How to Get Started with JCI Accreditation

1. How to Get Started with JCI Accreditation

2. The Accreditation Journey: General Suggestions • The importance of leadership commitment: Board, CEO, and clinical leaders • Leadership’s responsibility to assuring systems are designed for quality and safety • Set a realistic timeframe for preparation, such as 18-24 months • Allocation of resources: may include facility enhancement, training, recruitment of new staff, and redesign of systems

3. The Accreditation Journey:Where to Start? • Available Resources • JCI Accreditation Standards for Hospitals, 2nd edition • Survey Process Guide (detailed electronic version available on line) • Web-based training on introduction to the international accreditation process • Newsletters and publications, both print and electronic • Annual JCI Practicum each July • Annual JCI Executive Briefings – networking opportunity with accredited organizations

4. The Accreditation Journey:Begin with Education • Education for organizational leaders and managers • Introduction to accreditation philosophy and approach • Accreditation as a quality improvement and risk reduction strategy • Review of the standards and measurable elements • Discussion of the survey process and what to expect • Project planning and next steps

5. The Accreditation Journey:Baseline Assessment • Conduct a detailed baseline assessment of the organization’s current adherence to the standards and each measurable element • Use knowledgeable and credible evaluators (either internal or external consultants) who will critically and objectively assess each area • Score as Met, Partially Met, or Not Met and cite specific findings and recommendations • Priority focus on the core standards in bold • Include all areas of the organization in the assessment

6. The Accreditation Journey:Baseline Assessment • In addition to addressing standards adherence, collect and analyze baseline quality data as required by the quality monitoring standards • Examples: medication errors, hospital-associated infection rates, antibiotic usage, surgical complications, etc. • Establish an ongoing monitoring system for data collection (e.g. monthly, with quarterly data analysis) to identify problem areas and track progress in improvement

7. The Accreditation Journey:Action Planning • Using the findings of the baseline assessment, develop a detailed project plan with assigned responsibilities, deliverables, and timeframes • Start first with priority areas of the core standards • Example: Revise informed consent policy, develop a new informed consent statement, educate staff --- in the next two month time period • If available, use a software program such as MS Project or Excel to confirm project plan in writing • Hold leaders and staff accountable to plan

8. The Accreditation Journey:Team Approach • Assign oversight of each chapter of standards to a respected champion/leader who will identify team members from throughout the hospital • Involve those who may also be skeptical of the process • Look for good people skills, time management skills, and consensus building skills • Be prepared to change as new champions emerge, and some leaders drop out

9. The Accreditation Journey:Policies and Procedures • In addition to overall project plan, it is often helpful to compile a list of all required policies and procedures that will need development and revision • These may take some time to get revise or develop, undergo organizational review, and obtain final approval • Be certain that your policy reflects your actualpractice, as this is what the surveyors will evaluate your organization against

10. The Accreditation Journey:Mid-Point Strategies • Continue to monitor your progress in meeting the standards, such as through a mini-evaluation of each chapter at regular intervals (e.g quarterly) • Don’t be afraid to adjust your project plan to be more realistic --- change often takes longer than one expects • Continue to involve as many staff as possible in the process --- make it an organizational quality goal that together you are wishing to achieve

11. Strategies that have Worked • Importance of physician commitment to the accreditation process • Must see accreditation standards as a framework by which organizational processes will be improved • Care will ultimately be of higher quality and safer for their patients • Reassure physicians that accreditation is not intended to tell them how to practice medicine!

12. Strategies that have Worked • Learn from what others have done well and adapt the experience to the needs of your organization • Ask JCI for assistance and clarification with standards interpretation --- don’t waste time going down the wrong path • Take advantage of resources such as the JCR Good Practices Database (e.g. download electronic example policies and plans and adapt to your organization)

13. Pitfalls to Avoid • Top leaders give “lip service” to the process, but are totally unrealistic in what it will take to achieve it in terms of time and resources • Staff end up feeling that accreditation is extra work for which they are not rewarded or recognized • Over-eager managers use the standards as a stick rather than as a carrot --- can make entire accreditation process feel punitive and inspecting rather than motivating

14. Final Mock Survey • Plan for a final “mock survey” at least 4-6 months in advance of the target date of the actual accreditation survey • Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organization with a fresh and objective eye • Need to plan final revisions and corrections based on the findings of the final mock survey

15. The Accreditation Survey • Request an application from JCI at least 6 months in advance of target dates for survey • Once application completed, a surveyor team will be compiled and dates confirmed • Team leader will be in contact to coordinate agenda and plans for the survey • Support staff in doing the good work that they always do, so that survey does not cause anxiety and fear

16. After the Survey • Celebrate the success! • May need to work on areas for improvement and submit a follow-up progress report to JCI • Maintain the momentum from the survey --- establish an ongoing system of standards compliance and survey readiness