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Innovative education
for today’s quality
professionals
JCI: Leading practices shared with the world
As the international not-for-profit affiliate of The Joint
Commission, JCI helps to improve the quality and safety
of health care through accreditation services, education,
publications, and advisory services. JCI experts understand
and help meet the needs of diverse health care organizations
and systems in more than 90 countries by providing
high-value, cost-effective services at every stage in the
quality improvement journey.
jointcommissioninternational.org
HealthCareQualityManagement&PatientSafetyDiplomaProgram
Overview
Innovative education
for today’s quality
professionals
Develop your staff through leading
education from JCI
Quality and safety improvement leads directly to
better patient outcomes, improves operational productivity,
increases patient and staff satisfaction, and reduces costs.
This unique program is designed to advance quality and
safety in your organization.
Government ministries, hospitals, health systems,
and universities are working with Joint Commission
International®
(JCI) to bring evidence-based education
to staff through JCI’s Health Care Quality Management
& Patient Safety Diploma Program.
Partner with JCI to achieve your quality and safety goals
Every day JCI consultants work with health care organizations to establish and refine
their quality programs. These organizations face similar challenges: What does an optimal
quality department look like? What kind of data do we need to collect? How can we
measure and repeat success?
To help organizations create and strengthen quality initiatives, JCI has created its
distinctive Health Care Quality Management & Patient Safety Diploma Program.
This university-level educational experience specifically for hospital staff teaches best
practice performance improvement strategies.
Participants learn how to apply evidence-based tools and practices within their
organizations and share practical solutions with their care teams. Program graduates
are better equipped to drive quality initiatives within their organizations and achieve
measurable goals and sustainable results.
Benefits to participants
Understand and advocate for a consistent quality function
Become adept at collecting and reporting data
Use quality data to augment and monitor performance improvement
Share tools and strategies with team members
Gain knowledge and training
Benefits to health care organizations
Elevate, expand, and standardize the quality function
Train staff in the latest, most sophisticated quality methods
Infuse care teams with expertise from newly trained staff
Strengthen staff support of sustainable improvements
Achieve stated quality and safety goals
The integrated curriculum is presented in eight modules over 10 months (a traditional
academic year)*:
1 Principles of Quality Management and Patient Safety in Health Care
2 Leadership and Planning in Quality Management
3 Information Management in Health Care Quality
4 Systems Approach to Quality Management
5 Data Collection in Performance Measurement and Quality Management
6 Principles of Performance Measurement and Data Analysis
7 Patient Safety and Risk Management
8 Fundamentals of Health Care Improvement
For each module, faculty and participants meet in class for five full days. A variety of
educational techniques are employed, including lectures, discussions, case study reviews,
interactive group exercises, and student assignments using an array of quality tools and
methods. The educational experience allows for personalized attention and dialogue.
Students are evaluated and mentored throughout the program. Their progress is monitored
and, with successful completion, they receive a diploma.
How the diploma program works
*The curriculum can be modified to address
your organization’s most pressing quality and
safety needs.
“Before this program, I tended to avoid quality issues
because I was afraid they would constrain my practice of
medicine. However, this program completely changed my
thinking and by graduation I became a quality champion.
Today I enjoy applying what I learned to improve
performance at my hospital.”
Selecting your quality champions
JCI’s Health Care Quality Management & Patient Safety Diploma Program represents
an excellent career-building opportunity for individuals who have been charged with
establishing or managing a quality department or with strengthening quality initiatives
within their organizations.
To be eligible, participants must work full-time in a hospital or health care facility, have
quality-focused responsibilities, and meet other eligibility requirements established by
the sponsoring university or organization. Once selected, students must participate in
classes, complete required readings and homework, and pass mandatory tests.
Helping you on your quality journey
For information about this innovative program, contact:
Asia-Pacific
Prabhu Vinayagam, Managing Director, Asia-Pacific Office
Email pvinayagam@jcrinc.com
Voice +65 6829 7208
Middle East
Ashraf Ismail, Managing Director, Middle East Office
Email aismail@jcrinc.com
Voice +971 4369 4930
Other Regions
Lori Shanahan, Associate Director, International Services
Email lshanahan@jcrinc.com
Voice +1 630 268 7443
Primary care physician
2012 graduate
Saudi Arabia
JCI: Leading practices shared with the world
As the international not-for-profit affiliate of The Joint
Commission, JCI helps to improve the quality and safety
of health care through accreditation services, education,
publications, and advisory services. JCI experts understand
and help meet the needs of diverse health care organizations
and systems in more than 100 countries by providing
high-value, cost-effective services at every stage in the
quality improvement journey.
jointcommissioninternational.org
QMAR0714
Headquarters
1515 West 22nd Street
Suite 1300W
Oak Brook, Illinois 60523
USA
Voice +1 630 268 7400
Fax +1 630 268 7405
Joint Commission International Consulting
Email jciconsulting@jcrinc.com
Voice +1 630 268 2900
Joint Commission International Accreditation
Email jciaccreditation@jcrinc.com
Voice +1 630 268 4800
Joint Commission International ®
(JCI) is a division of Joint Commission
Resources, Inc.®
, a wholly controlled not-for-profit affiliate of The Joint
Commission. JCI provides leadership in international health care
accreditation and quality improvement.
Asia-Pacific Office
37th Floor
Singapore Land Tower
50 Raffles Place
Singapore 048623
Email jciasiapacific@jcrinc.com
Voice +65 6829 7208
Fax +65 6826 4181
Middle East Office
P.O. Box 505018
Bldg 27, Suite B503
Dubai Healthcare City
Dubai
United Arab Emirates
Email jcimiddleeast@jcrinc.com
Voice +971 4369 4930
Fax +971 4362 4951
Other Regions
jciamericas@jcrinc.com
jciafrica@jcrinc.com
jcieurope@jcrinc.com
Follow us
Faculty
The Health Care Quality Management & Patient Safety Diploma Program created by Joint Commission International
(JCI) features a faculty with decades of experience in performance improvement and patient safety.
Shakil Ahmad, MBBS, DipMed, MHCM, CPQM, JCI Consultant, Certified Green Belt
Dr. Ahmad has more than 16 years of experience in international health care management and quality as well
as expertise in medical staff leadership, privileging, credentialing, and bylaws. He has held positions as a quality
improvement physician, hospital administrator, head of medical staff performance and review, senior quality specialist,
and quality manager.
During his tenure with a regulatory health authority in the United Arab Emirates, Dr. Ahmad was responsible for
overseeing JCI accreditation at two hospitals and implementing regulatory policies and standards. He has chaired
and presented at numerous international conferences, including the ISQua (International Society for Quality in Health
Care) Conference in London, the International Quality Conference in Muscat, Oman, and the Middle East Quality
Conference in Dubai. Dr. Ahmad earned a medical degree from the Royal Postgraduate Medical School, London (UK)
and a master’s degree from Oxford Brookes University, Oxford (UK).
Zakarai Zaki Al-Attal, MSN, PhD, CPHQ, JCI Consultant
Dr. Al-Attal is an expert in implementing quality concepts in organizations to enhance the quality of health care
services. Most recently, he was director of quality and performance management at the Dubai Health Authority, where
he oversaw quality, risk management, performance management, and accreditation programs in four government
hospitals and specialized centers of the Authority. Currently he works with the ministry of health.
His experience includes consulting engagements in the Middle East, Asia-Pacific, Europe, and Africa. He has served
as a quality council member of Dubai Healthcare City and as a lecturer at the Dubai Women’s Medical College and
at the residency programs of the Authority. Dr. Al-Attal earned a doctorate from the University of Salford, Manchester
(UK), a master’s degree in quality management from Wollongong University, Dubai (UAE), and a master’s degree in
nursing from Jordan University.
Yvonne P. Burdick, MHA, FACHE, EDAC, JCI Consultant, Certified Yellow Belt
Ms. Burdick has more than 30 years of experience in health care and has held leadership positions in hospital and
ambulatory care settings. She has been involved in the development and implementation of health service accreditation
systems and quality improvement programs internationally, including serving on the ISQua panel to review
international principles for accreditation. Working in collaboration with the World Health Organization in countries
throughout Latin America and the Caribbean, Ms. Burdick participated in projects focused on quality improvement
programs and accreditation systems.
