What is accreditation?

Accreditation is a process in which an entity, separate and distinct from the health care organization, usually nongovernmental, assesses the health care organization to determine if it meets a set of requirements (standards) designed to improve the safety and quality of care. Accreditation is usually voluntary. Accreditation standards are usually regarded as optimal and achievable. Accreditation provides a visible commitment by an organization to improve the safety and quality of patient care, to ensure a safe care environment, and to continually work to reduce risks to patients and staff. Accreditation has gained worldwide attention as an effective quality evaluation and management tool. What are the benefits of accreditation? The accreditation process is designed to create a culture of safety and quality within an organization that strives to continually improve patient care processes and results. In doing so, organizations improve public trust that the organization is concerned for patient safety and the quality of care; provide a safe and efficient work environment that contributes to worker satisfaction; negotiate with sources of payment for care with data on the quality of care; listen to patients and their families, respect their rights, and involve them in the care process as partners; create a culture that is open to learning from the timely reporting of adverse events and safety concerns; and establish collaborative leadership that sets priorities for and continuous leadership for quality and patient safety at all levels. What is JCIs relationship to The Joint Commission? JCI is the international arm of The Joint Commission (U.S.A.); JCIs mission is to improve the quality and safety of health care in the international community. For more than 75 years, The Joint Commission (U.S.A.) and its predecessor organization have been dedicated to improving the quality and safety of health care services. Today, The Joint Commission is the largest accreditor of health care organizations in the United Statesit surveys nearly 16,000 health care programs through a voluntary accreditation process. The Joint Commission and JCI are both nongovernmental, not-for-profit United States corporations.

What are the purpose and the goal of JCI accreditation initiatives? JCI accreditation is a variety of initiatives designed to respond to a growing demand around the world for standards-based evaluation in health care. The purpose is to offer the international community standards based, objective processes for evaluating health care organizations. The goal of the program is to stimulate demonstration of continuous, sustained improvement in health care organizations by applying international consensus standards, International Patient Safety Goals, and data measurement support. In addition to the standards for hospitals contained in this fourth edition, JCI has developed standards and accreditation programs for the following: Ambulatory Care Clinical Laboratories Primary Care Centers The Care Continuum (home care, assisted living, long term care, hospice care) Medical Transport Organizations JCI also offers certification of clinical care programs, such as programs for stroke care, cardiac care, or joint replacement. JCI accreditation programs are based on an international framework of standards adaptable to local needs. All the JCI accreditation and certification programs are characterized by the following: International consensus standards, developed and maintained by an international task force, and approved by an international Board, are the basis of the accreditation program. The underlying philosophy of the standards is based on principles of quality management and continuous quality improvement. The accreditation process is designed to accommodate the legal, religious, and/or cultural factors within a country. Although the standards set uniform, high expectations for the safety and quality of patient care, country-specific considerations related to compliance with those expectations are part of the accreditation process. The on-site survey team and agenda will vary depending on the organizations size and type of services provided. For example, a large multispecialty organization may require a four- or five-day survey by a physician, a nurse, and an administrator, while a 50bed, single-specialty hospital may require a shorter survey by a smaller team.

 JCI accreditation is designed to be valid, reliable, and objective. Based on the analysis of the survey findings, final accreditation decisions are made by an international accreditation committee. How were the standards initially developed and refined for this fourth edition? A 12-member International Standards Subcommittee, composed of experienced physicians, nurses, administrators, and public policy experts, guides the development and revision process of the JCI accreditation standards. The subcommittee consists of members from six major world regions: Latin America and the Caribbean, Asia and the Pacific Rim, the Middle East, Central and Eastern Europe, Western Europe, and Africa. The work of the subcommittee is refined based on an international field review of the standards and the input from experts and others with unique content knowledge. How are the standards organized? The standards are organized around the important functions common to all health care organizations. The functional organization of standards is now the most widely used around the world and has been validated by scientific study, testing, and application. The standards are grouped by those functions related to providing patient care and those related to providing a safe, effective, and wellmanaged organization. These functions apply to the entire organization as well as to each department, unit, or service within the organization. The survey process gathers standards compliance information throughout the entire organization, and the accreditation decision is based on the overall level of compliance found throughout the entire organization. Are the standards available for the international community to use? Yes. These standards are available in the international public domain for use by individual health care organizations and by public agencies in improving the quality of patient care. The standards only can be downloaded at no cost from the JCI Web site for consideration of adapting them to the needs of individual countries. The translation and use of the standards as published by JCI requires permission.

When there are national or local laws related to a standard, what applies? When standard compliance is related to a laws and regulations, whichever sets the higher or stricter requirement applies. How do I use this standards manual? This international standards manual can be used to guide the efficient and effective management of a health care organization; guide the organization and delivery of patient care services and efforts to improve the quality and efficiency of those services; review the important functions of a health care organization; become aware of those standards that all organizations must meet to be accredited by JCI; review the compliance expectations of standards and the additional requirements found in associated intent statements; become aware of the accreditation policies and procedures and the accreditation process; and become familiar with the terminology used in the manual. What are the measurable elements of a standard? The measurable elements (MEs) of a standard are those requirements of the standard and its intent statement that will be reviewed and assigned a score during the accreditation survey process. The MEs simply list what is required to be in full compliance with the standard. Each element is already reflected in the standard or intent statement. Listing the MEs is intended to provide greater clarity to the standards and help organizations educate staff about the standards and prepare for the accreditation survey. What is the Strategic Improvement Plan (SIP)? A Strategic Improvement Plan (SIP) is a required written plan of action that the organization develops in response to not met findings identified in the JCI Official Survey Findings Report. The written SIP is expected to establish the strategies/approach that the organization will implement to address each not met finding; describe specific actions the organization will use to achieve compliance with the not met standards/ measurable elements cited; describe methodology to prevent reoccurrence and to sustain improvement over time; and

 identify the measures that will be used to evaluate the effectiveness of the improvement plan (submission of data to occur over the subsequent three years). The SIP must demonstrate that the organizations actions lead to full compliance with the standards and measurable elements. The SIP is reviewed and approved by the JCI office staff after the Accreditation Certification Letter and Gold Seal have been awarded. How frequently will the standards be updated? Information and experience related to the standards will be gathered on an ongoing basis. If a standard no longer reflects contemporary health care practice, commonly available technology, quality management practices, and so forth, it will be revised or deleted. It is currently anticipated that the standards will be revised and published at least every three years.