treatments, they increase
  the risk of adverse outcomes for patients. This
  enhanced risk may result in
• new or continued illnesses
• unnecessary hospitalization
• increased costs
• time away from work, reduced life quality, or
  even death.

26
So thats the theory. What about real-life?
27
Group of nurses and AHPs starting out with JACIE
28
Where do I start
29
Common issues

• Seems like a lot of work.
• What is the objective?
• Will it make my job easier?
• I am already under pressure with normal duties
• I feel unsupported
• Will management lead this effort?

30
Not easy to do so what helps?

• Information (like today)
• Listen to other experiences (like today)
• Network with colleagues
• Take part the process

31

• If you do not design the future someone or
  something else will design it for you
• Edward de Bono
• Psychologist and physician

32
Accreditation process
33
Who needs to be involved?
34
Persons in overall process
35
Phases
36
Applicant Preparation phase

• Hardest part
• Means changes in work practice and culture
• Implies resources
• Must maintain all staff involved in process

37
Applicant Preparation phase

• Carry out a self-check using the Accreditation
  Checklist
• Highlight areas where centre already complies
• Indicates areas that need more work
• Assess level of readiness for inspection

38
Tools assistance

• Standards
• JACIE Office
• JACIE Online
• Medical Director
• Inspectors
• Online documentation
• Exchange visits

39
Tools assistance

• Deficiencies listing
• Accreditation Manual

40
Quality Management Guide

• Practical reference guide to implementing
  quality management in a stem cell transplantation
  (SCT) programme in accordance with JACIE
  Standards
• Phase 1 (commenced) To write and publish a guide
  to implementing quality systems in stem cell
  transplant programmes in line with the JACIE
  Standards on quality management
• Expect to complete first edition Summer 2007
• Phase 2 (from 2008) To update the guide on a
  regular basis based on continued accrual of
  experience and best practice

41
The Inspection

• Preparation

42
The Inspection-Preparation

• Read the Inspection Guide
• Contents
• Initial Application
• Preparing for the Inspection
• The Inspection
• Post-Inspection
• Documentation
• E.g. Pre-inspection document checklist
• Sample inspection timetable for 1.5 day
  inspection
• Sample Inspection Report
• Sent to inspectors and applicants before audit
• Available on web site

43
The Inspection-Preparation

• Nurse Expert (pilot scheme)
• Will look at nurse-related documentation
• Provide input to the clinical inspector
• At pilot stage
• Tried in 1 UK inspection
• Depends on availability of qualified nurse experts

44
The Inspection

• 1.5 days
• Thorough examination of all aspects of the
  programme in accordance with the Accreditation
  Checklist
• Verification of the applicants self-check
• ALL members of staff can be interviewed by the
  inspectors

45
The JACIE Office
46
(No Transcript)
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JACIE Office

• Located in Barcelona
• Shares office with EBMT Secretariat in Barcelona
• Manage applications
• General enquiries
• Training courses
• Relationship with other bodies

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JACIE Office

• CONTACT
• jacie_at_ebmt.org
• www.jacie.org

Eoin James MacHale (Ireland)
49
JACIE network
50

• If you do not design the future someone or
  something else will design it for you
• Edward de Bono
• Psychologist and physician

51
Nurses AHPs in the accreditation process
52
Whats an S-O-P?
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Involvement

• Nurses often the people who write the SOPs
• Most have no experience or training in this

54
Whats an SOP?

• Standard Operating Procedure (SOP)
• Agreed way of doing something
• What and why
• With what equipment
• Objectives
• How
• References (other SOPs, expert literature etc)
• Examples

55
List of SOPs Part B Clinical

• Donor patient confidentiality
• Donor patient evaluation, selection treatment
• Donor consent
• Biological product deviations
• Quality management improvement
• Personnel training
• Competency assessment
• Errors, accidents adverse events
• Corrective actions
• Outcome analysis
• Audits
• Facility maintenance monitoring

• Disposal of medical biohazard waste
• Emergency safety procedures
• Disaster response
• Patient consent
• Emergency safety procedures
• Infection prevention control
• Administration of preparative regimen
• Transplantation of haematopoietic progenitor
  cells
• Blood product transfusion

21 in total
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List of SOPs Part C Collection

• Donor recipient confidentiality
• Donor treatment
• Donor consent
• Biological product deviations
• Quality management improvement
• Personnel training competency assessment
• Errors, accidents, adverse events complaints
• Corrective actions
• Outcome analysis
• Audits
• Facility maintenance monitoring
• Disposal of medical biohazard waste
• Emergency safety procedures

• Disaster response
• Release exceptional release
• Product tracking
• Transportation
• Reagent supply management
• Cleaning sanitation
• Equipment maintenance monitoring
• Donor screening
• Management of paediatric donors, if applicable
• Product collection
• Labelling
• Expiration Dates
• Storage

26 in total
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QUALITY