Trained as a research scientist and laboratory manager, her management experience encompasses clinical research,
toxicology, occupational health, safety, and environmental affairs. Ms. Burdick earned a bachelor’s degree in biological
sciences from the University of Edinburgh (Scotland) and a master’s degree in hospital administration from the
Medical College of Virginia (USA). She is accredited and certified in evidence-based design by the Center for
Health Design.
Expert faculty provide leading-edge
quality perspectives
Hyunok (Heidi) Kim Do, RN, DNSc, JCI Consultant
Dr. Do has more than 30 years of leadership, management, and teaching experience in health care and international
expertise as a consultant and nursing leader in Southeast Asia. She is a recognized expert in performance improvement,
outcomes management, program development, and statistical tools and techniques. She has consulted in Asia-Pacific
and presented at several JCI practicums.
Her experience includes serving as an administrator for a U.S. rehabilitation hospital and a vice president of patient
services for a U.S. health system. She also served as vice president of nursing services for a Korean hospital. Educational
positions include assistant professor at a U.S. school of nursing, clinical instructor, and nursing education coordinator.
Dr. Do earned a doctorate in nursing science from Boston University, Massachusetts (USA) and a master’s degree in
nursing from The Ohio State University (USA).
Linda L. Faber, PhD, RN, FACHE, Senior JCI Consultant, Certified Yellow Belt and Change Agent
With more than three decades of experience in health care leadership, management, and performance improvement,
Dr. Faber serves as a JCI faculty member and as an assistant clinical professor at the University of California-
Los Angeles School of Nursing (USA). She has consulted in Brazil, Denmark, Spain, Italy, Japan, and Ireland, sharing
her expertise in performance improvement, outcomes management, systems analysis, and leadership in organizational
development, staff education, and training.
In previous positions, Dr. Faber served as director of performance improvement and director of nursing research,
education, and quality improvement for a U.S. medical center; associate chief of nursing research for a U.S. Veterans
Health Administration medical center; and positions as a nurse manager, supervisor for mental health and acute care
facilities, and clinical specialist in behavioral health. Dr. Faber earned a doctorate in public health, master’s degree in
nursing, and a certificate in quality management and performance from University of California-Los Angeles (USA).
Kornelia Fiausch, RN, MAS, JCI Consultant, Certified Yellow Belt
Ms. Fiausch has more than 16 years of experience as a director of nursing services, with special expertise in intensive
care, staff leadership, and geriatrics. She has consulted internationally in Europe, the Middle East, and Asia-Pacific
and has presented at several JCI practicums.
She serves as the director of nursing for Landeskrankenhaus Villach (Austria) and is a certified judicial expert for the
area of nursing. Ms. Fiausch earned her master’s degree in hospital management from the University of Economics of
Vienna (Austria), as well as certificates in nursing management and hospital management.
Deborah Flores, EdD, MEd, RN, CPHQ, JCI Consultant
Dr. Flores has been a senior leader in large and small health care organizations for the past 16 years. In addition to her
work with JCI, she is an administrator in an ambulatory clinic in Central America and a first assist in the operating
room of two hospitals in the region.
Her expertise encompasses quality and performance improvement, patient safety, and population health. Previous
positions include vice president of performance improvement for a research medical center, system vice president of
quality improvement for a health system, and assistant vice president at a children’s hospital. She has also served as an
associate clinical professor for Texas A&M University (USA). Dr. Flores earned a doctorate in health promotion and
a master’s degree in health education from Temple University, Philadelphia (USA).
Safak Guven, MD, MBA, JCI Consultant
Dr. Guven is a physician executive with board certification in endocrinology. He has been recognized for outcome-
driven clinical program and system development in hospitals and outpatient clinics. His background includes
international leadership experience and expertise in strategic planning, operations and process improvement in
hospitals, quality management, team creation, and physician and administration relationships.
He established the Diabetes Care Center at the University of Cairo (Egypt) and has taught at several universities.
He has delivered international consulting and educational programs in the Middle East, Europe, Asia-Pacific, and
the Americas. Dr. Guven earned a medical degree from Marmara University School of Medicine, Istanbul (Turkey)
and a master’s degree in business administration from Northwestern University, Illinois (USA).
Helen Hoesing, RN, MPH, PhD, Senior JCI Consultant, Certified Change Agent
With more than four decades of experience in health care, Dr. Hoesing has demonstrated expertise as a nursing
executive and performance improvement specialist. She has been a consultant and faculty member for The Joint
Commission for the past 35 years and taught programs on health care quality improvement, patient safety, nursing,
and standards in Asia-Pacific, the Americas, the Middle East, Africa, and Europe. In earlier positions she served as vice
president for a health system and acute care facility in Nebraska (USA) and other administrative roles in acute care and
home care.
Her consulting expertise encompasses performance improvement, work and process redesign, leadership education
and skill building, patient safety assessment, and incorporating tracer methodology and period performance review
as management tools. Dr. Hoesing earned a doctorate in management/administration from Walden University,
Minnesota (USA) and a master’s degree in public health from the University of Minnesota (USA).
Thomas W. Kozlowski, PhD, ACSW, Senior JCI Consultant, Certified Yellow Belt and Change Agent
Dr. Kozlowski has more than 30 years of experience in health care and has consulted with organizations in Asia,
Europe, the Middle East, and the Americas. Experienced with a wide array of health care settings, his expertise includes
operational and patient safety assessment, performance improvement, executive leadership and governing bodies, and
other quality-driven areas. Drs. Kozlowski and Richard Wright developed the JCI Health Care Quality Management
& Patient Safety Diploma Program.
In addition to 13 years with The Joint Commission, he has served as an administrator in hospitals, mental health and
chemical dependency programs, and foster care organizations; a chief executive officer for an ambulatory health care
system; an interim director of accreditation, regulation, and quality for an academic teaching hospital and multisite
ambulatory system; and a corporate director of quality improvement and research for a health maintenance organization.
Dr. Kozlowski holds faculty appointments with two U.S. academic institutions. He earned a doctorate in health care
administration from Walden University, Minnesota (USA), a master’s degree in social work from the University of Illi-
nois (USA), and a bachelor’s degree in psychology from St. Mary’s University, Minnesota (USA).
David Marx, MD, PhD, JCI Consultant
Dr. Marx specializes in quality and performance improvement and has more than 19 years of experience in national
and international health care quality and safety management. He is in charge of a Czech national hospital accreditation
project and has coordinated the development of two editions of national standards for hospitals and one edition of
national long term care standards.
As a JCI consultant, Dr. Marx has provided consulting and education in Europe and the Middle East and has worked
with several European health care institutions to test and implement JCI standards. He has served as a senior lecturer
for Charles University, the director of quality at University Hospital, Prague, and the director general for the Ministry
of Health—all in the Czech Republic. Dr. Marx earned a medical degree from Charles University, Prague (Czech
Republic) and a doctorate in public health from Palacky University, Olomouc (Czech Republic).
Judith A. Moomjian, RN, MPA, CPHQ, FACHE, JCI Consultant, Certified Yellow Belt and Change Agent
Ms. Moomjian has extensive experience in domestic and international health care, providing international hospital
accreditation-related consulting in Asia-Pacific, Europe, the Americas, and the Middle East. She has demonstrated
expertise as a hospital and long term care administrator, nursing executive, and performance improvement specialist.
Areas of focus include patient safety, medication management, infection prevention and control, tracer methodology,
and environment of care, to name a few. Ms. Moomjian piloted and assisted with revisions to JCI’s first international
continuum-of-care standards and has participated in JCI practicums. She earned a master’s degree in health care
administration from Long Island University, New York (USA) and a nursing diploma from Mt. Sinai Hospital School
of Nursing, New York (USA).
QMBR0714
Derick P. Pasternak, MD, MBA, FACPE, Senior JCI Consultant
As a board-certified internal medicine specialist, Dr. Pasternak has more than three decades of health care experience and
has served 14 years as a health care executive. With expertise in patient safety, quality measurement and management,
and medical staff affairs, he has consulted in the Middle East, Asia-Pacific, Europe, and Latin America.
Dr. Pasternak established JCI’s Dubai office in 2006 and managed it for three years, working with clients in the
Middle East, North Africa, and India. He has served as a clinical professor at the University of Washington School
of Public Health (USA). Dr. Pasternak is the author of several articles and an e-book on health care quality and
medical management. He earned a medical degree from Harvard University (USA) and a master’s degree in business
administration from the University of New Mexico (USA).
