THE JOINT COMMISSION INTERNATIONAL-IMPLEMENTATION

AND ACCREDITATION IN HEALTH CARE SERVICE

ORGANISATIONS* Dr.K.Ravichandran, Chair Person, School of Business

Studies,

Madurai Kamaraj University, Madurai, India

**Dr.Karthick Prasanna, Senior Operations Manager, Corniche

Hospital,

Abu Dhabi,UAE

Introduction

Across the world, the external assessment of health care

services is being increasingly used to regulate, improve and

promote health care services. The external quality review of

hospitals plays an important role not only in protecting

patients from such harm, but also in complementing the

hospitals’ own internal quality efforts.

Developed countries have a growing experience in pursuing

accreditation as a tool to improve quality, whereas

developing countries are still striving to introduce this

concept and adapt it to their particular situations. Some

basic principles for a health services accreditation system

have been founded at the international level. First, it is

voluntary; second, standards are clearly defined; third,

compliance is assessed by periodic external review by health

professionals; and fourth, the outcome of the review denotes

compliance (yes/no, rating scale). In addition,

accreditation is awarded for a time-limited period, and the

whole process is generally independent of the financing

system. Besides its basic purpose of assessing hospitals’

compliance with standards, a hospital accreditation

programme may play an educative, consultative and

informative role, and provides a platform for continued

dialogue among various stakeholders.

Implementing the exacting standards of accreditation is

usually a tough task to begin with. With so many standards

to deal with, there is a need for meticulous planning and

thorough implementation, which involves active participation

of all the employees. As the process aims to influence the

functioning of the organisation itself, change management –

the process of generating a buy in by all, attains utmost

importance prior to implementation. “Organizations that do

this well really get to see a huge difference in the way

they manage their hospitals”, claims Rooney.

What is accreditation?

Accreditation is a process in which an entity, separate and

distinct from the health care organization, usually

nongovernmental, assesses the health care organization to

determine if it meets a set of requirements (standards)

designed to improve the safety and quality of care.

Accreditation is usually voluntary. Accreditation standards

are usually regarded as optimal and achievable.

Accreditation provides a visible commitment by an

organization to improve the safety and quality of patient

care, ensure a safe care environment, and continually work

to reduce risks to patients and staff. Accreditation has

gained worldwide attention as an effective quality

evaluation and management tool. Comprehensive accreditation

addresses all dimensions of healthcare delivery viz.APPROPRIATENESS, AVAILABILITY, CONTINUITY, EFFECTIVENESS,

RESPONSIVE & CARING, SAFETY AND RISK MINIMISATION and TIMELINESS.

Thus it is a mechanism to meet the challenges while

bestowing all round benefits. All accreditation systems aim

for the optimal, which is continually updated and improved

by constantly benchmarking with the possible and attainable.

And this is what makes it so successful.

What are the benefits of accreditation?

The accreditation process is designed to create a culture of

safety and quality within an organization that strives to

continually improve patient care processes and results. In

doing so, organizations

improve public trust that the organization is concerned

for patient safety and the quality of care;

provide a safe and efficient work environment that

contributes to worker satisfaction;

negotiate with sources of payment for care with data on

the quality of care;

listen to patients and their families, respect their

rights, and involve them in the care process as

partners;

create a culture that is open to learning from the

timely reporting of adverse events and safety concerns;

and

establish collaborative leadership that sets priorities

for and continuous leadership for quality and patient

safety at all levels.

What is JCI?

Joint Commission International (JCI) is an extension of

Joint Commission for the Accreditation of Healthcare

organizations (JCAHO). JCAHO is a body that accreditates

more than 90% of healthcare organisations in the United

States. JCI accreditation standards are based on

international consensus standards and set uniform,

achievable expectations for structures, processes and

outcomes for hospitals. (JCI) helps organizations worldwide

improve patient safety and quality of care through

comprehensive consulting services, international

accreditation, educational programs, multimedia resources

and publications. JCI has extensive international experience

working with public and private health care organizations

and local governments in more than 80 countries.

Why JCI accreditation?

JCI is a “Big Brother” of other accreditation bodies and

arguably the best known accrediting body in health care

today. JCI’s standards for hospitals clearly define the

principles and processes needed to assess the key functions

of healthcare settings. Among the various international

accreditations available, the one awarded by JCI, the

international arm of the US-based accreditation body Joint

Commission on Accreditation for Healthcare Organisations

(JCAHO) has become very popular.

