Hospital

Accreditation

Dr. Ahmed Mohammed Kheir

Preventive Medicine and Public Health Consultant
Quality & Organizational Development Consultant
FFPH - RCP - UK
MSc Q&S, PG Dip. LOD - RCSI- Ireland
MBBS, PG Dip. HE, UofK – MPTH, USMT
MD in Community Medicine SMSB
 What is Quality ?

Meet customer
Excellence Adding value Satisfaction
needs

Standardizatio
Error-free right things perfectness
n

optimizing the
State of Mind
whole system

2
 Quality
is a perceptual, conditional and
somewhat subjective attribute
and may be understood
differently by different people.

Consumers Producers
• may focus on the • might measure the
specification quality of conformance quality, or
a product/service, or how degree to which the
it compares to product/service was
competitors in the produced correctly.
marketplace.

3
 Quality Definition
ISO 9000:
• Degree to which a set of inherent characteristics fulfills requirements.” The standard defines
requirement as need or expectation.

Six Sigma:
• "Number of defects per million opportunities.”

Subir Chowdhury:
• "Quality combines people power and process power."

Edward Deming:
• "Quality is defined from the customer’s point of view as anything that enhances their satisfaction".

Philip B. Crosby:
• "Conformance to requirements.

Joseph M. Juran:
• "Fitness for use.” Fitness is defined by the customer.

American Society of Quality (ASQ)

1.The totality of features and characteristics of a product or service that bear on its ability to satisfy
stated or implied needs

4
SYSTEM – Simple Business
Model
• Donabedian’s model (IPO, SPO)
1980

Structur Outcom
Process
e es

5
 Accreditation –A Definition
Usually a voluntary process by which a government or non-government agency
grants recognition to health care institutions which meet certain standards that
require continuous improvement in structures, processes, and outcomes.
 Accreditation –A Definition
Accreditation is often confused with :
• Licensure-governmental activity that sets minimum standards to
protect the public
• Certification-evaluates special capability or unique skills/ability
Standard A statement that defines the performance
expectations, structures, or processes that must be in place
for an organization to provide safe and high-quality patient
care, treatment, and services.
standardized measure A performance measure that has precisely
defined specifications, has standardized data collection
protocols, meets established evaluation criteria, and can be
uniformly adopted for use.
Standards-based evaluation
1. An assessment process that determines a health care
organization’s or practitioner’s compliance with
preestablished standards. Also see accreditation;
certification.
2. 2. A statement that defines the performance expectations,
structures, or processes that must be in place for an
The Value of JCI Accreditation
JCI is the world’s largest health care accreditor. JCI’s Gold Seal of
Approval® is a widely recognized benchmark representing the most
comprehensive evaluation process in the health care industry.
JCI standards are designed to do the following:
• Ensure a safe environment that reduces risk for care recipients and
caregivers
• Offer quantifiable benchmarks for quality and patient safety
• Stimulate and demonstrate continuous, sustained improvement
through a reliable process
• Improve outcomes and patient experience
• Enhance efficiency
• Reduce costs through standardized care
standard A statement that defines the performance expectations, structures, or processes that
must be in place for an organization to provide safe and high-quality patient care, treatment,
and services.
plan A method for outlining detailed strategies and resource needs for meeting short- and
long-term goals and objectives. Examples of plans include, but are not limited to, those
addressed in the facility management and safety program (safety plan, security plan,
hazardous materials plan, emergencies plan, fire safety plan, medical equipment plan, and
utility systems plan).

policy A statement of expectations meant to influence or determine decisions and actions.

Policies are the rules and principles that guide and inform the organization’s procedures and
processes.
procedure How a task is performed, usually including step-by-step instructions.
process A set of actions that produce or lead to a particular result.