Francine Westergaard, RN, MSN, MBA, Senior JCI Consultant, Certified Yellow Belt and Change Agent
With more than 26 years of nursing experience as a practitioner, educator, administrator, and researcher,
Ms. Westergaard is adept at providing applications for improvement to assist organizations as they facilitate change.
Her expertise encompasses operational assessment, patient safety, medication management, performance improvement,
tracer methodology, and senior executive dialogue.
She has provided consulting and education for major hospitals, health systems, and ministries of health in the
Americas, Asia-Pacific, Europe, Africa, and the Middle East. Previous positions include progressive leadership positions
in hospital and ambulatory care settings. Ms. Westergaard earned a master’s degree in business administration from
Walden University, Minnesota (USA) and a master’s degree in nursing from Lewis University, Illinois (USA).
Richard A. Wright, MD, MPH, FACPE, JCI Consultant, Certified Green Belt and Change Agent
Dr. Wright is a board-certified internal medicine and infectious disease specialist with expertise in performance
improvement and evaluation, care process redesign, and disease management. He provides consulting services for
hospitals in the Middle East, Asia-Pacific, Europe, the U.S., and other facilities in the Americas, with focused expertise
in performance improvement, quality management, leadership development, and the use of Lean Redesign methods to
improve clinical processes. Drs. Wright and Thomas Kozlowski developed the JCI Health Care Quality Management
& Patient Safety Diploma Program.
Serving as a professor of preventive medicine and biometrics at the University of Colorado School of Medicine,
Dr. Wright teaches and oversees research related to primary and preventive care. He has also served as a senior
executive with Denver Health Authority and an epidemiologist with the U.S. Centers for Disease Control and
Prevention. Dr. Wright has authored numerous articles on health care quality and management and received a national
award for research and innovation in primary care in 2005. He earned a medical degree from the University of
Minnesota (USA) and a master’s degree in public health from Loma Linda School of Public Health, California (USA).
Nellie Yeo, MBA, MN, JCI Consultant, Certified Yellow Belt
With more than 25 years of experience in health care, Ms. Yeo specializes in quality and patient safety. In her current
position as chief quality officer of the National Healthcare Group (NHG) and executive director of NHG College
in Singapore, she is responsible for establishing, developing, implementing, and evaluating the NHG quality and
clinical governance framework.
Ms. Yeo has consulted in Asia-Pacific, Europe, Africa, and the Middle East. She has served on committees within the
Singapore health care system and is a member of leading international quality organizations. She earned a master’s
degree in business administration from Nanyang Technological University (Singapore) and a master’s degree in nursing
from the University of California (USA).
Visit jointcommissioninternational.org for more details on our distinguished faculty.
Modules
The Health Care Quality Management & Patient Safety Diploma Program
created by Joint Commission International (JCI) presents in-depth knowledge
through eight comprehensive education modules. Each module defines pre-class
preparation, in-class lectures and exercises, and application of learning at the
student’s organization. Students are tested on core concepts and learnings at the
end of each module.
The curriculum can be modified and specific topics highlighted to address your
organization’s most pressing quality and safety needs.
Proven strategies and tools
highlighted in a modular curriculum
Module 1: Principles of Quality Management and Patient Safety in Health Care
This module provides participants with knowledge of definitions, concepts, and methods of
quality management with an emphasis on connecting quality to the voice of the customer.
- Principles of health care quality management
- Dimensions and evolution of quality management
- Definitions, concepts, and methods of quality management
- Cost of quality concepts and analysis
- Principles and methods of prioritization
- Role of process variation and gap analysis
- Voice-of-the-customer concepts and analysis
- Design and components of a quality management program
- Developing a learning organization
Module 2: Leadership and Planning in Quality Management
This module provides participants with an understanding of the role of leadership,
teamwork, and change management in developing and sustaining improvements in quality
and patient safety.
- Definitions, styles, and the role of leadership
- Strategic planning concepts and methods
- Change management principles and methods
- Teamwork and group decision-making methods
- Use of facilitation in managing teams
- Engaging clinical leaders in quality
- Design and use of project charters
- Critical factors for sustaining improvement
Module 3: Information Management in Health Care Quality
This module provides participants with an understanding of how to manage information
critical to promoting organization-wide quality and patient safety.
- Role of information management in promoting quality and patient safety
- Types and uses of medical record reviews
- Use of medical records for abstracting data
- Development of policies and procedures
- Use of quality management meetings for decision-making
- Design of quality improvement meetings
- Methods for communicating quality management information
- Use of balanced scorecards for monitoring strategic initiatives
8MODULES
Module 4: Systems Approach to Quality Management
This module provides participants with an understanding of system thinking and instructs
them in the design and use of process maps for quality improvement.
- Concepts and methods of system thinking
- Concepts and methods of Lean Redesign
- Concepts of process variation
- Method for describing and analyzing processes
- Use of SIPOC (Supplier-Input-Process-Output-Customer) tool for analyzing processes
- Methods of analyzing and improving patient flow
- Use of JCI tracer methods to evaluate standards compliance
Module 5: Data Collection in Performance Measurement and Quality Management
This module provides participants with knowledge of concepts, methods, and tools for
selecting and describing performance measures and for collecting data.
- Concepts of performance measurement
- Methods for prioritizing and selecting performance measures
- Methods for describing performance measures
- Use of targets and benchmarks for comparisons
- Sample sizes and methods
- Developing data collection plans
- Methods for aggregating and tabulating collected data
- Evaluation of data reliability
- Design of customer surveys
Module 6: Principles of Performance Measurement and Data Analysis
This module provides participants with knowledge of using basic statistics and graphing
to analyze and display data.
- Statistical functions for data analysis
- Measuring central tendency and variation
- Six Sigma methods for analyzing processes variation
- Graphing functions
- Use of pie charts, bar graphs, Pareto charts, and trend line charts
- Use of statistical process control charts
- Impact and comparison analysis
- Use of reports for summarizing data
Module 7: Patient Safety and Risk Management
This module provides participants with an understanding of patient safety with an emphasis
on preventing adverse events and minimizing associated risks.
- Concepts of patient safety and risk management
- Establishing a culture of safety
- Characteristics of HROs (high-reliability organizations)
- Management of adverse events
- Reporting and analysis of near misses and medical errors
- Role of human factors in preventing medical errors
- Role of patient disclosure
- Risk assessment concepts and methods
- Concepts and methods of FMEA (Failure Modes and Effects Analysis)
Module 8: Fundamentals of Health Care Improvement
This module provides participants with an understanding of how to use systematic models for
developing strategies for sustainable improvement.
- Overview of performance improvement models
- Approaches to team-based consensus
- Applying the FOCUS (Find-Organize-Clarify-Understand-Select) PDCA (Plan-Do-Check-
Act) model for improvement
- Applying the Six Sigma DMAIC (Define-Measure-Analyze-Improve-Control) improvement
model
- A3 framework for managing improvement projects
- Application of Lean improvement strategies
- Supply chain management concepts and methods
- Analysis of process flow
QMCR0714
CaseStudies
The Ministry of Defense oversees 22 hospitals throughout Saudi Arabia. Ministry
leaders sought to strengthen quality and patient safety functions within their
hospitals, based on a gap analysis that showed weak quality leadership even within
large urban facilities.
After a thorough evaluation of other programs, the Ministry chose to sponsor the
Health Care Quality Management & Patient Safety Diploma Program created
by Joint Commission International (JCI). In December 2012 the inaugural class
graduated and received diplomas in Quality Management and Patient Safety from
Prince Sultan Military College, which offers a concentration in health care careers.
Sponsor: Ministry of Defense, Kingdom of Saudi Arabia
Affiliated academic institution: Prince Sultan Military College of Health Sciences, Dhahran
The college certified the diploma program, appointed a program coordinator, provided housing
to students, and served as the venue for all multimedia class work.
		Program champion:
		 Dr. Noura AlNowaiser
		 Director of Continuous Quality Improvement and Patient Safety Department
		 Medical Services General Directorate, Ministry of Defense
Goals:
- Enhance the quality management skills of selected professionals
- Improve the quality and safety performance within health care facilities
- Build a long-term infrastructure for quality leadership throughout the Ministry of Defense’s hospitals
Number of graduates: 62 completed the program and earned diplomas. Graduates included
physicians, nurses, engineers, and other specialties.