JCI standards make sure the ‘right person’ is in the ‘right

place’ at the ‘right time’ doing the ‘right thing’. In

short, it means that we are giving our patients the best and

safest care possible. High standards, wide scope and

rigorous process of evaluation have made JCI accreditation a

‘gold standard’ in hospital accreditation. Already, as many

as 30 Asian hospitals have got themselves accredited. And

this number is only going up. India, so far has 9 accredited

hospitals with a few others preparing for it. There are 13

hospitals in UAE got accreditation so far.

What are the JCI standards?

The accreditation process for any hospital, the

accreditation process represents bringing about a

significant change in the way it functions. A comprehensive

accreditation, such as that of JCI, needs to be implemented

organization-wide, with the involvement of all the employees

who take part in the patient’s journey from admission to

discharge. In JCI, third edition has been introduced

effective from January 2008 and updated in February in which

there are 13 chapters of standards that lead organisations

to best practice levels. These standards are further divided

into measurable parameters, which focus on aspects such as

patient safety, patient rights, facilities, and physicians’

credentials besides policies and procedures of the

organisation. To get accredited a hospital will have to

fully meet most of these parameters and the remaining ones

at least partially. The JCI accreditation is valid for 3

years and has to be renewed on a regular basis.

There are 13 chapters to the standards: 3rd Edition

Patient-Centered Standards

1. Access to Care and Continuity of Care

2. Patient and Family Rights

3. Assessment of Patients

4. Care of Patients

5. Anesthesia and Surgical Care

6. Medication Management and Use

7. Patient and Family Education

Health Care Organization Management Standards

8. Quality Improvement and Patient Safety

9. Prevention and Control of Infections

10.Governance, Leadership, and Direction

11.Facility Management and Safety

12.Staff Qualifications and Education

13.Management of Communication and Information

PURPOSE OF A SURVEY

An accreditation survey assesses an organization’s

compliance with JCI standards and their intent statements.

The survey evaluates the organization’s compliance based on

interviews with staff and patients and other verbal

information;

on-site observations of patient care processes by the

surveyors;

policies, procedures, and other documents provided by

the organization; and

results of self-assessments when part of the

accreditation process.

The survey is a key to accreditation. The JCIA

accreditation process seeks to assist organizations in the

identification and correction of problems and improve the

quality of care and service(s) provided. In addition to

evaluating compliance with standards and their elements of

performance, significant time is spent in consultation and

education. JCIA expects hospitals to be in compliance with

ALL Core Standards, ALL of the time.

SURVEY PROCESSS AND SCORING

A JCIA accreditation survey provides an assessment of an

organization’s compliance with standards and their elements

of performance. JCIA evaluates an organization’s compliance

based on:

Patient and staff interviews via “tracer methodology”

about actual practice at Al Corniche Hospital.

Performance improvement data/trends.

Verbal information provided to JCIA.

On-site observations by JCIA surveyors.

When conducting an accreditation survey, JCI seeks to

evaluate the organization’s compliance with the applicable

standards and to score those standards based on performance

throughout the organization over time (for example, the

preceding 12 months for a triennial re-survey or the

preceding four months for an initial survey).

Joint Commission surveyors are experienced nurses,

physicians, and administrators. They are keenly aware of

their roles as outside reviewers responsible for documenting

compliance with Joint Commission standards. But they seek to

carry out that role more as peer reviewers than as enforcers

or regulators. In interacting with hospital staff, they

strive to foster a collegial atmosphere characterized by a

joint interest in improving hospital performance.

It follows, therefore, that surveyors view education as a

central part of their mission. Well-versed in the Joint

Commission standards, they tend to be ambassadors of those

standards, helping hospital staff to understand their intent

and significance. Beyond that, they also use the survey as a

way of informing hospitals about promising approaches they

have found at other hospitals, even providing the names of

individuals to contact.

The Joint Commission uses a standard agenda in surveying

hospitals. In 2 to 5 days, depending on hospital size,

surveyors conduct dozens of individually scheduled sessions

that cover the major aspects of a hospital’s operations (see

appendix A for a sample agenda). The survey pace is rapid,

typically allowing 45 to 60 minutes for each meeting or

patient care visit before moving on to the next visit. A

few 15-minute intervals might be allotted each day as

unscheduled for surveyors’ personal time or phone calls.

Everyday morning, surveyors summarize their previous day

observation to the group of hospital management.

The survey provides surveyors with a general overview of the

hospital. It facilitates standardized assessments across

facilities and protects against inconsistencies or the

special interests of individual surveyors. Also, because the

schedule, which hospitals receive in advance, spells out

exactly which surveyor will be where over the course of the

survey, individual departments can prepare by having

everyone ready for the surveyor and the area cleaned and

organized. The packed agenda, however, affords few

opportunities for surveyors to develop hunches, follow

leads, or even respond to complaints. Racing from session to

session, surveyors have little time to probe deeply.

