Pathway to JCI Accreditation for Hospitals

Your partner in accreditation success

Join the elite group of over 800 organizations that have achieved Joint Commission International (JCI) accreditation and earned the Gold Seal of Approval^® in quality and patient safety. Achieving JCI accreditation can have a profound impact on your performance, culture, image, and business operations.

800+ Accredited
Organizations

100+ Countries
Served by JCI

Organize your activities. Monitor your progress.
Change the order or timing to match your journey.

A proven pathway to accreditation

Here are 10 steps that hospitals and academic medical centers typically follow toward accreditation success.
Average duration 18-24 months.

Step 1 Start-up

Become familiar with JCI's accreditation standards and survey process

Duration: 2-3 months

A male doctor with glasses gazing off image while contemplating.

Become familiar with JCI's accreditation policies and procedures

Checkmarked The most current accreditation policies and procedures are posted on JCI's website. Review these documents as soon as possible in your accreditation journey.

Follow this link to review JCI's policies and procedures.

Review the JCI Hospital Accreditation Manual and Survey Process Guide

Checkmarked The English version of the JCI Hospital Accreditation Manual 6th Edition is available for purchase. Translations of the manual in various languages will be available in mid to late 2017. The JCI Survey Process Guide for Hospitals 6th Edition, which details how to prepare for what will happen during a JCI on-site survey, will be available in April 2017.

Follow this link to purchase the JCI Hospital Accreditation Manual in your language.

Excite your leadership

Checkmarked Supportive leadership is vital to successfully achieving Joint Commission International Accreditation.

Click to view a pdf about how JCI accreditation can benefit your organization

Share start-up information with your team

For us, selecting JCI as our accrediting body was an obvious choice. JCI remains the undisputed gold standard in international accreditation. The standards are frequently updated and are attuned to an international audience, which is very essential to us.

Rana M. Al Mandil, MD, MHA Director, Quality & Strategic Planning Administration King Fahad Specialist Hospital-Dammam, Saudi Arabia

*The use of Joint Commission International (JCI) advisory services is not necessary to obtain a JCI accreditation award, nor does it influence the granting of such awards.

Step 2 Plan

Conduct gap analysis and build action plan

Duration: 2-3 months

Business men in a meeting wearing keffiyeh and/or suits

Perform a baseline assessment of your hospital's performance against JCI standards

Checkmarked Quality and accreditation specialists frequently perform baseline assessments by assigning groups of standards or measurable elements to staff in that area of practice. Staff then researches the hospital's level of compliance with those standards or measureable elements.

Click to read about helpful questions for assessing compliance

Assign staff responsibilities

Checkmarked An effective action plan includes details about who on your team is responsible for which tasks. It is also important to select a primary accreditation contact and have them begin your organization's electronic application with JCI (E-App).

Build your accreditation action plan

Checkmarked An action plan outlines a hospital's intended actions towards performance improvement. The plan can be used to respond to a minor shortfall in standards compliance after the baseline assessment or as a part of a root cause analysis of a more significant underperformance.

Being the first hospital in Japan to be JCI accredited was a powerful message to all stakeholders of a commitment to continuous quality improvement and safety based on global standards. It positively altered our corporate culture.
We have gone from good, to measurably better, to best.

John Wocher Executive Vice President Kameda Medical Center, Japan

*The use of Joint Commission International (JCI) advisory services is not necessary to obtain a JCI accreditation award, nor does it influence the granting of such awards.

Step 3 Process

Update policies and procedures

Duration: 2 months

Female in pink scrubs looking at a whiteboard of checklists

Assess your hospital's current policies and procedures

Develop a process to create JCI-compliant policies

Checkmarked Policies and procedures fail when they are:

Unclear, wordy, or difficult to understand
Too general or confusing
Poorly designed or hard to navigate
Difficult for staff to find or locate

Since its first accreditation in 2007, Severance Hospital has made not only structural improvements, but also quality improvements in medical services that led to improved customer satisfaction. Changes in medicine and technology have accelerated. The structural improvements necessary for JCI reaccreditation have enabled Severance to adapt to those changes promptly.