Criteria for student selection:
- Full-time hospital employees
- Hold a bachelor of science degree
- English proficiency in reading, writing, and speaking
Developing quality leaders in
Saudi Arabia
“We deliberately chose young, highly motivated
individuals because we want to prepare them for
quality leadership roles throughout our hospitals.
They were attracted by the promise of enhanced
knowledge and career advancement.”
							
			Dr. Noura AlNowaiser
Practical skill-building: Students praised the
curriculum and gave high marks to the stakeholder
analysis, decision metrics, and data interpretation.
They gained confidence in public speaking and
presenting case studies and storyboards to their
fellow students.
Some individuals, challenged by the data exercises, were provided with additional tutoring in
Excel and data analytics. Others struggled with Failure Modes and Effects Analysis (FMEA)
but mastered the tool to analyze risks and spot failures before they occur.
“Our students worked incredibly hard to identify and solve quality problems. Their progress
was amazing and one of the faculty members commented that their written work was better
than what he typically sees within hospitals.”
							Dr. Noura AlNowaiser
Lively student interaction: Students worked in groups and enjoyed many opportunities to
share ideas. As the program progressed, students were assigned to different groups to become
familiar with each other and their organizational challenges. Most of them were comfortable
with mixed-gender groups, but one all-male and one all-female group were maintained to respect
cultural preferences.
Intense faculty involvement: Experienced JCI faculty members were very involved in the
group exercises and available for questions. They coached the students in ways to bring best
practices back to their hospitals and provided them with the right tools to drive improvements.
“One of the reasons we chose the JCI program was because they offered an experienced yet
friendly faculty. Their approach was nonthreatening and they focused on practical solutions
beyond pure theory.”
							Dr. Noura AlNowaiser
CASE STUDY
Participants enjoyed meeting colleagues
from other hospitals and sharing ideas for
performance improvement.
Positive response from hospitals: Hospital leaders understand that the graduates are
well-equipped to expand and improve vital quality activities within their organizations.
These leaders look forward to sending additional employees to future programs.
“One graduate (a family physician) has done an exceptional job of introducing a culture
of safety into his hospital, an organization with a very weak track record. Through his
leadership and use of data and storyboarding skills, he is having a real impact in turning
things around.”
							Dr. Noura AlNowaiser
Post-graduation activities: Students bonded so well during the program that they have
continued to connect with each other after graduation through email and conference calls.
An in-person refresher course is in development to provide a forum for graduates to share
progress and lessons learned.
Next steps for growth: The diploma program will be repeated September 2013–June 2014
at Prince Sultan Military College. The curriculum has been modified from 10 modules to
eight and classes will be clustered into four sessions (two modules covered per session). The
compressed schedule is more convenient and honors Ramadan. Enrollment for the next
session filled quickly; hopeful students were wait-listed for future classes.
“The program has proven to be very popular with
many high-achieving employees. They see it as a
strong credential for their careers.”
			Dr. Noura AlNowaiser
Recommendations to prospective sponsors:
For organizations considering the diploma program,
Dr. Noura AlNowaiser suggests that decision makers:
- Define clear objectives
- Lobby for and obtain financial support
- Secure a classroom environment that provides
internet access and supports multimedia learning
- Market anticipated results to health care organizations within the system
- Market anticipated benefits to eligible students, including enhanced knowledge, skills,
and recognition accompanied by potential promotions and salary increases
Paula Wilson, president and CEO of JCI, congratulates
a graduate of the program.
Dr. Noura (center) with graduates ready
to return to their health care organizations
and put leading-edge quality tools to work.
QMD031913
Contacts
QMER0714
Headquarters
1515 West 22nd Street
Suite 1300W
Oak Brook, Illinois 60523
USA
Voice +1 630 268 7400
Fax +1 630 268 7405
Joint Commission International Consulting
Email jciconsulting@jcrinc.com
Voice +1 630 268 2900
Joint Commission International Accreditation
Email jciaccreditation@jcrinc.com
Voice +1 630 268 4800
Asia-Pacific Office
37th Floor
Singapore Land Tower
50 Raffles Place
Singapore 048623
Email jciasiapacific@jcrinc.com
Voice +65 6829 7208
Fax +65 6826 4181
Middle East Office
P.O. Box 505018
Bldg 27, Suite B503
Dubai Healthcare City
Dubai
United Arab Emirates
Email jcimiddleeast@jcrinc.com
Voice +971 4369 4930
Fax +971 4362 4951
Other Regions
jciamericas@jcrinc.com
jciafrica@jcrinc.com
jcieurope@jcrinc.com
jointcommissioninternational.org
Helping you on
your quality journey
For information about this
innovative program, contact:
Asia-Pacific
Prabhu Vinayagam, MBBS
Managing Director, Asia-Pacific Office
Email pvinayagam@jcrinc.com
Voice +65 6829 7208
Middle East
Ashraf Ismail, MD, MPH, CPHQ
Managing Director, Middle East Office
Email aismail@jcrinc.com
Voice +971 4369 4930
Other Regions
Lori Shanahan, MPA
Associate Director, International Services
Email lshanahan@jcrinc.com
Voice +1 630 268 7443
Follow us
CertificateCourses
Certificate Courses in
Quality & Safety
Advancing staff development
through custom education
Joint Commission International (JCI) offers a series of certificate courses
that cover pivotal quality and patient safety issues.
Faculty members have decades of experience in performance improvement and patient safety
and understand how to share leading practices with your staff. Now you can work directly with
JCI to bring evidence-based education to your organization and elevate clinical expertise.
Each course runs for approximately one week and focuses on dynamic, engaging in-class learning
and interaction. Participants who successfully complete a course are awarded a certificate of
excellence in that particular topic.
Course 1
Principles of Quality
Management and
Patient Safety in
Health Care
This course lays a foundation
for the study of quality
management, patient safety,
performance improvement,
and voice-of-the-customer
concepts.
Course 2
Leadership and
Planning in Quality
Management
Participants learn about the
styles and role of leadership
and how to build a culture
of safety in a high-reliability
organization.
Course 3
Information
Management in Health
Care Quality
This course provides an
understanding of medical
record reviews, policies
and procedures, and
communication about
quality management
information.
Course 4
Systems Approach to
Quality Management
Participants are introduced to
system thinking and how to
design and use process maps
for quality improvement.
Course 5
Data Collection in
Performance
Measurement and
Quality Management
Participants gain knowledge
about concepts, methods,
and tools for selecting and
describing performance
measures and collecting data.
Course 6
Principles of
Performance
Measurement and
Data Analysis
This course explains how
to use basic statistics and
graphing to analyze and
display data.
Course 7
Patient Safety and
Risk Management
Content focuses on how to
establish a culture of safety.
Failure Modes and Effects
Analysis and other assessment
tools are shared to help
participants develop and
implement risk-reduction
strategies.
Course 8
Fundamentals of Health
Care Improvement
The improvement methods
taught in this course are
organized to be used at each
stage of the performance
improvement cycle.
Choose from a suite of courses that address crucial quality issues
QMG0714
Design your own curriculum
Some organizations have created custom programs by clustering several certificate courses around
a guiding theme. Here are examples of custom-built curriculum. JCI staff will be happy to build
a configuration that meets your organization’s quality and safety needs.
Theme
Introduction to Quality and Safety
Leadership in Quality
The Power of Data
Focus
A primer and excellent foundation for
staff new to quality management
Overview of leadership models and
adverse event management
Core program on data collection, analysis,
and its impact on quality management
Courses
1 and 2
Portions of
1, 2, and 7
5 and 6
Duration
Two weeks
One week
Two weeks
Helping you on your quality journey
For more information about sponsoring certificate courses or a diploma program for your staff,
contact the JCI office in your region.
