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Prepared By: Mouad Hourani, RN, MPh.
Reference: JCI survey process guide for hospitals
What is Accreditation?
1. A process to determine if an organization meets a
set of requirements designed to improve quality and
2. Usually nongovernmental
3. Usually voluntary.
What are the benefits of accreditation?
1. Improve quality of care.
2. Ensure a safe environment.
3. Continually work to reduce risks to patients and
How Are The Standards Organized?
1. Organized around important functions of the
2. Grouped by functions related to providing patient
care in a safe, effective, well managed
3. Functions apply to the entire organization as well
as to each department, unit or service.
This section, new to the accreditation
manual, consists of specific requirements
for participation in the JCI accreditation
process and for maintaining an
accreditation award. For a hospital seeking
accreditation for the first time, compliance
with many of the Accreditation Participation
Requirements (APR) is assessed during
Section I: Accreditation Participation
Section II: Patient-Centered
This section contains standards
related to the patient and includes
the standards in the following.
International Patient Safety Goals
The International Patient Safety Goals (IPSG)
promote specific improvements in patient
safety. The goals highlight problematic areas
in health care and describe evidence- and
expert-based consensus solutions to
problems related to patient safety.
Recognizing that sound system design is
intrinsic to the delivery of safe, high-quality
health care, the goals generally focus on
Access to Care and Continuity of
These standards address which patient
needs can be met by the hospital, the
efficient flow of services to patients, and
the appropriate transfer or discharge of
patients to their home or to another care
Patient and Family Rights
These standards address issues such
as promoting consideration of patients’
values, recognizing the hospital’s
responsibilities under law, and
informing patients of their
responsibilities in the care process.
Standards regarding patient rights with
respect to informed consent, resolution
of complaints, and confidentiality are
This chapter addresses patient
assessment at all points of care within the
hospital. Assessment includes collecting
information and data on the patient’s
physical and psychosocial history,
analyzing the data and information to
identify the patient’s health care needs,
and developing a plan of care to meet
those identified needs. This chapter also
Assessment of Patients
Care of Patients (COP)
This chapter discusses activities basic
to patient care, including processes for
planning and coordinating care,
monitoring results, modifying care, and
conducting follow-ups. The chapter also
includes high-risk care services,
nutrition care, pain management, and
Anesthesia and Surgical
This chapter addresses sedation
and anesthesia use and surgical
care. Topics include procedures for
preparing, monitoring, and planning
for aftercare for patients who
received sedation or anesthesia
and/or who had surgery.
Medication Management and
This chapter addresses systems and
processes for selecting, procuring,
transcribing, distributing, preparing,
documenting, and monitoring
Patient and Family
This chapter contains standards that
address the effectiveness of education
that is provided to patients and families
and the modalities employed to
successfully educate these individuals.
This chapter also examines patients’
readiness to learn by considering their
language needs and learning
The chapters in the this section examine
the benefits of the hospital’s management
system for patients, focusing on core
processes that support good
management. Examples of core
processes include leadership
requirements, infection prevention and
control, and the qualifications and
Section III: Organization Fun
The standards in this chapter identify the structure,
leadership, and activities to support the data collection,
analysis and improvement for the identified priorities—
hospital wide and department- and service-specific.
This includes the collection and analysis of data on, and
response to, hospital wide sentinel events, adverse events,
and near-miss events. The standards also describe the
central role of coordinating all the quality improvement and
patient safety initiatives in the hospital and providing
guidance and direction for staff training and communication
of quality and patient safety information. The standards do
not identify an organizational structure, such as a
Quality Improvement and Patient
Prevention and Control of
These standards address the methods a
hospital uses to design and implement a
program to identify and reduce the risk of
patients and staff acquiring and transmitting
infections. Areas covered in this chapter
include the process for reporting infections
and the types of ongoing surveillance
activities that are in place.
Effective leadership depends on successfully performing the
• Planning and designing services—defining a clear mission,
including a vision of the future and the values that underlie
• Directing services—developing and maintaining policies,
providing an adequate number of staff, and determining their
qualifications and competence.
• Integrating and coordinating services—identifying and
planning the clinical services required and integrating and
coordinating those services within and between departments.
• Improving performance—leaders’ critical roles in initiating
performance and maintaining a hospital’s performance
The GLD chapter has been greatly expanded in the fifth edition
Governance, Leadership, and Direct
Facility Management and
These standards measure the hospital’s
maintenance of a safe, functional, and
effective environment for patients, staff
members, and other individuals. Areas
addressed include emergency
preparedness, security, safety, life
safety, medical equipment, utility
systems, hazardous materials, and
Staff Qualifications and
This chapter includes sections on
human resources planning; staff
orientation, training, and education;
staff competence assessments;
handling staff requests; and
credentialing and privileging of
licensed independent practitioners,
Formerly named Management of
Communication and Information (MCI), these
standards have been focused to address how
well the hospital obtains, manages, and uses
information to provide, coordinate, and integrate
services. The principles of good information
management apply to all methods, whether
paper-based or electronic, and JCI standards
are equally compatible with either method.
