Standards Interpretation Question and Answer

QPS.10, from the “Quality Improvement and Patient Safety” Chapter of Joint Commission International Accreditation Standards for Hospitals, Third Edition

QUESTION
JCI’s Quality Improvement and Patient Safety standard QPS.10 requires some type of ongoing program to identify and reduce adverse events and patient safety risks. While the Intent Statement of QPS.10 provides failure mode effects analysis (FMEA) as an example, it seems the surveyors are really looking for FMEA rather than be more receptive to other strategies and tools. Recently I read the new JCR publication entitled Advanced Lean Thinking and the discussion of “Error Proofing” (click here for text from this chapter) and poka-yoke in chapter 4. Also mentioned in other chapters are Kaizen Events, Six Sigma, Lean Thinking and other approaches and tools. Will any of these tools, such as “poka-yoke” satisfy the requirements of this standard?

RESPONSE
The number and type of tools available to organizations for quality evaluation and improvement and in patient safety has increased exponentially. It was not too long ago when the only tool seemed to be retrospective chart audits, and quality assurance. Some organizations now train staff on all the latest tools while other organizations select one tool and stick with it. Some organizations even mix elements of different tools together and give it their own original name.

Realizing this, the surveyors try to look beyond the name of the tool and have the organizations describe the tool, how they use it and the results. Even FMEA can be used in different ways and for different purposes: for example, to evaluate an entire process to see if it should be replaced (total process redesign), or to evaluate a process to identify one or more risk points for which the risks need to be removed or compensated (process improvement).

The key elements of QPS.10 the surveyors are looking for is:
• The tool is used in a proactive manner to evaluate a process with the aim to identify and reduce risk, not to evaluate a past event
   such as by Root Cause Analysis;
• The tool is used on a high-risk process as identified by the organization’s leaders; and
• Use of the tool alone is not sufficient to meet the expectations of the standard. Rather, it is that using the tool has resulted in the 
   redesign of a risky process.