Asia-Pacific
Prabhu Vinayagam, MBBS
Managing Director
Asia-Pacific Office
Email pvinayagam@jcrinc.com
Voice +65 6829 7208
Middle East
Ashraf Ismail, MD, MPH, CPHQ
Managing Director
Middle East Office
Email aismail@jcrinc.com
Voice +971 4369 4930
Other Regions
Lori Shanahan, MPA
Associate Director
International Services
Email lshanahan@jcrinc.com
Voice +1 630 268 7443
jointcommissioninternational.org
Innovative education
for today’s quality
professionals
JCI: Leading practices shared with the world
As the international not-for-profit affiliate of The Joint
Commission, JCI helps to improve the quality and safety
of health care through accreditation services, education,
publications, and advisory services. JCI experts understand
and help meet the needs of diverse health care organizations
and systems in more than 90 countries by providing
high-value, cost-effective services at every stage in the
quality improvement journey.
jointcommissioninternational.org
HealthCareQualityManagement&PatientSafetyDiplomaProgram

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QUALITY MANAGEMENT AND PATIENT SAFETY DIPLOMA BY JCI

  • 1. Innovative education for today’s quality professionals JCI: Leading practices shared with the world As the international not-for-profit affiliate of The Joint Commission, JCI helps to improve the quality and safety of health care through accreditation services, education, publications, and advisory services. JCI experts understand and help meet the needs of diverse health care organizations and systems in more than 90 countries by providing high-value, cost-effective services at every stage in the quality improvement journey. jointcommissioninternational.org HealthCareQualityManagement&PatientSafetyDiplomaProgram
  • 3. Innovative education for today’s quality professionals
  • 4. Develop your staff through leading education from JCI Quality and safety improvement leads directly to better patient outcomes, improves operational productivity, increases patient and staff satisfaction, and reduces costs. This unique program is designed to advance quality and safety in your organization. Government ministries, hospitals, health systems, and universities are working with Joint Commission International® (JCI) to bring evidence-based education to staff through JCI’s Health Care Quality Management & Patient Safety Diploma Program.
  • 5. Partner with JCI to achieve your quality and safety goals Every day JCI consultants work with health care organizations to establish and refine their quality programs. These organizations face similar challenges: What does an optimal quality department look like? What kind of data do we need to collect? How can we measure and repeat success? To help organizations create and strengthen quality initiatives, JCI has created its distinctive Health Care Quality Management & Patient Safety Diploma Program. This university-level educational experience specifically for hospital staff teaches best practice performance improvement strategies. Participants learn how to apply evidence-based tools and practices within their organizations and share practical solutions with their care teams. Program graduates are better equipped to drive quality initiatives within their organizations and achieve measurable goals and sustainable results. Benefits to participants Understand and advocate for a consistent quality function Become adept at collecting and reporting data Use quality data to augment and monitor performance improvement Share tools and strategies with team members Gain knowledge and training Benefits to health care organizations Elevate, expand, and standardize the quality function Train staff in the latest, most sophisticated quality methods Infuse care teams with expertise from newly trained staff Strengthen staff support of sustainable improvements Achieve stated quality and safety goals
  • 6. The integrated curriculum is presented in eight modules over 10 months (a traditional academic year)*: 1 Principles of Quality Management and Patient Safety in Health Care 2 Leadership and Planning in Quality Management 3 Information Management in Health Care Quality 4 Systems Approach to Quality Management 5 Data Collection in Performance Measurement and Quality Management 6 Principles of Performance Measurement and Data Analysis 7 Patient Safety and Risk Management 8 Fundamentals of Health Care Improvement For each module, faculty and participants meet in class for five full days. A variety of educational techniques are employed, including lectures, discussions, case study reviews, interactive group exercises, and student assignments using an array of quality tools and methods. The educational experience allows for personalized attention and dialogue. Students are evaluated and mentored throughout the program. Their progress is monitored and, with successful completion, they receive a diploma. How the diploma program works *The curriculum can be modified to address your organization’s most pressing quality and safety needs.
  • 7. “Before this program, I tended to avoid quality issues because I was afraid they would constrain my practice of medicine. However, this program completely changed my thinking and by graduation I became a quality champion. Today I enjoy applying what I learned to improve performance at my hospital.” Selecting your quality champions JCI’s Health Care Quality Management & Patient Safety Diploma Program represents an excellent career-building opportunity for individuals who have been charged with establishing or managing a quality department or with strengthening quality initiatives within their organizations. To be eligible, participants must work full-time in a hospital or health care facility, have quality-focused responsibilities, and meet other eligibility requirements established by the sponsoring university or organization. Once selected, students must participate in classes, complete required readings and homework, and pass mandatory tests. Helping you on your quality journey For information about this innovative program, contact: Asia-Pacific Prabhu Vinayagam, Managing Director, Asia-Pacific Office Email pvinayagam@jcrinc.com Voice +65 6829 7208 Middle East Ashraf Ismail, Managing Director, Middle East Office Email aismail@jcrinc.com Voice +971 4369 4930 Other Regions Lori Shanahan, Associate Director, International Services Email lshanahan@jcrinc.com Voice +1 630 268 7443 Primary care physician 2012 graduate Saudi Arabia
  • 8. JCI: Leading practices shared with the world As the international not-for-profit affiliate of The Joint Commission, JCI helps to improve the quality and safety of health care through accreditation services, education, publications, and advisory services. JCI experts understand and help meet the needs of diverse health care organizations and systems in more than 100 countries by providing high-value, cost-effective services at every stage in the quality improvement journey. jointcommissioninternational.org QMAR0714 Headquarters 1515 West 22nd Street Suite 1300W Oak Brook, Illinois 60523 USA Voice +1 630 268 7400 Fax +1 630 268 7405 Joint Commission International Consulting Email jciconsulting@jcrinc.com Voice +1 630 268 2900 Joint Commission International Accreditation Email jciaccreditation@jcrinc.com Voice +1 630 268 4800 Joint Commission International ® (JCI) is a division of Joint Commission Resources, Inc.® , a wholly controlled not-for-profit affiliate of The Joint Commission. JCI provides leadership in international health care accreditation and quality improvement. Asia-Pacific Office 37th Floor Singapore Land Tower 50 Raffles Place Singapore 048623 Email jciasiapacific@jcrinc.com Voice +65 6829 7208 Fax +65 6826 4181 Middle East Office P.O. Box 505018 Bldg 27, Suite B503 Dubai Healthcare City Dubai United Arab Emirates Email jcimiddleeast@jcrinc.com Voice +971 4369 4930 Fax +971 4362 4951 Other Regions jciamericas@jcrinc.com jciafrica@jcrinc.com jcieurope@jcrinc.com Follow us
  • 10. The Health Care Quality Management & Patient Safety Diploma Program created by Joint Commission International (JCI) features a faculty with decades of experience in performance improvement and patient safety. Shakil Ahmad, MBBS, DipMed, MHCM, CPQM, JCI Consultant, Certified Green Belt Dr. Ahmad has more than 16 years of experience in international health care management and quality as well as expertise in medical staff leadership, privileging, credentialing, and bylaws. He has held positions as a quality improvement physician, hospital administrator, head of medical staff performance and review, senior quality specialist, and quality manager. During his tenure with a regulatory health authority in the United Arab Emirates, Dr. Ahmad was responsible for overseeing JCI accreditation at two hospitals and implementing regulatory policies and standards. He has chaired and presented at numerous international conferences, including the ISQua (International Society for Quality in Health Care) Conference in London, the International Quality Conference in Muscat, Oman, and the Middle East Quality Conference in Dubai. Dr. Ahmad earned a medical degree from the Royal Postgraduate Medical School, London (UK) and a master’s degree from Oxford Brookes University, Oxford (UK). Zakarai Zaki Al-Attal, MSN, PhD, CPHQ, JCI Consultant Dr. Al-Attal is an expert in implementing quality concepts in organizations to enhance the quality of health care services. Most recently, he was director of quality and performance management at the Dubai Health Authority, where he oversaw quality, risk management, performance management, and accreditation programs in four government hospitals and specialized centers of the Authority. Currently he works with the ministry of health. His experience includes consulting engagements in the Middle East, Asia-Pacific, Europe, and Africa. He has served as a quality council member of Dubai Healthcare City and as a lecturer at the Dubai Women’s Medical College and at the residency programs of the Authority. Dr. Al-Attal earned a doctorate from the University of Salford, Manchester (UK), a master’s degree in quality management from Wollongong University, Dubai (UAE), and a master’s degree in nursing from Jordan University. Yvonne P. Burdick, MHA, FACHE, EDAC, JCI Consultant, Certified Yellow Belt Ms. Burdick has more than 30 years of experience in health care and has held leadership positions in hospital and ambulatory care settings. She has been involved in the development and implementation of health service accreditation systems and quality improvement programs internationally, including serving on the ISQua panel to review international principles for accreditation. Working in collaboration with the World Health Organization in countries throughout Latin America and the Caribbean, Ms. Burdick participated in projects focused on quality improvement programs and accreditation systems. Trained as a research scientist and laboratory manager, her management experience encompasses clinical research, toxicology, occupational health, safety, and environmental affairs. Ms. Burdick earned a bachelor’s degree in biological sciences from the University of Edinburgh (Scotland) and a master’s degree in hospital administration from the Medical College of Virginia (USA). She is accredited and certified in evidence-based design by the Center for Health Design. Expert faculty provide leading-edge quality perspectives