Namsik Chung MD, PhD, FAHA, FASE General Director, Severance Hospital Professor of Cardiology, Younsel University College of Medicine, South Korea

*The use of Joint Commission International (JCI) advisory services is not necessary to obtain a JCI accreditation award, nor does it influence the granting of such awards.

Step 4 Focus

Target improvements where needed

Duration: 2-3 months

Close up of the face of a male medical practitioner looking into a microscope

Examine challenges

Checkmarked Begin with the International Patient Safety Goals (IPSGs). These goals highlight problematic areas in health care and describe evidence-based solutions to these problems. The goals focus on systemwide solutions wherever possible.

Identify patients correctly
Improve effective communication
Improve the safety of high-alert medications
Ensure correct-site, correct-procedure, correct-patient surgery
Reduce the risk of health care-associated infections (HAIs)
Reduce the risk of patient harm resulting from falls

Infographic example of Prevent Central Line-Associated Bloodstream Infections

Use infographics to educate staff about challenges. Click to view.

Assess your hospital's risk for adverse events

Checkmarked Create a method for collecting information on any adverse event. This system may involve staff completing written reports, submitting email forms, or using a telephone hotline. Analyze information from these reporting systems to show patterns of risk.

Fire Infographic Cover of Implementation Preventing Surgical Fires

Inspect all areas of your hospital, as this infographic indicates. Click to view.

Remedy challenges without delay

Checkmarked Prioritize high-risk, problem-prone compliance issues, as well as those that will take the longest time to address.

Cover of Step4-Part3-Inpatient to outpatient discharge handoff tool article from Journal

The San Francisco Veterans Association Medical Center used this tool to address handoff risks and gaps. Click to view.

JCI accreditation has motivated and assisted our organization in striving to deliver a service of patient-centered safety and quality excellence, placing Bon Secours at the forefront of modern health care and providing a secure footing into the future in the ever challenging delivery of quality private health care in Ireland.

Kieran McNamara Health and Safety Officer Bon Secours Hospital Cork, Ireland

*The use of Joint Commission International (JCI) advisory services is not necessary to obtain a JCI accreditation award, nor does it influence the granting of such awards.

Step 5 Fix
Barriers

Work with staff to overcome obstacles

Duration: 2-3 months

Group brainstorming in front of mobile whiteboard

Explain how to achieve a culture of safety

Checkmarked In a safety culture, both staff and leadership acknowledge mistakes, learn from them, and take action to correct them. All individuals focus on maintaining excellence in performance and accept that safety and quality of care, treatment, and services are a personal responsibility.

Hospitals that move toward high reliability establish codes of behavior that are modeled by leaders (including nurses and physicians) who champion efforts to eliminate intimidation and encourage and reward the reporting of blameless errors and unsafe conditions.

Drs. Mark Chassin and Jerod Loeb explain how to achieve a safety culture in this Milbank Quarterly article.

Train staff in new procedures

Involve physician leaders

We chose JCI as the best organization to conduct the specialized training we needed. Some of our hospitals have already received JCI accreditation and we wanted to base the curriculum on JCI's exacting standards

Abdullah Assiri MD, FACP Director, Infection Prevention and Control Ministry of Health, Saudi Arabia

*The use of Joint Commission International (JCI) advisory services is not necessary to obtain a JCI accreditation award, nor does it influence the granting of such awards.

Step 6 Readiness

Assess your readiness at the midpoint

Duration: 2-3 months

Female in center focus in business attire attentive at a meeting

Prepare your staff for mock survey

Conduct patient tracers

Checkmarked Tracers are a foundational element of JCI on-site surveys. The tracer process allows surveyors to select a patient and use that individual's record as a road map. Some hospitals find that bringing in mock surveyors from JCI helps their staff better prepare for actual survey conditions.

How to conduct a mock tracer page screen shot from a pdf

Learn about tracer methodology using this document and others like it. Click to view.