Outcomes of Accreditation Surveys

The Accreditation Committee of JCI makes accreditation

decisions based on the findings of the survey. An

organization can receive one of the following two

accreditation decisions:

Accredited: An accreditation decision that results when an

organization demonstrates

acceptable compliance with each JCI standard (a score

of at least “5” on each standard);

acceptable compliance with the standards in each

chapter (an aggregate score of at least “7” for each

chapter);

overall acceptable compliance (an aggregate score of at

least “8.5” on all standards); and

acceptable compliance with all International Patient

Safety Goals (a score of at least “5” on all goal

requirements).

Accreditation Denied: An accreditation decision that results

when an organization is consistently not in compliance with

JCI standards and International Patient Safety Goals,

including one or more standards scored less than a “5”;

an aggregate score of less than “7” for each chapter;

an aggregate score of less than “8.5” on all standards;

one or more International Patient Safety Goal

requirements is scored a “0”;

a required follow-up focused survey (also see Glossary)

has not resulted in acceptable compliance with the

applicable standards and/or International Patient

Safety Goal requirements;

when JCI withdraws its accreditation for other reasons;

or

when the organization voluntarily withdraws from the

accreditation process.

Accreditation Decision Process

The final accreditation decision is based on an

organization’s compliance with JCI standards. Organizations

do not receive a numeric score as part of the final

accreditation decision. When an organization successfully

meets the JCI requirements, it will be awarded an

accreditation decision of “Accredited” via JCI’s Official

Accreditation Survey Findings Report. This decision

indicates that an organization is in compliance with all

applicable standards and International Patient Safety Goals

at the time of the on-site survey or has successfully

addressed all survey requirements for improvement in its

written progress report within 60 days after survey for re-

surveys, or within six months for initial surveys.

Length of Accreditation Awards

An accreditation award is valid for three years unless

revoked by JCI. The award is retroactively effective on the

first day after JCI completes the organization’s survey or,

when follow-up is required, completes any focused surveys.

An organization’s accreditation is not automatically renewed

after three years. Rather, an organization seeking to

continue its accreditation must again undergo a full

accreditation survey, resolve any follow-up conditions, and

again be found to be in satisfactory compliance with the

standards and International Patient Safety Goals.

International Patient Safety Goals

The purpose of the International Patient Safety Goals is to

promote specific improvements in patient safety and has been

introduced effective from January 2008.

The goals highlight problematic areas in health care and

describe evidence- and expert-based consensus solutions to

these problems. Recognizing that sound system design is

intrinsic to the delivery of safe, high-quality health care,

the goals generally focus on system-wide solutions, wherever

possible.

The goals are structured in the same manner as the other

standards, including a standard (goal statement), an intent

statement, and measurable elements. The goals are scored

similar to other standards as “met,” “partially met” or “not

met.” The Accreditation Decision Rules consider compliance

with the International Patient Safety Goals as a separate

decision rule.

Affordability

Affordability and resources are the key factors in the JCIA

implementation process. While the benefits of international

accreditation are quite attractive, the fact is that

accreditations such as JCI’s could be very expensive for a

majority of medium-to-smaller hospitals in the region. A JCI

accreditation would cost a hospital approximately US$

100,000 and this does not include the expenses incurred for

upgrading its facilities. The Apollo Indraprastha Hospital

in New Delhi, India – first hospital in India to get the JCI

accreditation – spent close to Rs. 30 crore (US$ 600,000

approximately) to upgrade its facilities. Medium-sized

hospitals may not have such financial muscle!

The benefits are multi-fold. Both the healthcare provider

and customer stand to gain if an organization complies with

the standards. The benefits that ensure accreditations

include better care for the patients, a customer-centric

approach, improved branding as a result of increased

confidence within the community, high employee morale and

continuous monitoring of standards. Over a period of time

the hospital would experience cost reductions as efficiency

go up and more is achieved through less effort. Medical

errors that cost hospitals thousands of dollars every year

could be reduced as well. The final beneficiaries would be

the patients since the new processes would be designed to

meet their requirements and they have access to the best

treatment. Says Rooney, “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.” Further, as processes get streamlined and

designed around the patient needs, there is also a better

chance for the hospital to provide evidence-based medicine

to their patients.