  • 11. Hyunok (Heidi) Kim Do, RN, DNSc, JCI Consultant Dr. Do has more than 30 years of leadership, management, and teaching experience in health care and international expertise as a consultant and nursing leader in Southeast Asia. She is a recognized expert in performance improvement, outcomes management, program development, and statistical tools and techniques. She has consulted in Asia-Pacific and presented at several JCI practicums. Her experience includes serving as an administrator for a U.S. rehabilitation hospital and a vice president of patient services for a U.S. health system. She also served as vice president of nursing services for a Korean hospital. Educational positions include assistant professor at a U.S. school of nursing, clinical instructor, and nursing education coordinator. Dr. Do earned a doctorate in nursing science from Boston University, Massachusetts (USA) and a master’s degree in nursing from The Ohio State University (USA). Linda L. Faber, PhD, RN, FACHE, Senior JCI Consultant, Certified Yellow Belt and Change Agent With more than three decades of experience in health care leadership, management, and performance improvement, Dr. Faber serves as a JCI faculty member and as an assistant clinical professor at the University of California- Los Angeles School of Nursing (USA). She has consulted in Brazil, Denmark, Spain, Italy, Japan, and Ireland, sharing her expertise in performance improvement, outcomes management, systems analysis, and leadership in organizational development, staff education, and training. In previous positions, Dr. Faber served as director of performance improvement and director of nursing research, education, and quality improvement for a U.S. medical center; associate chief of nursing research for a U.S. Veterans Health Administration medical center; and positions as a nurse manager, supervisor for mental health and acute care facilities, and clinical specialist in behavioral health. Dr. Faber earned a doctorate in public health, master’s degree in nursing, and a certificate in quality management and performance from University of California-Los Angeles (USA). Kornelia Fiausch, RN, MAS, JCI Consultant, Certified Yellow Belt Ms. Fiausch has more than 16 years of experience as a director of nursing services, with special expertise in intensive care, staff leadership, and geriatrics. She has consulted internationally in Europe, the Middle East, and Asia-Pacific and has presented at several JCI practicums. She serves as the director of nursing for Landeskrankenhaus Villach (Austria) and is a certified judicial expert for the area of nursing. Ms. Fiausch earned her master’s degree in hospital management from the University of Economics of Vienna (Austria), as well as certificates in nursing management and hospital management. Deborah Flores, EdD, MEd, RN, CPHQ, JCI Consultant Dr. Flores has been a senior leader in large and small health care organizations for the past 16 years. In addition to her work with JCI, she is an administrator in an ambulatory clinic in Central America and a first assist in the operating room of two hospitals in the region. Her expertise encompasses quality and performance improvement, patient safety, and population health. Previous positions include vice president of performance improvement for a research medical center, system vice president of quality improvement for a health system, and assistant vice president at a children’s hospital. She has also served as an associate clinical professor for Texas A&M University (USA). Dr. Flores earned a doctorate in health promotion and a master’s degree in health education from Temple University, Philadelphia (USA). Safak Guven, MD, MBA, JCI Consultant Dr. Guven is a physician executive with board certification in endocrinology. He has been recognized for outcome- driven clinical program and system development in hospitals and outpatient clinics. His background includes international leadership experience and expertise in strategic planning, operations and process improvement in hospitals, quality management, team creation, and physician and administration relationships. He established the Diabetes Care Center at the University of Cairo (Egypt) and has taught at several universities. He has delivered international consulting and educational programs in the Middle East, Europe, Asia-Pacific, and the Americas. Dr. Guven earned a medical degree from Marmara University School of Medicine, Istanbul (Turkey) and a master’s degree in business administration from Northwestern University, Illinois (USA).
  • 12. Helen Hoesing, RN, MPH, PhD, Senior JCI Consultant, Certified Change Agent With more than four decades of experience in health care, Dr. Hoesing has demonstrated expertise as a nursing executive and performance improvement specialist. She has been a consultant and faculty member for The Joint Commission for the past 35 years and taught programs on health care quality improvement, patient safety, nursing, and standards in Asia-Pacific, the Americas, the Middle East, Africa, and Europe. In earlier positions she served as vice president for a health system and acute care facility in Nebraska (USA) and other administrative roles in acute care and home care. Her consulting expertise encompasses performance improvement, work and process redesign, leadership education and skill building, patient safety assessment, and incorporating tracer methodology and period performance review as management tools. Dr. Hoesing earned a doctorate in management/administration from Walden University, Minnesota (USA) and a master’s degree in public health from the University of Minnesota (USA). Thomas W. Kozlowski, PhD, ACSW, Senior JCI Consultant, Certified Yellow Belt and Change Agent Dr. Kozlowski has more than 30 years of experience in health care and has consulted with organizations in Asia, Europe, the Middle East, and the Americas. Experienced with a wide array of health care settings, his expertise includes operational and patient safety assessment, performance improvement, executive leadership and governing bodies, and other quality-driven areas. Drs. Kozlowski and Richard Wright developed the JCI Health Care Quality Management & Patient Safety Diploma Program. In addition to 13 years with The Joint Commission, he has served as an administrator in hospitals, mental health and chemical dependency programs, and foster care organizations; a chief executive officer for an ambulatory health care system; an interim director of accreditation, regulation, and quality for an academic teaching hospital and multisite ambulatory system; and a corporate director of quality improvement and research for a health maintenance organization. Dr. Kozlowski holds faculty appointments with two U.S. academic institutions. He earned a doctorate in health care administration from Walden University, Minnesota (USA), a master’s degree in social work from the University of Illi- nois (USA), and a bachelor’s degree in psychology from St. Mary’s University, Minnesota (USA). David Marx, MD, PhD, JCI Consultant Dr. Marx specializes in quality and performance improvement and has more than 19 years of experience in national and international health care quality and safety management. He is in charge of a Czech national hospital accreditation project and has coordinated the development of two editions of national standards for hospitals and one edition of national long term care standards. As a JCI consultant, Dr. Marx has provided consulting and education in Europe and the Middle East and has worked with several European health care institutions to test and implement JCI standards. He has served as a senior lecturer for Charles University, the director of quality at University Hospital, Prague, and the director general for the Ministry of Health—all in the Czech Republic. Dr. Marx earned a medical degree from Charles University, Prague (Czech Republic) and a doctorate in public health from Palacky University, Olomouc (Czech Republic). Judith A. Moomjian, RN, MPA, CPHQ, FACHE, JCI Consultant, Certified Yellow Belt and Change Agent Ms. Moomjian has extensive experience in domestic and international health care, providing international hospital accreditation-related consulting in Asia-Pacific, Europe, the Americas, and the Middle East. She has demonstrated expertise as a hospital and long term care administrator, nursing executive, and performance improvement specialist. Areas of focus include patient safety, medication management, infection prevention and control, tracer methodology, and environment of care, to name a few. Ms. Moomjian piloted and assisted with revisions to JCI’s first international continuum-of-care standards and has participated in JCI practicums. She earned a master’s degree in health care administration from Long Island University, New York (USA) and a nursing diploma from Mt. Sinai Hospital School of Nursing, New York (USA).
