How to Get Started

with JCI Accreditation

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

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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

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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

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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
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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

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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

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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

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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

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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
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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!

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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)

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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

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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

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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

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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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