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Announcement of Changes to the JCI Hospital Accreditation Survey Process

Added on 22 February 2017 in General News

With the publication of the Joint Commission International Accreditation Standards for Hospitals, 6th edition, JCI Accreditation is implementing changes to the survey process in 2017. The intention of these changes is to encourage JCI-accredited organizations to pursue a more effective continuous compliance framework and to align more closely to the patient safety philosophy that lies at the core of JCI’s standards.

Revision of Accreditation Decision Rules

Currently, hospitals and academic medical center hospitals must meet the requirements of five decision rules in order to be accredited. The decision rules were recently reviewed and determined to need updating in order to maintain their relevance. As such, JCI Accreditation has made changes to these rules that will become effective 1 July 2017. Details of the changes will be reviewed at the 2017 JCI Accreditation Update education events and published in the Joint Commission International Survey Process Guide for Hospitals,6th edition, scheduled for release 1 April 2017. Decision rule changes are not planned for any other accreditation programs—such as ambulatory care, laboratory, or long term care—at this time.

Revisions to the Track Record or Look-back Period
Hospitals and Academic Medical Center Hospitals Undergoing INITIAL Surveys

JCI wants to encourage organizations that are starting on the JCI accreditation journey to be well prepared. These health care organizations should establish sustainable processes and systems that will enable them to be in continuous and robust compliance with JCI’s accreditation standards. As such, hospitals and academic medical center hospitals that will undergo their first survey on 1 January 2018 or later are required to have a six-month track record (increased from the current requirement of four months).

Hospitals and Academic Medical Center Hospitals Undergoing TRIENNIAL Surveys

Once a health care organization receives JCI accreditation, it should strive to implement policies, procedures, and processes that support continuous compliance with the standards as well as year-round data collection and recordkeeping. As such, beginning 1 January 2018, JCI Accreditation will begin actively informing all hospitals and academic medical center hospitals undergoing surveys that continuous compliance with the standards must be in place starting the day after their accreditation survey.

The intent is that for any survey conducted on or after 1 January 2021, JCI surveyors will be able to evaluate the performance of an organization and the effectiveness of its systems by looking as far back as the date of the organization’s previous survey. At that time, 1 January 2021, the current 12-month look-back period for triennial surveys will be retired.

If you have questions regarding this announcement, please contact your JCI Accreditation Account Executive or submit your questions via email to


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