CONCLUSION

Unquestionably, the Joint Commission is the central force in

the external review of hospital quality. However some

debates are going on whether Accreditation improves quality

and safety of the healthcare. Achieving accreditation does

not guarantee that care is optimal. In general,

Accreditation process is focusing on establishing a

framework and foundation for consistent quality practice.

However, the introduction of key performance indicators will

reflect more directly the quality of hospital care delivery.

The sustainability of the programme depends to a great

degree on the commitment of hospitals and their sense of

ownership. A general re-education of health professionals

and the community towards creating an inherent culture of

quality improvement is still needed in developing countries.

Sample Accreditation Survey Agenda

JOINT COMMISSION INTERNATIONALAccreditation Survey Agenda

Name of the HospitalDate

DAY ONE, (Date)Time Physician

NameNurse

NameAdministrator

Name

08:00 -08:30

Opening Conference

08:30 –09:00

Hospital’s Overview of Organizational Structure (Orientation toOrganization)

09:00 –11:00

Document Review

11:00 -12:00

IndividualPatient Tracer

Individual PatientTracer

Facility Tour

12:00-13:00

Lunch and Tracer PlanningSurveyors will eat alone as this time is used for planning..

13:00 –16:00

IndividualPatient Tracer

Individual PatientTracer

Facility Tour

16:00-17:00 Surveyor Resolution/Document Review/ Planning Time

DAY TWO, (Date)Time Physician

NameNurse

NameAdministrator

Name

08:00 –09:00

Daily Briefing(Time for surveyors to share with the organization observations

of the day before)

09:00 -10:30 Individual

Patient TracerIndividual Patient

Tracer Facility Tour continued

10:30 -12:00 Individual

Patient Tracer Individual Patient

Tracer

Facility Tour continued (if needed)

orIndividual Patient Tracer

12:00 -13:00

Lunch and Tracer PlanningSurveyors will eat alone as this time is used for planning.

13:00 –16:00

IndividualPatient Tracer

Individual PatientTracer

Review of FacilityManagement and Safety

Documents

16:00-17:00

Surveyor Resolution/Document Review/ Planning Time(No organizational preparation required for this time. Surveyors will meet alone)

DAY THREE, (Date)Time Physician

NameNurse

NameAdministrator

Name

08:00 –09:00

Daily Briefing(Time for surveyors to share with the organization observations of

the day before)

09:00 -10:30

Individual PatientTracer

Individual PatientTracer

orParticipate in DataUse System Tracer

Data Use System Tracer (Hospital may present a brief presentation on an improvementproject. Presentation islimited to 20 Minutes.)

10:30 –12:00

Staff Qualifications &Education Interviewfor Medical Staff

Staff Qualifications & │Staff Qualifications & Education Interview │ Education Interview for Nursing Personnel │ for Other Staff

12:00 -13:00

Lunch and Tracer PlanningSurveyors will eat alone as this time is used for planning.

13:00 –15:00

Medication Management System Tracer

Individual PatientTracer

or Participate in Medication Management System Tracer

Individual Patient Tracer

15:00 -16:30

Individual PatientTracer

Infection ControlSystem Tracer

Closed Medical Record Review

16:30 -17:00

Surveyor Resolution/Document Review/ Planning Time(No organizational preparation required for this time. Surveyors

will meet alone)

DAY FOUR, (Date)Time Physician

NameNurse

NameAdministrator

Name

08:00 –09:00

Daily Briefing

09:00 -10:30

Individual PatientTracer

Individual PatientTracer

Individual PatientTracer

10:30 –12:00

Leadership Session (all surveyors together)

12:00 -13:00

Lunch Surveyors will eat alone.

13:00 –15:00

Integrate Findings(Surveyors Only)

15:00-16:00

Exit Conference(Leaders can decide who participates in this session, the size

of the group is not limited)

REFERANCES

1. www.jointcommisioninternational.com

2. JCIA Standards 2nd & 3rd Edition

3. The Impact Of Hospital Quality-Related Practices On

Health Outcomes .

4. Eastern Mediterranean Health Journal, Vol. 13, No. 1,

2007

5. World Development Report. Investing in Health.

Washington DC, World Bank, 1993.

6. Shaw CD. Toolkit for accreditation pro-grams.

Australia, International Society for Quality in Health

Care, 2004.

7. Nandraj S et al. A stakeholder’s approach towards

hospital accreditation in India. Health policy &

planning, 2001, Suppl. 2:70–9.

8. Eastern Mediterranean Health Journal, Vol. 13, No. 1,

2007

9. Asian Hospital & Health Care Management Publication.

Nov 2006