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How to Get Started
with JCI Accreditation
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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6333147 how-to-get-started-with-jci-accreditation

  • 1. How to Get Started with JCI Accreditation
  • 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