  • 13. QMBR0714 Derick P. Pasternak, MD, MBA, FACPE, Senior JCI Consultant As a board-certified internal medicine specialist, Dr. Pasternak has more than three decades of health care experience and has served 14 years as a health care executive. With expertise in patient safety, quality measurement and management, and medical staff affairs, he has consulted in the Middle East, Asia-Pacific, Europe, and Latin America. Dr. Pasternak established JCI’s Dubai office in 2006 and managed it for three years, working with clients in the Middle East, North Africa, and India. He has served as a clinical professor at the University of Washington School of Public Health (USA). Dr. Pasternak is the author of several articles and an e-book on health care quality and medical management. He earned a medical degree from Harvard University (USA) and a master’s degree in business administration from the University of New Mexico (USA). Francine Westergaard, RN, MSN, MBA, Senior JCI Consultant, Certified Yellow Belt and Change Agent With more than 26 years of nursing experience as a practitioner, educator, administrator, and researcher, Ms. Westergaard is adept at providing applications for improvement to assist organizations as they facilitate change. Her expertise encompasses operational assessment, patient safety, medication management, performance improvement, tracer methodology, and senior executive dialogue. She has provided consulting and education for major hospitals, health systems, and ministries of health in the Americas, Asia-Pacific, Europe, Africa, and the Middle East. Previous positions include progressive leadership positions in hospital and ambulatory care settings. Ms. Westergaard earned a master’s degree in business administration from Walden University, Minnesota (USA) and a master’s degree in nursing from Lewis University, Illinois (USA). Richard A. Wright, MD, MPH, FACPE, JCI Consultant, Certified Green Belt and Change Agent Dr. Wright is a board-certified internal medicine and infectious disease specialist with expertise in performance improvement and evaluation, care process redesign, and disease management. He provides consulting services for hospitals in the Middle East, Asia-Pacific, Europe, the U.S., and other facilities in the Americas, with focused expertise in performance improvement, quality management, leadership development, and the use of Lean Redesign methods to improve clinical processes. Drs. Wright and Thomas Kozlowski developed the JCI Health Care Quality Management & Patient Safety Diploma Program. Serving as a professor of preventive medicine and biometrics at the University of Colorado School of Medicine, Dr. Wright teaches and oversees research related to primary and preventive care. He has also served as a senior executive with Denver Health Authority and an epidemiologist with the U.S. Centers for Disease Control and Prevention. Dr. Wright has authored numerous articles on health care quality and management and received a national award for research and innovation in primary care in 2005. He earned a medical degree from the University of Minnesota (USA) and a master’s degree in public health from Loma Linda School of Public Health, California (USA). Nellie Yeo, MBA, MN, JCI Consultant, Certified Yellow Belt With more than 25 years of experience in health care, Ms. Yeo specializes in quality and patient safety. In her current position as chief quality officer of the National Healthcare Group (NHG) and executive director of NHG College in Singapore, she is responsible for establishing, developing, implementing, and evaluating the NHG quality and clinical governance framework. Ms. Yeo has consulted in Asia-Pacific, Europe, Africa, and the Middle East. She has served on committees within the Singapore health care system and is a member of leading international quality organizations. She earned a master’s degree in business administration from Nanyang Technological University (Singapore) and a master’s degree in nursing from the University of California (USA). Visit jointcommissioninternational.org for more details on our distinguished faculty.
  • 15. The Health Care Quality Management & Patient Safety Diploma Program created by Joint Commission International (JCI) presents in-depth knowledge through eight comprehensive education modules. Each module defines pre-class preparation, in-class lectures and exercises, and application of learning at the student’s organization. Students are tested on core concepts and learnings at the end of each module. The curriculum can be modified and specific topics highlighted to address your organization’s most pressing quality and safety needs. Proven strategies and tools highlighted in a modular curriculum
  • 16. Module 1: Principles of Quality Management and Patient Safety in Health Care This module provides participants with knowledge of definitions, concepts, and methods of quality management with an emphasis on connecting quality to the voice of the customer. - Principles of health care quality management - Dimensions and evolution of quality management - Definitions, concepts, and methods of quality management - Cost of quality concepts and analysis - Principles and methods of prioritization - Role of process variation and gap analysis - Voice-of-the-customer concepts and analysis - Design and components of a quality management program - Developing a learning organization Module 2: Leadership and Planning in Quality Management This module provides participants with an understanding of the role of leadership, teamwork, and change management in developing and sustaining improvements in quality and patient safety. - Definitions, styles, and the role of leadership - Strategic planning concepts and methods - Change management principles and methods - Teamwork and group decision-making methods - Use of facilitation in managing teams - Engaging clinical leaders in quality - Design and use of project charters - Critical factors for sustaining improvement Module 3: Information Management in Health Care Quality This module provides participants with an understanding of how to manage information critical to promoting organization-wide quality and patient safety. - Role of information management in promoting quality and patient safety - Types and uses of medical record reviews - Use of medical records for abstracting data - Development of policies and procedures - Use of quality management meetings for decision-making - Design of quality improvement meetings - Methods for communicating quality management information - Use of balanced scorecards for monitoring strategic initiatives 8MODULES
  • 17. Module 4: Systems Approach to Quality Management This module provides participants with an understanding of system thinking and instructs them in the design and use of process maps for quality improvement. - Concepts and methods of system thinking - Concepts and methods of Lean Redesign - Concepts of process variation - Method for describing and analyzing processes - Use of SIPOC (Supplier-Input-Process-Output-Customer) tool for analyzing processes - Methods of analyzing and improving patient flow - Use of JCI tracer methods to evaluate standards compliance Module 5: Data Collection in Performance Measurement and Quality Management This module provides participants with knowledge of concepts, methods, and tools for selecting and describing performance measures and for collecting data. - Concepts of performance measurement - Methods for prioritizing and selecting performance measures - Methods for describing performance measures - Use of targets and benchmarks for comparisons - Sample sizes and methods - Developing data collection plans - Methods for aggregating and tabulating collected data - Evaluation of data reliability - Design of customer surveys Module 6: Principles of Performance Measurement and Data Analysis This module provides participants with knowledge of using basic statistics and graphing to analyze and display data. - Statistical functions for data analysis - Measuring central tendency and variation - Six Sigma methods for analyzing processes variation - Graphing functions - Use of pie charts, bar graphs, Pareto charts, and trend line charts - Use of statistical process control charts - Impact and comparison analysis - Use of reports for summarizing data
  • 18. Module 7: Patient Safety and Risk Management This module provides participants with an understanding of patient safety with an emphasis on preventing adverse events and minimizing associated risks. - Concepts of patient safety and risk management - Establishing a culture of safety - Characteristics of HROs (high-reliability organizations) - Management of adverse events - Reporting and analysis of near misses and medical errors - Role of human factors in preventing medical errors - Role of patient disclosure - Risk assessment concepts and methods - Concepts and methods of FMEA (Failure Modes and Effects Analysis) Module 8: Fundamentals of Health Care Improvement This module provides participants with an understanding of how to use systematic models for developing strategies for sustainable improvement. - Overview of performance improvement models - Approaches to team-based consensus - Applying the FOCUS (Find-Organize-Clarify-Understand-Select) PDCA (Plan-Do-Check- Act) model for improvement - Applying the Six Sigma DMAIC (Define-Measure-Analyze-Improve-Control) improvement model - A3 framework for managing improvement projects - Application of Lean improvement strategies - Supply chain management concepts and methods - Analysis of process flow QMCR0714
  • 20. The Ministry of Defense oversees 22 hospitals throughout Saudi Arabia. Ministry leaders sought to strengthen quality and patient safety functions within their hospitals, based on a gap analysis that showed weak quality leadership even within large urban facilities. After a thorough evaluation of other programs, the Ministry chose to sponsor the Health Care Quality Management & Patient Safety Diploma Program created by Joint Commission International (JCI). In December 2012 the inaugural class graduated and received diplomas in Quality Management and Patient Safety from Prince Sultan Military College, which offers a concentration in health care careers. Sponsor: Ministry of Defense, Kingdom of Saudi Arabia Affiliated academic institution: Prince Sultan Military College of Health Sciences, Dhahran The college certified the diploma program, appointed a program coordinator, provided housing to students, and served as the venue for all multimedia class work. Program champion: Dr. Noura AlNowaiser Director of Continuous Quality Improvement and Patient Safety Department Medical Services General Directorate, Ministry of Defense Goals: - Enhance the quality management skills of selected professionals - Improve the quality and safety performance within health care facilities - Build a long-term infrastructure for quality leadership throughout the Ministry of Defense’s hospitals Number of graduates: 62 completed the program and earned diplomas. Graduates included physicians, nurses, engineers, and other specialties. Criteria for student selection: - Full-time hospital employees - Hold a bachelor of science degree - English proficiency in reading, writing, and speaking Developing quality leaders in Saudi Arabia
  • 21. “We deliberately chose young, highly motivated individuals because we want to prepare them for quality leadership roles throughout our hospitals. They were attracted by the promise of enhanced knowledge and career advancement.” Dr. Noura AlNowaiser Practical skill-building: Students praised the curriculum and gave high marks to the stakeholder analysis, decision metrics, and data interpretation. They gained confidence in public speaking and presenting case studies and storyboards to their fellow students. Some individuals, challenged by the data exercises, were provided with additional tutoring in Excel and data analytics. Others struggled with Failure Modes and Effects Analysis (FMEA) but mastered the tool to analyze risks and spot failures before they occur. “Our students worked incredibly hard to identify and solve quality problems. Their progress was amazing and one of the faculty members commented that their written work was better than what he typically sees within hospitals.” Dr. Noura AlNowaiser Lively student interaction: Students worked in groups and enjoyed many opportunities to share ideas. As the program progressed, students were assigned to different groups to become familiar with each other and their organizational challenges. Most of them were comfortable with mixed-gender groups, but one all-male and one all-female group were maintained to respect cultural preferences. Intense faculty involvement: Experienced JCI faculty members were very involved in the group exercises and available for questions. They coached the students in ways to bring best practices back to their hospitals and provided them with the right tools to drive improvements. “One of the reasons we chose the JCI program was because they offered an experienced yet friendly faculty. Their approach was nonthreatening and they focused on practical solutions beyond pure theory.” Dr. Noura AlNowaiser CASE STUDY Participants enjoyed meeting colleagues from other hospitals and sharing ideas for performance improvement.
