JCI Accreditation for Hospitals

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What is the Joint Commission International Accreditation

The Joint Commission on Accreditation of Hospitals was created in 1951 by merging the Hospital Standardization Program with similar programs run by the American College of Physicians, the American Hospital Association, the American Medical Association, & the Canadian Medical Association. It was in 1981, this was renamed the Joint Commission on Accreditation of Health-care Organizations (JCAHO). The objective was to ensure that every patient receives the highest quality of care possible, based on a quality accreditation programme.

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JCI Accreditation for Hospitals
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What are the JCI Accreditation Standards

A set of rigorous International Standards on Quality and Patient Safety developed with the mission to improve the safety and quality of healthcare services provided internationally. To meet this goal, JCI keeps upgrading the Standards keeping the requirements of patient safety and quality improvement.

Health care organizations that are desirous of meeting these standards need to undergo a very comprehensive and rigorous assessment conducted by the JCI team. Once accredited, the Healthcare Organization will need to take all efforts to sustain the system by continuing to meet the requirements of the Standards. The Organisations are regularly assessed through re-assessments.

Benefits to the Hospital from the JCI Standards

  • >>   A deep commitment to high-quality care by all across the Organisation
  • >>   A culture of safety for patients, visitors, and staff, built into the Organisation
  • >>   A willingness by the Organisation to conduct a rigorous preparation and face a survey
  • >>   A care delivery system based on recognised, evidence-based practices
  • >>   A leadership in continually complying with these exacting Standards of Quality & Safety

Different JCI Standards

The different JCI Standards available are :

  • >>   JCI Standards for Hospitals
  • >>   JCI Standards for Ambulatory Care
  • >>   JCI Standards for Home Care
  • >>   JCI Standards for Clinical Laboratories
  • >>   JCI Standards for Academic Medical Center Hospitals
  • >>   JCI Standards for Long Term Care Facilities
  • >>   JCI Standards for Medical Transport Organizations
  • >>   JCI Standards for Primary Care Centers

The JCI Accreditation Process

Steps :

  • 1.  Understand the Standards and its requirements and how they can be implemented in your health care organization.
  • 2.  Form a team from across the organization and assign them roles and responsibilities for implementation of the Standards in their functional areas.
  • 3.  Take up the Implementation of the Standards across the organization.
  • 4.  Once the Organisation feels ready to face the assessment, carry out a Mock Audit.
  • 5.  Based on the Mock Survey start the Application Process through e-App. This should ideally be done at-least 6 to 12 months before Accreditation Survey is to be done by the JCI Team.
  • 6.  Through the Survey, the JCI Team provides an objective assessment of quality, patient care and safety across all areas and departments of the Healthcare Organisation. The Survey Findings help the Organization to prioritize and focus on the corrective actions to be done.

Criticality Levels defined in the Assessment by the Joint Commission Team

The first 3 criticality levels have the greatest impact on the accreditation decision :

  • a)  Immediate threat to health or safety
  • b)  Situational decision rules
  • c)  Direct impact requirements
  • d)  Indirect impact requirements

Accreditation Categories

Based on the final score, the Final Accreditation Category is decided. These are :

  • 1.  Accredited
  • 2.  Provisional
  • 3.  Conditional
  • 4.  Preliminary denial
  • 5.  Denial of Accreditation

Corrective Action Plan & Strategic Improvement Plan

The Healthcare Organisation will need to prepare a Corrective Action Plan to close all the Non-Compliances found. The time frame for preparing and submitting the Action Plan will depend upon the criticality levels of the Survey Findings.
The JCI Team may in fact request the Organisation to submit a Strategic Improvement Plan (SIP) for certain findings of the Assessment, based again on its criticality.

Sustaining the JCI Accreditation

The key to sustaining the developed system and continuing the journey toward ongoing improvement is by regularly tracking the key performance indicators and through it monitoring compliance to the Standards.

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