The Joint Commission is a Chicago-based organization which accredits 15,000 hospitals in the United States. The Joint Commission International (JCI) is its subsidiary which accredits hospitals outside the U.S. As the medical travel trend grows, JCI accreditation is becoming an important benchmark for quality standards.

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JCI Frequently asked Questions
By Dr.Mahboob ali khan Phd
The Joint Commission is a Chicago-based organization which accredits 15,000
hospitals in the United States. The Joint Commission International (JCI) is its
subsidiary which accredits hospitals outside the U.S. As the medical travel trend
grows, JCI accreditation is becoming an important benchmark for quality
standards.
Patients are concerned about ensuring quality and safety when traveling
abroad for medical care. JCI accreditation sounds like a logical way of
screening unknown hospitals. Can you explain how JCI accreditation
ensures the consumer of quality and safety?
The need to focus on safety is at the center of all of JCI accreditation activities.
All accreditation standards support quality and safety efforts, whether a person
is seeking services from a JCI–accredited hospital, ambulatory care
organization, clinical laboratory, across the care continuum, at a medical
transport organization, or via a JCI–certified disease-specific care provider.
More specifically, standards related to safety and to reducing adverse events
provide a framework for helping to reduce the risk to and ensure the safety of
individuals who receive care, treatment, and services in a health care
organization.
Your question referred to a consumer’s ―screening‖ process, and to that point,
consumers ―screen‖ in the effort to avoid risking their good health in a
substandard health care facility. JCI accreditation is essentially a risk-reduction
activity. Compliance with JCI accreditation standards is intended to reduce the
risk of adverse outcomes and improve safety. JCI standards emphasize the need
to consider risks and to take action to reduce risks before an unwanted event
affects patients or staff. This focus on reducing risks to patients and staff can be
seen in both JCI’s patient-related standards and organization-related standards.
JCI is a subsidiary of the Joint Commission, which has accredited 15,000
U.S. hospitals. How do the international accreditation standards differ
from the U.S. standards?
Development of our international accreditation standards is actively overseen by
a global task force, whose members were drawn from each of the world’s
populated continents. Although many of the JCI standards are similar to those
of the United States–based Joint Commission, U.S. standards reflect many local,
state and national laws which do not apply internationally. JCI standards are
broader-based in order to respect country and cultural differences.

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With each revision, though—especially in the upcoming third edition of our
hospital standards, which will be published in July 2007 and enforced January
2008—international standards are becoming more challenging, rapidly closing
the gap between JCI and U.S. standards.
There are currently about 110 hospitals with JCI accreditation. Why are
there relatively few hospitals accredited by JCI? Is it because very few
hospitals in the world meet your standards? Or is it because the
accreditation process is expensive?
JCI’s hospital accreditation numbers are lesser than those of The Joint
Commission and there are two major reasons for the disparity:
First, JCI is in its infancy when compared The Joint Commission’s 56-year
tenure as an accrediting body. JCI launched its accreditation program in 1999
and has steadily built on its cadre of participating organizations each year.
We’re not where we want to be yet, but we’re comfortable that we’re moving
rapidly in the right direction.
Second, JCI accreditation is voluntary, not mandatory. Organizations choose
JCI accreditation not because they have to—it’s because they want to. Our
accredited organizations want an external quality evaluation model. They want
to bring the common understanding of key quality and patient safety concepts
such as good medication management, infection control, facility management,
community disaster planning, and other risk reduction strategies to their
organization. And, finally, they know that providing the highest quality and
safety of health services for their patients makes not only good management
sense, but good business sense.
What must a hospital typically do in order to get ready for an initial JCI
inspection? How long does it generally take to prepare for this?
We tell organizations that preparing for their initial JCI accreditation survey is
likely to take 12 to 24 months. Leaders who insist on setting an achievable time
frame communicate the importance of taking a steady, comprehensive approach
to accreditation. This approach seeks systems improvements that require
thoughtful analysis to establish, implement, and sustain. Organizations perform
a baseline assessment, measure the gap between their performance and JCI
standards, and then spend the ensuing months refining their policies and
procedures to make certain they are in compliance. Rushing through the
accreditation preparation misses the point that quality and safety standards must
become part of routine operations in order to have a meaningful, lasting impact
that improves quality and safety.