Involve your staff

Checkmarked Tracers provide a forum for discussion of important topics related to the safety and quality of care at the organization level. They follow the course of a patient's treatment within the hospital, allowing staff to assess the health care hospital's compliance with JCI standards in multiple departments by many caregivers.

Patient safety walkarounds to uncover correctable system flaws article from Journal

Communicate tracer findings to staff and promote brainstorming for solutions, as described in this article. Click to view.

Joint Commission International accreditation has helped us improve our processes in patient care and patient safety to a level of standard that has elevated us to be the benchmark in health care delivery in our part of the world.

Dr. Mahesh Vakamudi Chief Operating Officer Professor & Head Anesthesiology, Sri Ramachandra Medical Centre, India

*The use of Joint Commission International (JCI) advisory services is not necessary to obtain a JCI accreditation award, nor does it influence the granting of such awards.

Step 7 Training

Continue training for sustainable changes

Duration: 2-3 months

A doctor in scrubs assessing patient in a keffiyeh

Keep your staff educated and motivated about improving procedures

Checkmarked Introduce every individual in your hospital or academic medical center to the JCI accreditation philosophy and approach. Educate staff about how accreditation can be used as a risk reduction strategy. This education is crucial to motivate staff and inspire commitment at all levels.

Female presenting at the front of a convention hall

Use this resource to determine your staff's educational needs. Click to view.

Complete your mock survey planning

Checkmarked Communicating tracer findings to staff promotes brain-storming for solutions.

Keep these items on hand to get the most out of your mock survey.

List of systemwide priority improvements
List of individual measures for departments and services
Clinical practice guidelines and any associated pathways and protocols
Current map of hospital campus
Sample of all medical record forms
Required organizational plans (for example, facility management and safety plan)
Required policies and procedures, written documents, and bylaws

JCI provides IMH (Institute of Mental Health) with the framework for clinical and organizational excellence, which enables us to monitor and anticipate the improvements that are needed to continuously provide quality and safe clinical care.

Hung Choon Chua CEO Institute of Mental Health, Singapore

*The use of Joint Commission International (JCI) advisory services is not necessary to obtain a JCI accreditation award, nor does it influence the granting of such awards.

Step 8 Monitor and Adjust

Evaluate and refine processes

Duration: 2-3 months

Doctor monitoring vitals on screens overhead

Use your accreditation team to spot deficiencies

Encourage staff to make corrections

Checkmarked Service quality awards prove effective for some organizations in motivating staff to make corrections.

Learn how the Weinburg Surgical Suite at The Johns Hopkins Hospital utilized "Good Catch" awards. Click to view.

Build a cohesive spirit

Checkmarked Pursuing JCI accreditation requires a strong commitment from all members of a hospital or academic medical center, including leadership, quality management, and frontline staff. This experience can bring out unprecedented cooperation among all levels of staff because everyone is working toward the same goals.

Journal on Volunteer Reporting of Hazards PDF image

Learn how the Memorial Herman Health System in Texas got its entire organization "from boardroom to bedside" excited about the journey towards high reliability health care. Click to view.

JCI accreditation has been the best platform to standardize and improve the quality of care processes within our organization. It has helped us achieve our goal in creating a safe culture for both internal and external customers.

Dr. Abdulla Al Khaya CEO Latifa Hospital, United Arab Emirates

*The use of Joint Commission International (JCI) advisory services is not necessary to obtain a JCI accreditation award, nor does it influence the granting of such awards.

Step 9 Mock
Survey

Use a mock survey to assess your readiness

Duration: 2-3 months

Group of medical professionals in a stairway with clipboards listening to a main doctor speak

Conduct your final mock survey

Spot necessary improvements

Checkmarked Spotting improvements means identifying areas of noncompliance and assessing your improvement efforts. This is a checkpoint to ensure that your organization is on the right path.

Plan corrections

Checkmarked In the months following your final mock survey, bring specific problems to the attention of staff, consider new methods for achieving hospital goals, and make improvements.

Early corrections help your hospital feel prepared and confident.

Female instructor at the head of a group of attentive attendies in a conference room

Prioritize improvements based on mock survey.

