A Proven Pathway to Accreditation
Here are 12 steps that health care organizations typically follow toward accreditation success.
Become familiar with JCI’s accreditation standards and fundamentals of the accreditation process, which you need to know before you begin.
- Become familiar with JCI’s policies and procedures
- Review the JCI Hospital Accreditation Manual and Survey Process Guide
- Share start-up information with your team
Tools to understand JCI basics:
*The use of Joint Commission International (JCI) advisory services is not necessary to obtain a Joint Commission International Accreditation award, nor does it influence the granting of such awards.
Leadership engagement in accreditation is vital from the start.
Identifying accreditation leaders as well as other steps to launch the accreditation preparation process helps ensure that there is organization buy-in at all levels.
Tools to select and prepare accreditation leaders:
Accreditation requires collaboration, communication, a culture of safety, change management, and continuous improvement.
Tools to commit to the central components of accreditation:
Chapter teams focus on specific chapters of the JCI standards manual.
Choosing your teams and getting them ready for the next steps in accreditation preparation will promote accountability, create a sense of ownership, and improve overall staff engagement.
Tools to organize and educate chapter teams:
Policies guide the care, treatment, and services you provide.
Creating, implementing, monitoring, and maintaining policies in an effective way that also meets JCI standards will help you sustain compliance.
- Develop a process to create JCI-compliant policies
Tools to develop and manage policies:
Most organizations have many and varied policies.
Bringing them all together for review and standardization will help assess your organization’s baseline compliance.
Tools to collect and evaluate policies:
Tracers are a primary tool for risk assessment and gap analysis.
JCI has resources to help you understand what they are and explain the activities and skills involved in conducting them.
Tools for understanding tracer methodology:
A critical part of accreditation preparation is finding the gaps between your current practice and what JCI requires.
JCI can help you plan and carry out that activity, including categorizing the types of gaps you find.
Tools to find and analyze gaps:
Knowing how to manage data is necessary to be able to assess quality and patient safety.
Data collection, display, and analysis plays a critical role in continuous quality improvement.
Tools to leverage data for continuous improvement:
Every organization needs action plans that outline how to address issues found in the initial gap analysis.
JCI can help you find possible strategies to try.
- Build your accreditation action plan that outlines intended actions towards performance improvement
Tools to develop and implement action plans:
Most of your accreditation preparation will involve monitoring, modifying, and documenting action plans to ensure improvement and compliance.
- Assess your hospital’s risk for adverse events and create a method for collecting information
- Use your accreditation team to spot deficiencies using tools from the Survey Process Guide for Hospitals
- Encourage staff to make corrections
Tools to improve and document standards compliance:
As your survey date approaches, you want to be ready.
You need to understand the final few things you need to do for a successful survey — and what you may need to do after the survey is over.
- Prepare your staff for a mock survey*
- Conduct your final mock survey 4-6 months before your actual survey to ensure time to resolve non-compliance issues
- Spot necessary improvements by identifying areas of noncompliance
- Plan and make final preparations
Tools for planning and finalizing survey readiness:
*The use of Joint Commission International (JCI) advisory services is not necessary to obtain a Joint Commission International Accreditation award, nor does it influence the granting of such awards.