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Having said that, it is also important to note that once an organization has gone
through a survey and has been accredited by JCI, we encourage—and expect—
the organization to strive for continuous standards compliance; that is, to always
be ready for a survey. Organizations that are continually performing in the
patient’s best interests don’t have to prepare for a survey; they’re ready all day,
every day.
Renewal of accreditation is every three years. Are there any spot checks in
the interim?
There are no ―spot checks‖ in the truest sense of those words, but there are
reasons for JCI to return to an organization sooner than the triennial survey.
First, we have begun performing ―validation surveys‖ in all organizations
within 60 to 180 days of all initial or triennial re-surveys. These validation
surveys are free to an organization and do not impact the organization’s
accreditation decision, but they do provide JCI with immediate feedback on the
validity of the survey’s results.
Also, if during an organization’s survey we find standards not met, we will
respond by scheduling what we call a ―focused survey‖ for that organization. A
focused survey is exactly as it sounds—a concentrated examination of only the
areas in which an organization does not meet standards. If, in the view of the
JCI Accreditation Committee, the organization’s performance during the
focused survey meets standards, the organization is then deemed accredited.
Does JCI collect safety data (mortality rates, hospital acquired infections,
etc.) for international hospitals, benchmarked to U.S. averages? If not, does
any other organization collect such information so that consumers can
check the track record of an international hospital?
We do collect data and we intend to do even more collection in the future. JCI
introduced the Hospital Quality Indicator project in January 2006 in response to
accredited hospitals expressing an interest in performance measurement to
support quality improvement efforts and to provide a valid base for local,
national, and international comparisons. This initiative focuses on data
collection for seven standardized performance indicators currently in use in the
United States:
For Acute Myocardial Infarction:
Measure 1. Aspirin at Arrival
Measure 2. Aspirin Prescribed at Discharge
Measure 3. Angiotensin Converting Enzyme Inhibitor or Angiotensin Receptor
Blocker for Left Ventricular Systolic Dysfunction

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Measure 4. Beta Blocker Prescribed at Discharge
Measure 5. Beta Blocker at Arrival
For Heart Failure:
Measure 1. Left Ventricular Function Assessment
Measure 2. Angiotensin Converting Enzyme Inhibitor or Angiotensin Receptor
Blocker for Left Ventricular Systolic Dysfunction
Measures are assessed for interpretability, applicability, and usefulness to the
international community, feasibility of data collection, data collection effort,
and overall resource use. In addition to indicator evaluation, assessment of the
potential limitations related to electronic data transmission, preferences for data
feedback mechanisms, expectations regarding support services, and data use by
JCI in accreditation activities are also being addressed. Evaluation findings are
being used to assist in planning for a voluntary, automated, standardized
indicator set.
Accredited hospital organizations, which volunteer to participate, collect
indicator data using tools provided by JCI. These tools include a data dictionary,
data elements, and Indicator Information Forms for the seven indicators.
Although these data are not currently available to the public, we envision a
future public-reporting scenario similar to The Joint Commission’s Quality
Check Web portal, which provides public access to United States hospitals’
performance on The Joint Commission’s National Patient Safety Goals and
National Quality Improvement Goals. The latter goals allow hospitals to report
quarterly on key quality of care indicators in up to five treatment areas: heart
attack, heart failure, community acquired pneumonia, pregnancy and related
conditions, and surgical infection prevention.
In your presentation, you mentioned that JCI has a policy about “truth and
admission.” Could you elaborate?
Patient safety has made significant strides in some parts of the world during the
past 10 years, thanks to a willingness to acknowledge that adverse events occur
in health care and that a systematic approach must be employed to reduce the
very real risk of patient harm. We feel that honesty from all parties—caregivers,
patients, and patients’ families—is an essential aspect of safe heath care. Just as
caregivers expect patients to provide honest answers in order to discern the
proper course of the patient’s care, patients and their families have the right to
honest communication with caregivers to help the patients or loved ones make
informed decisions.