Understanding JCI's global approach to continuous quality improvement and patient safety was a valuable investment that led our organizational culture to become better.

Takaaki Kameda MD, PhD Chairman of the Board, Kameda Group CEO, Kameda Medical Center, Japan

*The use of Joint Commission International (JCI) advisory services is not necessary to obtain a JCI accreditation award, nor does it influence the granting of such awards.

Step 10 Final
Stage

Make final modifications

Duration: 6-7 months

Group of medical staff smiling while discussing documentation

Make final preparations for your survey

Complete your JCI survey

Checkmarked The survey process involves: an opening conference, leadership interviews, staff qualification and education, a facility tour, and a leadership conference - among other key interactions.

After a successful accreditation survey, your hospital can proudly display the Gold Seal of Approval®.

Join world Hospital Search

Checkmarked World Hospital Search is a complete, online directory of all JCI Accredited organizations. Upgrading to a deluxe profile is free and includes complete contact information, your areas of specialty, and your accreditation information. Request a free, deluxe profile to improve your organization's visibility.

Follow this link to visit World Hospital Search.

Our challenge of seeking JCI accreditation has dramatically changed the culture of St. Luke's International Hospital. I was deeply impressed with the educational nature of the survey. And now, with the structural and managerial improvements, we are confident of providing the highest level of safety and quality of care.

Tsuguya Fukui, MD, MPH, PhD President St. Luke's International Hospital, Japan

*The use of Joint Commission International (JCI) advisory services is not necessary to obtain a JCI accreditation award, nor does it influence the granting of such awards.

Pathway to JCI Accreditation for Hospitals

Your partner in accreditation success

800+ Accredited Organizations

100+ Countries Served by JCI

Organize your activities. Monitor your progress.Change the order or timing to match your journey.

Step 1 Start-up

Become familiar with JCI's accreditation standards and survey process

Become familiar with JCI's standards and survey process

Become familiar with JCI's accreditation policies and procedures

Checkmarked The most current accreditation policies and procedures are posted on JCI's website. Review these documents as soon as possible in your accreditation journey.

Review the JCI Hospital Accreditation Manual and Survey Process Guide

Excite your leadership

Checkmarked Supportive leadership is vital to successfully achieving Joint Commission International Accreditation.

Share start-up information with your team

Checkmarked Quality and accreditation specialists find that some departments and staff need a deeper understanding of accreditation than others. For example, nurses may need more information than technicians because of their roles in overseeing care.

Tools for your journey

JCI Accreditation Standards for Hospitals, 6th edition (English) includes standards for hospitals and academic medical centers and emphasizes the role of leadership in creating a culture of safety.

JCI Accreditation Hospital Survey Process Guide, 6th edition is designed to help hospitals and academic medical centers prepare for the on-site JCI survey.

Introductory consultation* by JCI experts helps your leaders and staff to understand the accreditation process, assess readiness, and prepare for a successful survey.

JCI Practicum on Accreditation and Quality Improvement is a live five-day event on JCI's methods, standards, and best practices. Learn from experienced surveyors and observe a simulated JCI tracer in a local hospital.

Step 2 Plan

Conduct gap analysis and build action plan

Conduct gap analysis and build action plan

Perform a baseline assessment of your hospital's performance against JCI standards

Checkmarked Quality and accreditation specialists frequently perform baseline assessments by assigning groups of standards or measurable elements to staff in that area of practice. Staff then researches the hospital's level of compliance with those standards or measureable elements.

Assign staff responsibilities

Checkmarked An effective action plan includes details about who on your team is responsible for which tasks. It is also important to select a primary accreditation contact and have them begin your organization's electronic application with JCI (E-App).

Build your accreditation action plan

Checkmarked An action plan outlines a hospital's intended actions towards performance improvement. The plan can be used to respond to a minor shortfall in standards compliance after the baseline assessment or as a part of a root cause analysis of a more significant underperformance.

Tools for your journey

Baseline Assessment* by JCI consultants compares your current services and processes to JCI standards and identifies areas for improvement.

Register with E-App. E-App tools are available once you complete your online profile.