The document provides guidance on the steps for an organization to take in preparing for JCI (Joint Commission International) accreditation. It recommends that organizations: 1) allocate 18-24 months to prepare; 2) conduct an initial assessment of adherence to JCI standards; 3) develop an action plan and project timeline to address gaps; and 4) complete a final mock survey 4-6 months before the actual accreditation survey to ensure readiness. The key steps outlined include establishing leadership commitment, educating staff, ongoing monitoring of quality data, and adjusting strategies based on mid-point evaluations to facilitate a successful accreditation process.
2. 2
The Accreditation Journey:
General Suggestions
• The importance of leadership commitment: Board,
CEO, and clinical leaders
• Leadership’s responsibility to assuring systems are
designed for quality and safety
• Set a realistic timeframe for preparation, such as
18-24 months
• Allocation of resources: may include facility
enhancement, training, recruitment of new staff,
and redesign of systems
3. 3
The Accreditation Journey:
Where to Start?
• Available Resources
JCI Accreditation Standards for Hospitals, 2nd
edition
Survey Process Guide (detailed electronic version
available on line)
Web-based training on introduction to the international
accreditation process
Newsletters and publications, both print and electronic
Annual JCI Practicum each July
Annual JCI Executive Briefings – networking
opportunity with accredited organizations
4. 4
The Accreditation Journey:
Begin with Education
• Education for organizational leaders and managers
Introduction to accreditation philosophy and approach
Accreditation as a quality improvement and risk
reduction strategy
Review of the standards and measurable elements
Discussion of the survey process and what to expect
Project planning and next steps
5. 5
The Accreditation Journey:
Baseline Assessment
• Conduct a detailed baseline assessment of the
organization’s current adherence to the standards
and each measurable element
Use knowledgeable and credible evaluators (either
internal or external consultants) who will critically and
objectively assess each area
Score as Met, Partially Met, or Not Met and cite specific
findings and recommendations
Priority focus on the core standards in bold
Include all areas of the organization in the assessment
6. 6
The Accreditation Journey:
Baseline Assessment
• In addition to addressing standards adherence,
collect and analyze baseline quality data as
required by the quality monitoring standards
Examples: medication errors, hospital-associated
infection rates, antibiotic usage, surgical
complications, etc.
• Establish an ongoing monitoring system for data
collection (e.g. monthly, with quarterly data
analysis) to identify problem areas and track
progress in improvement
7. 7
The Accreditation Journey:
Action Planning
• Using the findings of the baseline assessment,
develop a detailed project plan with assigned
responsibilities, deliverables, and timeframes
Start first with priority areas of the core standards
Example: Revise informed consent policy, develop a
new informed consent statement, educate staff --- in
the next two month time period
If available, use a software program such as MS
Project or Excel to confirm project plan in writing
Hold leaders and staff accountable to plan
8. 8
The Accreditation Journey:
Team Approach
• Assign oversight of each chapter of standards to a
respected champion/leader who will identify team
members from throughout the hospital
• Involve those who may also be skeptical of the
process
• Look for good people skills, time management
skills, and consensus building skills
• Be prepared to change as new champions emerge,
and some leaders drop out
9. 9
The Accreditation Journey:
Policies and Procedures
• In addition to overall project plan, it is often
helpful to compile a list of all required policies
and procedures that will need development and
revision
• These may take some time to get revise or
develop, undergo organizational review, and
obtain final approval
• Be certain that your policy reflects your actual
practice, as this is what the surveyors will
evaluate your organization against
10. 10
The Accreditation Journey:
Mid-Point Strategies
• Continue to monitor your progress in meeting the
standards, such as through a mini-evaluation of
each chapter at regular intervals (e.g quarterly)
• Don’t be afraid to adjust your project plan to be
more realistic --- change often takes longer than
one expects
• Continue to involve as many staff as possible in
the process --- make it an organizational quality
goal that together you are wishing to achieve
11. 11
Strategies that have Worked
• Importance of physician commitment to the
accreditation process
Must see accreditation standards as a framework by
which organizational processes will be improved
Care will ultimately be of higher quality and safer for
their patients
Reassure physicians that accreditation is not intended
to tell them how to practice medicine!
12. 12
Strategies that have Worked
• Learn from what others have done well and adapt
the experience to the needs of your organization
• Ask JCI for assistance and clarification with
standards interpretation --- don’t waste time
going down the wrong path
• Take advantage of resources such as the JCR
Good Practices Database (e.g. download
electronic example policies and plans and adapt
to your organization)
13. 13
Pitfalls to Avoid
• Top leaders give “lip service” to the process, but
are totally unrealistic in what it will take to
achieve it in terms of time and resources
• Staff end up feeling that accreditation is extra
work for which they are not rewarded or
recognized
• Over-eager managers use the standards as a stick
rather than as a carrot --- can make entire
accreditation process feel punitive and inspecting
rather than motivating
14. 14
Final Mock Survey
• Plan for a final “mock survey” at least 4-6 months
in advance of the target date of the actual
accreditation survey
• Use evaluators (internal or external consultants)
who were not involved in the baseline assessment
and preparation, who will look at the organization
with a fresh and objective eye
• Need to plan final revisions and corrections based
on the findings of the final mock survey
15. 15
The Accreditation Survey
• Request an application from JCI at least 6 months
in advance of target dates for survey
• Once application completed, a surveyor team will
be compiled and dates confirmed
• Team leader will be in contact to coordinate
agenda and plans for the survey
• Support staff in doing the good work that they
always do, so that survey does not cause anxiety
and fear
16. 16
After the Survey
• Celebrate the success!
• May need to work on areas for improvement and
submit a follow-up progress report to JCI
• Maintain the momentum from the survey ---
establish an ongoing system of standards
compliance and survey readiness