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There is a growing body of research indicating that patients and families will
forgive medical errors more readily if the caregiver will admit them. Likewise,
with increased public reporting of medical errors—in the United States, The
Joint Commission has required its accredited organizations to report their
adverse events since 2001, which are then compiled into what is called the
Sentinel Event Database—and infection control data and the like, there is a
positive trend toward more open and honest communication between caregiver
and patients. We agree wholeheartedly, and our standards reflect this. One JCI
hospital standard states that the hospital must inform patients and families about
how they will be told about the outcomes of care and treatment, including
unanticipated outcomes, and who will tell them. With that sort of
communication model in place, patients and families can be assured that they
From a consumer’s (or patient’s) standpoint, what is the difference
between JCI accreditation and other accreditations, such as ISO? As long
as a hospital has some sort of accreditation, is that a reasonable assurance
of quality and safety?
ISO is not truly a health care accreditation body; it is more of a federation of
national standards bodies. While concepts within ISO requirements may apply
to health care, many of the concepts do not easily apply, especially to the
clinical aspects of health care. ISO requirements are more focused on
manufacturing, and ISO standards concentrate on adhering to a specified
process of quality management designed to consistently produce a product (or
service) that meets pre-established specifications and on assessing that
conformity.
Although I think it’s safe to say that some sort of accreditation is better than
none, we are convinced that JCI’s accreditation process provides the best
organizational available path to health care excellence.
What is the function of JCI’s Center for Patient Safety?
The Joint Commission International Center for Patient Safety (ICPS) is virtual
organization that allows The Joint Commission, JCR, and JCI to further its
patient safety mission: to continuously improve patient safety in all health care
settings.
The Center’s Web site is a valuable online resource for health care
professionals, patients, and their families. Nearly 1,000 articles and Web links
covering topics ranging from adverse events and product safety to the National
and International Patient Safety Goals are available for download, free of
charge. A monthly electronic newsletter, Patient Safety Links, is available at no
cost to subscribers.

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The Center is also the operational arm for the World Health Organization
(WHO) Collaborating Centre on Patient Safety, the world’s first such
organization dedicated solely to patient safety. The Collaborating Centre
focuses worldwide attention on patient safety solutions and best practices with
the intent of reducing safety risks to patients, and it helps coordinate
international efforts to share, develop, and disseminate these solutions as
broadly as possible.
Tell me more about JCI's collaboration with the WHO?
Since its launch in August 2005, the WHO Collaborating Centre for Patient
Safety has been building an international network to identify, evaluate, adapt
and disseminate patient safety solutions worldwide. The Collaborating Centre is
identifying existing solutions that would be applicable to a wide variety of
countries and health-care settings.
Patient safety solutions are any system design or intervention that has
demonstrated the ability to prevent or mitigate patient harm stemming from
health care processes. Solutions disseminated by the Collaborating Centre will
be evidence-based, and presented in a standard format.
In order to facilitate the accurate identification of solutions and the adaptation of
solutions to different needs, an international steering committee composed of
recognized leaders and experts in patient safety was convened. At the inaugural
meeting of the International Steering Committee in June 2006, the following
nine solutions were prioritized for further development:
1. Look-alike/Sound-alike Medications
2. Patient Identification
3. Hand-Off Communication
4. Wrong Site, Wrong Procedure, Wrong Person Surgery
5. High-Concentration Medications
6. Medication Reconciliation
7. Catheter and Tubing Misconnections
8. Needle Reuse
9. Hand Hygiene
Three Regional Advisory Groups were also established to review the priority
draft solutions and provide feedback on how the solutions need to be adapted
for different regions of the world. A large international field review via
electronic survey was undertaken to determine the relevance, adaptability,
feasibility, and barriers to acceptance of the solutions in different regions of the

