to main content Prepare for JCI Accreditation | Joint Commission International

Form Your Accreditation Team

Your accreditation team is responsible for embedding and sustaining ongoing improvements. The team also follows up on corrective action plans. Candidates should be assigned to various positions on the team including accreditation committee members, chapter champions, and chapter team members.

Train your team on JCI standards by providing them with access to the Accreditation Manual and Survey Process Guide for your organization's setting type.
When assembling your accreditation team, consider questions from this Accreditation Team Selection Checklist.

Policies and Procedures

A policy refers to a statement of expectations meant to influence or determine decisions and actions, and encompasses the rules and principles that guide and inform your organization’s procedures and processes. A procedure is defined as how a task is performed and usually includes step-by-step instructions.

Policies should have a simple, straightforward name or title that clearly describes the purpose of the document and should meet the standard intent and measurable element requirements. View our sample policy to see what should be addressed to be effective.

Sample policy

Creating, implementing, monitoring and maintaining policies that meet JCI standards helps you sustain compliance. Use a policy inventory form to create a master inventory of policies.

Policy inventory form

Compare your scope of services and practices to our standards by completing a gap analysis. A gap analysis helps identify what JCI standards your organization is not meeting.

Gap analysis

View the Accreditation Survey Process Guides, which include a list of required policies, programs and written documents for the survey.

Required documentation

Develop an Action Plan, Address the Gaps, Continue to Practice

The JCI survey process is patient-centered, data-driven, and focused on evaluating actual care processes. The on-site accreditation survey is also intended to be a learning experience. To that end, we provide education and “best practice” guidance to help your staff continually improve performance.
Findings from a gap analysis help your accreditation team build a comprehensive action plan for JCI compliance. View a sample action plan form to see what’s involved.
Many health care organizations rehearse at least once before to the actual survey by conducting a mock survey approximately six months prior to the accreditation survey.*
Tracers are a primary tool to check compliance against the standards.
Additionally, you can use the Survey Readiness To-Do Checklist.

*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.