JCI is a non-profit organization that accredits healthcare facilities outside of the United States. It was founded in the late 1990s and currently accredits over 375 facilities across 47 countries. JCI has a global team of over 200 consultants and surveyors. It provides accreditation for various types of healthcare organizations. The 5th edition of JCI standards will take effect in 2014 and contains 285 standards across four sections relating to accreditation requirements, patient care, organizational management, and academic medical centers. JCI uses a thorough survey methodology including document review, mock surveys, and multi-day onsite surveys where surveyors follow patient cases and processes. Facilities must meet minimum scoring thresholds on standards and chapters to receive ac

1. Joint Commission International KeyJoint Commission International Key
ElementsElements
By Mahboob Ali Khan MHA CPHQBy Mahboob Ali Khan MHA CPHQ

2. Joint commission internationalJoint commission international
(JCI)(JCI)

3. Who JCI isWho JCI is
 Joint Commission InternationalJoint Commission International (JCI) was(JCI) was
founded in the late 1990s to surveyfounded in the late 1990s to survey
hospitals outside of the United States. JCI,hospitals outside of the United States. JCI,
which is also not-for- profit, currentlywhich is also not-for- profit, currently
accredits facilities in Asia, Europe, theaccredits facilities in Asia, Europe, the
Middle East, and South America. A countMiddle East, and South America. A count
of JCI-accredited hospitals worldwide (asof JCI-accredited hospitals worldwide (as
listed on the JCI website in June 2012)listed on the JCI website in June 2012)
shows 375 hospitals in 47 countries.shows 375 hospitals in 47 countries.

4. JCIA Global PresenceJCIA Global Presence
Our JCI team:Our JCI team:
 World headquarters in North AmericaWorld headquarters in North America
 Regional offices in Asia-Pacific, Europe, andRegional offices in Asia-Pacific, Europe, and
the Middle Eastthe Middle East
 A full service headquarters staffA full service headquarters staff
 More than 200 international consultants andMore than 200 international consultants and
accreditation surveyorsaccreditation surveyors

5. Services of JCIServices of JCI
 Advance certificationAdvance certification
 HospitalsHospitals
 Ambulatory healthcareAmbulatory healthcare
 Behavioral healthcareBehavioral healthcare
 Critical Access HospitalCritical Access Hospital
 Disease Specific CareDisease Specific Care

6. Services Of JCI (contd…)Services Of JCI (contd…)
 Home careHome care
 Health Care Staffing ServiceHealth Care Staffing Service
 Laboratory ServicesLaboratory Services
 Long term careLong term care
 Nursing care centerNursing care center
 Office based SurgeryOffice based Surgery

7. JCI 5JCI 5THTH
EditionEdition
 Will be effective from 1Will be effective from 1stst
April 2014April 2014
 Will consists of four sectionsWill consists of four sections
 Section one consists of accreditationSection one consists of accreditation
participation requirements APRparticipation requirements APR
 Section two Patient centered standardsSection two Patient centered standards
 1.IPSG1.IPSG
 2. ACC (Access to care and continuity of2. ACC (Access to care and continuity of
care)care)

8. JCI 5JCI 5thth
EditionEdition
 3. PFR (Patient and Family Rights)3. PFR (Patient and Family Rights)
 4. AOP (Assessment Of Patients)4. AOP (Assessment Of Patients)
 5. COP (Care Of Patients) ambulatory5. COP (Care Of Patients) ambulatory
 6. ASC (Anesthesia and Surgical Care)6. ASC (Anesthesia and Surgical Care)
 7. MMU (Medication Management and7. MMU (Medication Management and
Use)Use)
 8. PFE (Patient and Family Education)8. PFE (Patient and Family Education)

9. JCI 5JCI 5THTH
editionedition
 Section three consists of Health careSection three consists of Health care
organization management standardsorganization management standards
 9. QPS (Quality improvement and Patient9. QPS (Quality improvement and Patient
Safety)Safety)
 10. PCI (Prevention and Control of10. PCI (Prevention and Control of
Infections) laboratoryInfections) laboratory
 11. GLD (Governance, Leadership and11. GLD (Governance, Leadership and
Direction) for hospitals and academicDirection) for hospitals and academic
medical institutionsmedical institutions

10. JCI 5JCI 5thth
editionedition
 12.FMS (Facility Management and Safety)12.FMS (Facility Management and Safety)
 13.Staff qualification and education SQE13.Staff qualification and education SQE
 14.Management of Information MOI14.Management of Information MOI
 Section four academic medical centerSection four academic medical center
hospitals standardshospitals standards
 15.Medical profession education MPE15.Medical profession education MPE
 16.Human subjects research Programs16.Human subjects research Programs
HRPHRP

11. JCI 5th editionJCI 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

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

13. 10-14 Months
JCI survey methodologyJCI survey methodology
Organizational
Assessment
Ongoing
Technical
Assistance
Off-site Document
Review
Mock Survey
Hospital
Accreditation
Survey
Ongoing
Technical
Assistance

14. JCI Tracer MethodologyJCI Tracer Methodology
 Patient tracerPatient tracer Allows a surveyor to assess an
organization’s systems and processes by
 Following the treatment path an individual patient has
taken in the hospital, or
 Following a process in the hospital from a beginning to
an endpoint

15. Tracer Patient SelectionTracer Patient Selection
 JCI Surveyors typically select a patient from a list of
current admissions, after consultation with the hospital
staff.
 op diagnoses and procedures (surgical, medical,
obstetrical, intensive care)
 A patient on dialysis (if applicable)A patient on dialysis (if applicable)
 A psychiatric patient (if applicable)
 A pediatric patient (if applicable)
 A patient receiving lab/imaging services
 A patient receiving rehabilitation services
 Patients due for discharge that day or the next day

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

17. Scoring survey resultsScoring 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

18. Thank YouThank You