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world. The field review audience includes leading patient safety entities,
accrediting bodies, Ministries of Health international health professional
associations, and WHO and Joint Commission International network of
contacts. The target date for dissemination of the initial set of Solutions is May
2007.
Another one of the exciting programs spawned through the WHO Collaborating
Centre on Patient Safety is the ―Action on Patient Safety (High 5s) Initiative," a
seven-country collaborative project that leverages the implementation of five
standardized patient safety solutions to prevent avoidable catastrophic events in
hospitals. The overall goal of the initiative is to achieve significant, sustained,
and measurable reduction or elimination of five highly prevalent patient safety
problems in selected hospitals worldwide over a five-year period—hence ―High
5s.‖
The initiative builds on the partnership established by the Commonwealth Fund
with Australia, Canada, New Zealand, the United Kingdom, and the United
States of America, and the more recent expansion of this international program
to include Germany and The Netherlands.
The solution areas selected for the High 5s initiative were drawn from a broader
set of patient safety solutions that are being developed by the WHO
Collaborating Centre for Patient Safety for distribution to all of the WHO
member nations later in 2007. These include:
1. Prevention of patient care hand-over errors
2. Prevention of wrong site/wrong procedure/wrong person surgical errors
3. Prevention of continuity of medication errors
4. Prevention of high concentration drug errors
5. Promotion of effective hand hygiene practices
The Collaborating Centre will work with the participating countries to refine the
current draft solutions through the development of standardized operating
protocols similar to those used in high reliability industries such as aviation and
nuclear energy.
We are excited about the innovative programs we have developed with WHO to
date and we are open to more such alliances with WHO in the future.

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Can you explain what ISQua is, and how your role there relates to JCI?
ISQua is The International Society for Quality in Health Care, and, simply put,
is the ―accreditor’s accreditor.‖ I’m proud of my role with ISQua and am so
convinced of that organization’s value to the health care quality issue that JCI is
currently undergoing ISQua accreditation. ISQua’s mission and ours are
similar—excellent health care delivery for everyone—and we support that
undertaking completely.
International Accreditations
"Driven by the rise in medical tourism, Asian healthcare organisations are fast
embracing international accreditations and the awareness level is on the rise.
Joint Commission International (JCI), the leading international accreditation
body, has emerged as the gold standard in this area. It has already accredited 30
hospitals in the Asian region. JCI has also set up its first international office in
Singapore recently.
1. What has been the response so far from Asian Hospitals to your
accreditations? How do you view the demand for accreditations from Asia
going forward?
I think the response so far has been very strong in Asia. Driven by the response
JCI is opening its first Asia Pacific regional office in Singapore. Also, the
hospitals are keenly interested in learning about issues like quality
improvement, patient safety, Infection control or looking at how they can
improve their care, for example, in the area of disease management, so the
response really is strong. A recently held five-day practicum at Singapore was
fully booked about six weeks in advance! This shows that there is a very strong
interest in education about quality standards in Asia. Going forward, I think the
demand for accreditations will continue to be very strong. For one thing it’s
such a huge region and there is a lot of activity - both at the public and private
healthcare centres. And as we know, interest in healthcare tourism has really
sparked off an interest in looking at some kind of distinction amongst hospitals.
I think that the interest in accreditation will only continue to rise in the future.

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2. Is your strategy for tapping the Asian market different from that for
other markets in developed countries such as USA?
Asia, as I mentioned earlier, is a very broad and diverse region. In terms of
strategy, JCI has just tried to be responsive to organizations that have expressed
interest in some way working with us. It could be that they are interested in
accreditations – this could be on a national level as well. For example, on July
31, 2006 JCI signed a memorandum of understanding with the government of
China to work together in areas such as accreditations, quality improvement,
patient safety and standards. Again, we have a very strong relationship with the
Ministry of Health in Singapore and with some private associations in India. In
Hong Kong the government’s priorities are, looking at infection control and
readiness for hospitals to handle major disease outbreaks, there may be very
different issues for example in Malaysia and other countries.
I think we try to respond to the needs of the region. It’s often at a country level
dealing with issues that may be going on over there.
3. Do you think that the accreditations accorded to a few hospitals in the
region, should generate peer pressure among the hospitals in the region?
Well, I think that has already happened. In the unfolding of that scenario, JCI
has been more of an observer. I think it is certainly true that almost any where
in the world now, including the United States, healthcare is a very competitive
market and as I mentioned before, particularly in the area of health tourism,
where a hospital may be interested in attracting patients from outside its local
market, definitely an accreditation is a way to distinguish for a hospital. Also a
part of the competition is looking at working with multi-national corporations.
For example, some large multi-national corporations are very interested in
knowing where they should be sending their employees around the world for
treatments.
4. What do you think about the incentives being offered by many American
companies for getting treated in low-cost destinations like those in Asia?
There is sort of a growing movement among US companies. It is still relatively
small.

