Getting started with JCI accreditation dr prahhu

• JCI International Standards for Hospitals, 3nd Edition • Hospital Survey Process Guide • Web-based training on introduction to the international accreditation process • ISAS – Internat

 Evaluate the commitment of leadership

(Board, CEO, and clinical leaders) to a

never ending journey

 Assess the purity of purpose: to be a

safe, high quality organization

 Set a clear understanding that the

process will require significant leader

time Assigning accreditation only to the

quality department will not work

The Accreditation Journey

 List all barriers and strengths to success and plan strategies for each

 Understand implications for financial

and human resources These may

include facility enhancement, training,

recruitment of new staff, and redesign of systems

 Set a realistic timeframe for preparation Average preparation time?

• JCI International Standards for Hospitals, 3nd Edition

• Hospital Survey Process Guide

• Web-based training on introduction to the international accreditation process

• ISAS – International Self Assessment System

• Newsletters and publications, both print and electronic

• JCI Practicum – Several locations worldwide

• JCI Executive Briefings

Introduction to accreditation philosophy and approach

Discussion of accreditation as a patient-focused 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

Determine 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

Include all areas of the organization in the assessment

Consider an assessment of organizational “culture”

related to quality and patient safety

In addition to addressing standards adherence, analyze

and collect available baseline quality data as required by

the quality monitoring standards (QPS)

More data and data sources may be available than

you first realize

Begin to combine activities of

risk-management, quality risk-management, facility

safety, etc into one comprehensive data

set

Examples: medication errors,

hospital-associated infection rates, antibiotic usage,

falls, hazardous material spills, surgical

complications, etc

Using the findings of the baseline assessment, develop a

detailed project plan with assigned responsibilities,

deliverables, and timeframes

Example: Revise informed consent policy, develop a new informed consent statement, educate staff by 30

August Responsibility: One Person

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

The Accreditation Journey:

Action Planning Tips

 Think structure-process-outcome in the

implementation sequence, in other words develop

polices first Expectation required actions result

 Implement those requirements that will take the

longest to make fully functional such as the quality

monitoring system for the QPS indicators

 Do not forget the “track record” requirement = 4

months a first survey

Assign oversight of each chapter of standards to

a respected champion or leader who will select

team members from throughout the hospital

Tip: Involve those who may be skeptical of the

process

Look for good people skills, time management

skills, and consensus building skills

Be prepared to change assignments as new

The Accreditation Journey:

Policies and Procedures

In addition to an overall project plan, it is often helpful to

compile a list of all required policies and procedures that will need development or revision

 It may take more time than you think to write, have

organizational review, and get final approval on policies

 Be certain that your policy reflects your actual practice

This is how surveyors will evaluate your organization

 Plan time for education of new policies Test

understanding and compliance

 Create, refine and/or test your document management

system (Policy on Policies)

 Continue to monitor your progress in meeting the

standards; do a mini-evaluation of each chapter at

regular intervals

 It is not a setback to adjust your project plan if

necessary Changes in processes often take longer than expected

 Continue to involve as many staff as possible in the

process Make accreditation an organizational quality

goal that you are striving to achieve together

 Physicians must see accreditation standards as

a framework by which organizational processes

will be improved in order to support good

medical care

 Accreditation is not a peer review process as

many physicians suspect

 Accreditation supports the use of good

clinical science and best practices

More Successful Strategies

 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

 Top leaders give “lip service” to the process, but are

unrealistic in what it will take to achieve accreditation 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 make the entire accreditation

process feel punitive and inspecting rather than

motivating

 Plan for a final “mock survey” at least 6 months in

advance of the target date of your actual

accreditation survey

 Use evaluators (internal or external consultants) who

were not involved in the baseline assessment and

preparation They will look at the organization with

more objectivity If using internal evaluators, mix

disciplines and locations

written format to JCI Office

information in application after

submission

–Application is used to

number of surveyors

contract for survey

–Survey Scheduled within 180 days

The Accreditation Survey

 Request an application from JCI at least 6 months

or longer in advance of target dates for survey

 Once your application is completed, a surveyor

team will be assigned and dates confirmed

 A survey team leader will be in contact to

coordinate an agenda and plans for the survey

 Support staff in doing the work they routinely do so

 Celebrate your success!

 If there are areas for improvement, you may need

to submit documentation or a follow-up progress

report to JCI

 Maintain the momentum from your preparation and

survey Establish a system and process for ongoing

standards compliance and survey readiness

 Continue education