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.

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