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5. What are the key pre-requisites for a hospital to get accredited
successfully and retain it then on?
Well, one is that the hospital needs to have high level of commitment at the
leadership level. I think that is perhaps the most important variable for a
hospital to be able to be accredited. And the hospitals should also subject their
processes to a very critical self-evaluation. They may break those processes up
in terms of patient care or the safety of the facility or information management,
but the standards really look at the overall framework of almost every aspect of
the hospitals operations. So, it has to be the whole organization. It can’t just be
one person or one department (the quality department) that’s told to look at this
accreditation. This is something that ensures that the accreditation is sustained.
And that starts with the leadership.
6. Given the industry demographics of the Asian hospitals (most of which
are in the developing nations), do you think it is worthwhile for a mid-size
Asian hospital to go for accreditation in cost-benefit terms?
That’s probably an individual decision for each hospital. But I have seen it in
organizations with limited resources that JCI accreditation is still achievable and
reach the standards. The way JCI has designed the standards we want it to be a
very high level of care, but that could be how the organization meets the
standards could allow some creativity. And I think ultimately by improving care
and, for example, by reducing risks for patients it is a benefit in terms of cost
benefit ratio. For example, there will be lower infection rates, better retention of
staff, a general reduction in errors. That is also something that over a period of
time we would like to study to see the specific improvements going forward
with an organization. It would certainly be worthwhile in the long term for a
smaller organization to be accredited.

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7. What changes did Asian hospitals experience post-accreditation?
The difference is not so much to get the accreditation award, that’s the final step
of the journey, but for the organization overtime. It takes about one to two years
for an organization to become accredited. We have seen that the accreditation
has made a lot of difference in terms of important aspects of care. Some of the
feedback that we have got from hospitals in Asian region – and this is true about
the hospitals around the world –is significant reduction in medication errors,
reduced infection rates in hospital-acquired infections, improved pain
management, and also a much developed system of assuring the competence
level of the staff.
It’s interesting to note that some organizations have reduced medication errors
by almost 75% to 80 %. That obviously translates into a better patient
experience.
8. What challenges do hospitals face while preparing for accreditation and
post accreditation?
I think it is important to be aware of what it takes to do this. It is not just ―we’ll
get ready for getting the accreditation‖ and then getting back to business as
usual. It is really about transforming an organization and its processes. To really
implement the processes and the policies, staff training is needed to ensure that
this is sustained and I think the organizations that do this well really get to see a
huge difference in the way they manage their hospitals. And this is a challenge;
I mean that’s not something that is so easy to do. It takes strong commitment
from the top management and particularly for some of the physician leaders.
The physicians especially need to be very much on board with the entire
process.
But while the top management needs to be fully committed, the role of the other
staff cannot be ignored. We believe that their role is absolutely essential
because so many of the standards touch on aspects of the patient rights,
infection control, patient assessment and that’s actually by design –the way we
have set up the standards. It is not like chapters of what nurses do or the staff
does. It really is about taking a patient outward approach. And that is going to
impact anybody who is involved in the running of the hospital or whose work
interfaces with the patient’s stay at the hospital.

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9. What effect does the implementation of accreditation standards has on
the staff?
What we have heard from the organizations around the world, especially if this
is done in a very positive way, as something like the entire organization is
striving for, is that this can be enormously inspiring for the organization and
they can take a lot of pride in things like team building. Again it’s the role of
leadership to make it that way, and not really doing it because somebody else is
doing it but because we think that it’s the right thing to do.
10. What is your message to the hospital directors of Asia?
We strongly believe that accreditations have been a very valuable organizing
framework for looking at quality and patient safety and it demonstrates
commitment to international standards to improve healthcare quality and patient
safety. And JCI would encourage hospitals to go for the JCI or any other
accreditation program and to really look at it as a management tool to monitor
the operations on an ongoing basis. JCI would like very much to work with the
hospitals in Asia in a supportive way and help them to understand the standards
and help them to implement them by providing more education in the region
which was emphasized by the Singapore Practicum with more to follow in
countries like India, China and elsewhere in the region.