MHA students presentations , Manipal University

1. JOINT COMMISSION INTERNATIONAL
ACCREDITATION(JCIA)
• Presented By:-
MANOJ.P
142803008

2. ACCREDITATION
• Accreditation is a process in which an entity, separate & distinct from
the health care organization ,usually non governmental
• assesses the healthcare organization to determine if it meets a set of
requirements (standards) designed to improve the safety and quality
of care .
• Accreditation is usually voluntary.
• It has gained world wide attention as an effective quality evaluation
and management tool.

3. BENEFITS OF ACCREDITATION
• Improve public trust
• Provide a safe and efficient work environment
• Negotiate with sources of payment
• Listen to patients & their families ,respect their rights & involve them in the care process as
partners
• Create a culture that is open to learning
• Establish collaborative leadership & continuous leadership

4. Introduction to JCI
• Joint Commission International (JCI) was founded in
the late 1990s to survey hospitals outside of the
United States.
• JCI, which is also not-for- profit, currently accredits
facilities in Asia, Europe, the Middle East, and South
America.
• A count of JCI-accredited hospitals worldwide (as
listed on the JCI website till 2015) shows 820 hospitals
in 47 & above countries.
• 21 hospitals in India

5. JCIA Global Presence
JCI team:
 World headquarters in North America
Regional offices in Asia-Pacific, Europe, and the Middle East
 More than 200 international consultants and accreditation
surveyors

6. WHAT IS JCI?HOW IS IT GOOD FOR US ?
• JCI stands for JOINT COMMISSION INTERNATIONAL.
• It is US based , not for profit accreditation body , which sets & addresses
standards for the healthcare providers level of performance in key
functional areas , such as patient rights , patient treatment & infection
control
• JCI’S mission is to improve the quality of healthcare in the international
community by providing worldwide accreditation services
• JCIA is an initiative designed to respond to a growing around the world for
standards – based evaluation in health care.

7. HOW WILL IT HELP US?
• JCI standards would lead us to improved patient care, safety & path of
continuous quality improvement .
• This would strengthen patient , third party and insurer confidence
and would provide us a competitive edge
• JCI accreditation is the gold standard for quality as it reflects the
provision of the highest level of patient care & patient safety

8. • JCI ACCREDITATION. JCI accredits 8 types of healthcare programs:-
• 1.hospitals
• 2.academic medical center hospitals
• 3.ambulatory care facilities
• 4.clinical laboratories
• 5.home care facilities
• 6.long term care facilities
• 7.medical transport organizations
• 8.primary care centers

9. JCI 5TH Edition
• Effective from 1st April 2014
• Consists of four sections
Section 1 consists of accreditation participation requirements APR
Section 2 Patient centered standards
• 1.IPSG
• 2. ACC (Access to care and continuity of care)

10. JCI 5th Edition
• 3. PFR (Patient and Family Rights)
• 4. AOP (Assessment Of Patients)
• 5. COP (Care Of Patients) ambulatory
• 6. ASC (Anesthesia and Surgical Care)
• 7. MMU (Medication Management and Use)
• 8. PFE (Patient and Family Education)

11. JCI 5TH edition
Section 3 consists of Health care organization management standards
• 9. QPS (Quality improvement and Patient Safety)
• 10. PCI (Prevention and Control of Infections) laboratory
• 11. GLD (Governance, Leadership and Direction) for hospitals and
academic medical institutions

12. JCI 5th edition
• 12.FMS (Facility Management and Safety)
• 13.Staff qualification and education SQE
• 14.Management of Information MOI
Section 4 academic medical center hospitals
standards
• 15.Medical profession education MPE
• 16.Human subjects research Programs HRP

13. JCI 5th edition
5th edition of the Hospital Standards contains
• 285 Standards
• 1160 Measurable Elements
4thEdition of the Hospital Standards
• Contains 320 standards
• Over 1200 criteria measured during the survey/evaluation
process

14. REVISION OF STANDARDS
The standards will be revised and published at least every 3 years

15. JCI survey methodology
Thorough survey process becomes Operational:
 Typical survey team consists of a physician, nurse,
and administrator
 Surveyors evaluate various units within an
organization and meet to discuss their finding
 Surveys conduct a complete system analysis on
integration and coordination of care processes

16. ACCREDITATION SURVEYS
• Interview with staff & patients & other verbal information
• On-site observations of patient care process by surveyors
• Policies, procedures, clinical practice guidelines, and other documents
provided by the organization

17. Jci accreditation process timeline
CONTINUOUS QUALITY
IMPROVEMENT JOURNEY
6-9 MONTHS PRIOR
TO TRIENNIAL DUE
DATE
WITHIN 15 DAYS
OF SURVEY
SURVEY DATES
2 MONTHS PRIOR
TO SURVEY
4-6 MONTHS
PRIOR TO SURVEY
6-9 MONTHS
PRIOR TO SURVEY
12-24 MONTHS
PRIOR TO SURVEY
JCI Accreditation survey occurs
Submit revised application & schedule triennial JCI accreditation re- survey
Receive Accreditation Decision & Official Accreditation findings report from
JCI
JCI Survey team leader contacts your organization to determine survey
agenda
Receive & complete JCI survey Contract & Travel Instructions Form
Submit application for survey to JCI, & schedule survey dates with JCI
Obtain JCI standards manual & begin preparing for JCI accreditation.

18. Scoring the Survey Results
• Each standard must have a scoring of at least 5
• Each chapter must have a score of at least 8
• All standards must together average for at least 9
• All measurable elements are averaged to obtain the score for the
standard

19. Scoring survey results
• Each Measurable Element (ME) is scored
Met (10)
Partially Met (5)
Not Met (0)
• All Standards are averaged to obtain the score of the chapter
• All Chapters are averaged to obtain the overall score

20. IPSG
INTERNATIONAL PATIENT SAFETY GOALS
GOAL 1
• Identify patients correctly
GOAL 2
• Improve effective communication
GOAL 3
Improve the safety of high alert medications
a. IV potassium chloride = or > 2meq concentration
b. Sodium chloride >0.9%
c. Magnesium sulphate =or >50% concentration
d. Potassium phosphate = or > 3mmol/ml concentration

21. GOAL 4
• Ensure correct site , correct procedure & correct patient surgery
GOAL 5
• Reduce the risk of healthcare associated infection
GOAL 6
• Reduce the risk of patient harm resulting from falls

22. PIPELINE CARRYING COLOR CODES
As per BIS(Bureau of Indian Standards) :-
• Oxygen –yellow line & white strips
• Vacuum - blue & black strips
• Air – blue & white & black strips
• Nitrous oxide – yellow line with dark blue strips
• Dry nitrogen – yellow with light green strips
• ENTONX – blue & white strips
• Carbon dioxide – yellow with ash strips
• Calibration gas – white & red strips