  • 22. Positive response from hospitals: Hospital leaders understand that the graduates are well-equipped to expand and improve vital quality activities within their organizations. These leaders look forward to sending additional employees to future programs. “One graduate (a family physician) has done an exceptional job of introducing a culture of safety into his hospital, an organization with a very weak track record. Through his leadership and use of data and storyboarding skills, he is having a real impact in turning things around.” Dr. Noura AlNowaiser Post-graduation activities: Students bonded so well during the program that they have continued to connect with each other after graduation through email and conference calls. An in-person refresher course is in development to provide a forum for graduates to share progress and lessons learned. Next steps for growth: The diploma program will be repeated September 2013–June 2014 at Prince Sultan Military College. The curriculum has been modified from 10 modules to eight and classes will be clustered into four sessions (two modules covered per session). The compressed schedule is more convenient and honors Ramadan. Enrollment for the next session filled quickly; hopeful students were wait-listed for future classes. “The program has proven to be very popular with many high-achieving employees. They see it as a strong credential for their careers.” Dr. Noura AlNowaiser Recommendations to prospective sponsors: For organizations considering the diploma program, Dr. Noura AlNowaiser suggests that decision makers: - Define clear objectives - Lobby for and obtain financial support - Secure a classroom environment that provides internet access and supports multimedia learning - Market anticipated results to health care organizations within the system - Market anticipated benefits to eligible students, including enhanced knowledge, skills, and recognition accompanied by potential promotions and salary increases Paula Wilson, president and CEO of JCI, congratulates a graduate of the program. Dr. Noura (center) with graduates ready to return to their health care organizations and put leading-edge quality tools to work.
  • 25. QMER0714 Headquarters 1515 West 22nd Street Suite 1300W Oak Brook, Illinois 60523 USA Voice +1 630 268 7400 Fax +1 630 268 7405 Joint Commission International Consulting Email jciconsulting@jcrinc.com Voice +1 630 268 2900 Joint Commission International Accreditation Email jciaccreditation@jcrinc.com Voice +1 630 268 4800 Asia-Pacific Office 37th Floor Singapore Land Tower 50 Raffles Place Singapore 048623 Email jciasiapacific@jcrinc.com Voice +65 6829 7208 Fax +65 6826 4181 Middle East Office P.O. Box 505018 Bldg 27, Suite B503 Dubai Healthcare City Dubai United Arab Emirates Email jcimiddleeast@jcrinc.com Voice +971 4369 4930 Fax +971 4362 4951 Other Regions jciamericas@jcrinc.com jciafrica@jcrinc.com jcieurope@jcrinc.com jointcommissioninternational.org Helping you on your quality journey For information about this innovative program, contact: Asia-Pacific Prabhu Vinayagam, MBBS Managing Director, Asia-Pacific Office Email pvinayagam@jcrinc.com Voice +65 6829 7208 Middle East Ashraf Ismail, MD, MPH, CPHQ Managing Director, Middle East Office Email aismail@jcrinc.com Voice +971 4369 4930 Other Regions Lori Shanahan, MPA Associate Director, International Services Email lshanahan@jcrinc.com Voice +1 630 268 7443 Follow us
  • 27. Certificate Courses in Quality & Safety Advancing staff development through custom education Joint Commission International (JCI) offers a series of certificate courses that cover pivotal quality and patient safety issues. Faculty members have decades of experience in performance improvement and patient safety and understand how to share leading practices with your staff. Now you can work directly with JCI to bring evidence-based education to your organization and elevate clinical expertise. Each course runs for approximately one week and focuses on dynamic, engaging in-class learning and interaction. Participants who successfully complete a course are awarded a certificate of excellence in that particular topic. Course 1 Principles of Quality Management and Patient Safety in Health Care This course lays a foundation for the study of quality management, patient safety, performance improvement, and voice-of-the-customer concepts. Course 2 Leadership and Planning in Quality Management Participants learn about the styles and role of leadership and how to build a culture of safety in a high-reliability organization. Course 3 Information Management in Health Care Quality This course provides an understanding of medical record reviews, policies and procedures, and communication about quality management information. Course 4 Systems Approach to Quality Management Participants are introduced to system thinking and how to design and use process maps for quality improvement. Course 5 Data Collection in Performance Measurement and Quality Management Participants gain knowledge about concepts, methods, and tools for selecting and describing performance measures and collecting data. Course 6 Principles of Performance Measurement and Data Analysis This course explains how to use basic statistics and graphing to analyze and display data. Course 7 Patient Safety and Risk Management Content focuses on how to establish a culture of safety. Failure Modes and Effects Analysis and other assessment tools are shared to help participants develop and implement risk-reduction strategies. Course 8 Fundamentals of Health Care Improvement The improvement methods taught in this course are organized to be used at each stage of the performance improvement cycle. Choose from a suite of courses that address crucial quality issues
  • 28. QMG0714 Design your own curriculum Some organizations have created custom programs by clustering several certificate courses around a guiding theme. Here are examples of custom-built curriculum. JCI staff will be happy to build a configuration that meets your organization’s quality and safety needs. Theme Introduction to Quality and Safety Leadership in Quality The Power of Data Focus A primer and excellent foundation for staff new to quality management Overview of leadership models and adverse event management Core program on data collection, analysis, and its impact on quality management Courses 1 and 2 Portions of 1, 2, and 7 5 and 6 Duration Two weeks One week Two weeks Helping you on your quality journey For more information about sponsoring certificate courses or a diploma program for your staff, contact the JCI office in your region. Asia-Pacific Prabhu Vinayagam, MBBS Managing Director Asia-Pacific Office Email pvinayagam@jcrinc.com Voice +65 6829 7208 Middle East Ashraf Ismail, MD, MPH, CPHQ Managing Director Middle East Office Email aismail@jcrinc.com Voice +971 4369 4930 Other Regions Lori Shanahan, MPA Associate Director International Services Email lshanahan@jcrinc.com Voice +1 630 268 7443 jointcommissioninternational.org
  • 29. Innovative education for today’s quality professionals JCI: Leading practices shared with the world As the international not-for-profit affiliate of The Joint Commission, JCI helps to improve the quality and safety of health care through accreditation services, education, publications, and advisory services. JCI experts understand and help meet the needs of diverse health care organizations and systems in more than 90 countries by providing high-value, cost-effective services at every stage in the quality improvement journey. jointcommissioninternational.org HealthCareQualityManagement&PatientSafetyDiplomaProgram