program An organized, official system that guides action toward a specific goal. The program
identifies needs, lists strategies to meet those needs, includes staff involved, and sets goals
and objectives. The format of the program may include narratives, policies and procedures,
plans, protocols, practice guidelines, clinical pathways, care maps, or a combination of these.
General Eligibility Requirements
Any hospital may apply for JCI accreditation if it meets all the following criteria:
• The hospital is located outside of the United States and its territories.
• The hospital is currently operating as a health care provider in the country, is licensed to provide care and
treatment as a hospital (if required), and, at minimum, does the following:
• Provides a complete range of acute care clinical services—diagnostic, curative, and rehabilitative.
• Provides services that are available 365 days per year; ensures that all direct patient care services are
operational 24 hours per day, 7 days per week; and provides ancillary and support services as needed for
emergent, urgent, and/or emergency needs of patients 24 hours per day, 7 days per week (such as
diagnostic testing, laboratory, and operating theatre, as appropriate to the type of acute care hospital).
• In the case of a specialty hospital, provides a defined set of services, such as pediatric, eye, dental, and
psychiatry, among others.
• The hospital provides services addressed by the current JCI accreditation standards for hospitals.
• The hospital assumes, or is willing to assume, responsibility for improving the quality of its care and services.
• The hospital is open and in full operation, admitting and discharging a volume of patients that will permit the
complete evaluation of the implementation and sustained compliance with all current JCI accreditation
standards for hospitals.
• The hospital meets the conditions described in the “Accreditation Participation Requirements” (APR) chapter.
In addition, academic medical center hospital applicants must meet the additional following criteria:
• The applicant hospital is integrated (by organization or administration) with a medical school.
• The applicant hospital is the principal site for the education of both (1) medical students (undergraduates) and
(2) postgraduate medical specialty trainees (for example, residents or interns) from such medical school.
• At the time of application, the applicant hospital is conducting medical research with approval and oversight by
an Institutional Review Board (IRB) or research ethics committee.
Section I: Accreditation Participation
Requirements..................................................9
Accreditation Participation Requirements
APR.1 The hospital meets all requirements for timely submissions of data and information to Joint
(APR).................................................11
Commission International (JCI).
APR.2 The hospital provides JCI with accurate and complete information throughout all phases of the
accreditation process.
APR.3 The hospital reports within 30 days of the effective date of any change(s) in the hospital’s profile
(electronic database)
APR.4 The hospital permits on-site evaluations of standards and policy compliance or verification of
quality and safety concerns, reports, or regulatory authority sanctions at the discretion of JCI.
APR.5 The hospital allows JCI to request (from the hospital or outside agency) and review an original or
authenticated copy of the results and reports of external evaluations from publicly recognized bodies.
APR.7 The hospital selects and uses measures as part of its quality improvement measurement
system.
Section I: Accreditation Participation
Requirements..................................................9
Accreditation Participation Requirements
APR.8 The hospital accurately represents its accreditation status and the programs and services to which JCI
(APR).................................................11
accreditation applies. Only hospitals with current JCI accreditation may display the Gold Seal.
APR.9 Any individual hospital staff member (clinical or administrative) can report concerns about patient safety
and quality of care to JCI without retaliatory action from the hospital.
APR.10 Translation and interpretation services arranged by the hospital for an accreditation survey and any
related activities are provided by qualified translation and interpretation professionals who have no
relationship to the hospital.
APR.11 The hospital notifies the public it serves about how to contact its hospital management and JCI to report
concerns about patient safety and quality of care.
Methods of notice may include, but are not limited to, distribution of information about JCI, including contact
information in published materials such as brochures and/or posting this information on the hospital’s website.
APR.12 The hospital provides patient care in an environment that poses no risk of an immediate threat to
patient safety, public health, or staff safety.
Section II: Patient-Centered
Standards.....................................................................21
International Patient Safety Goals
(IPSG)...........................................................23
Access to Care and Continuity of Care
(ACC)....................................................39
Patient-Centered Care
(PCC)..............................................................................59
Assessment of Patients
(AOP)..............................................................................79
Care of Patients
(COP).....................................................................................107
Anesthesia and Surgical Care
Section III: Health Care Organization Management
Standards..............................171
Quality Improvement and Patient Safety
(QPS)................................................173
Prevention and Control of Infections
(PCI)......................................................187
Governance, Leadership, and Direction
(GLD).................................................211
Facility Management and Safety
(FMS).............................................................241
Staff Qualifications and Education
(SQE).........................................................271
Management of Information
Section IV: Academic Medical Center Hospital
Standards......................................319
Medical Professional Education
(MPE).............................................................321
Human Subjects Research Programs
(HRP)......................................................329
Assessment Auditing Tracing

Review Evaluation Monitoring

• Audit – activity during which is checked the internal QA
system at the institutional and/or program level. Audit is
an official inspection of an organization's accounts,
typically by an independent body.

• Evaluation / assessment – activity when is checked

teaching and learning processes and results, research,
staff, infrastructure etc. of a
university/academy/institute/program.
• Accreditation – result of evaluations activity presented in
the accreditation decision.
patient tracer These (see tracer methodology for a
description of tracers) occur during the on-site
survey and focus on evaluating an individual
patient’s total care experience within a health care
organization. Also see system tracer.

system tracer These (see tracer methodology for a

description of tracers) occur during the on-site
survey and focus on evaluating priority safety and
quality-of-care issues on a systemwide basis
throughout the organization. Examples of such
issues include infection prevention and control,
medication management, facility management,
and the use of data. Also see patient tracer.
Determining the Score
“Fully Met” Score
An ME is scored “fully met” if the answer is “yes” or “always” to the
specific requirements of the ME. Also considered are the following:
• A single negative observation may not prevent a score of “fully met.”
(Also see “Consideration of Impact and Criticality.”)
• If 90% or more of observations or records (for example, 9 out of 10)
are met
The track record related to a score of “fully met” is as follows:
• For triennial surveys before 31 December 2020, a 12-month look-
back period of compliance
• For triennial surveys on or after 1 January 2021, surveyors may look
as far back as the date of the hospital’s previous full survey
• For initial surveys, a 6-month look-back period of compliance
• No look-back period for a follow-up survey; sustainability of
improvement is used to evaluate compliance
Thank You