Management of Information (
Standard, Intent &
JCI standards define the performance expectation, structures, or
functions that must be in place for a hospital to be accredited by JCI.
JCI’s International Patient Safety Goals (page ) are considered
standards and are evaluated as are standards in the on-site survey.
A standard’s intent helps explain the full meaning of the standard. The
intent describes the purpose and rationale of the standard, providing an
explanation of how the standard fits into the overall program, sets
parameters for the requirement(s), and otherwise “paints a picture” of
the requirements and goals.
Measurable Elements (MEs):
Measurable elements (MEs) of a standard indicate
what is reviewed and assigned a score during the
on-site survey process. The MEs for each
standard identify the requirements for full
compliance with the standard. The MEs are
intended to bring clarity to the standards and to
help the organization fully understand the
requirements, to help educate leaders and health
care workers about the standards, and to guide
the organization in accreditation preparation.
Standard, Intent &
During an on-site survey, each measurable element (ME) of a
standard is scored as either “fully met," “partially met,” “not met,” or
“ Fully Met ” Score:
1. An ME is scored “fully met” if the answer is “yes” or “always” to
the specific requirements of the ME. Also considered are the
a) A single negative observation may not prevent a score of
b) If 90% or more of observations or records (for example, 9
out of 10) are met.
2. The track record related to a score of “fully met” is as follows:
1. An ME is scored “partially met” if the answer is “usually” or “sometimes” to
the specific requirements of the ME. Also considered are the following:
a) If 50% to 89% (for example, 5 through 8 out of 10) of records or
observations demonstrate compliance
b) Evidence of compliance cannot be found in all areas/departments in
which the requirement is applicable (such as inpatients but not
outpatients, surgery but not day surgery, sedating areas except
c) When there are multiple requirements in one ME, at least half (50%)
d) A policy/process is developed, implemented, and sustainable but
does not have the track record required for “fully met.”
e) A policy/process is developed and implemented but does not seem to
2. The track record related to a score of “partially met” is as follows:
“Partially Met” Score
1. An ME is scored “not met” if the answer is “rarely” or “never” to the
specific requirements of the ME. Also considered are the following:
a) If 49% or fewer (for example, 4 or less out of 10) records or
observations demonstrate compliance
b) When there are multiple requirements in one ME, 49% or fewer are
c) A policy/process is developed but is not implemented.
2. The track record related to a score of “not met” is as follows:
a) The requirements of the ME are “fully met”; however, there is only
a less than 5-month look-back period of compliance for triennial
a less than 1-month look-back period of compliance for initial
b) If an ME of a standard was scored “not met” and some or all of the
“Not Met” Score
An ME is scored “not applicable” if the
requirements of the ME do not apply based on
the hospital’s services, patient population, and
so forth (for example, the hospital does not
“Not Applicable” Score
The on-site review consists of the
1. Orientation to the Hospital’s Services and the Quality
2. Surveyor Planning Session.
3. Document Review.
4. Daily Briefing.
5. Leadership for Quality and Patient Safety Interview
6. Department/Service Quality Measurement Tracer.
7. Quality Program Interview.
8. Ethical Framework and Culture of Safety Interview.
9. Supply Chain Management and Evidence-Based
10. Individual Patient Tracer Activity.
The on-site review consists of the
11. Organ and Tissue Transplant Services Interview and Tracer.
12. Facility Tour.
13. System Tracer: Facility Management and Safety System.
14. System Tracer: Medication Management.
15. System Tracer: Infection Control.
16. Undetermined Survey Activities.
17. Optional Education Session: Hospital Decision Rules,
Scoring Guidelines, and Strategic Improvement Plan.
18. Staff and Medical Professional Education Qualifications
19. Closed Patient Medical Record Review.
20. Leadership Exit Conference.
Note: The survey team leader will conduct a brief meeting
prior to the Opening Conference and Agenda Review with the
CEO, survey coordinator, and translators to discuss the
logistics and expectations for the onsite survey and use of
translators. If there will be any approved observers, hospitals
must provide a list of their names, titles, and hospital
affiliations to the survey team leader.
During the Opening Conference and Agenda Review, the
surveyor(s) describes the structure and content of the survey
to the hospital.
Opening Conference and
Orientation to the Hospital’s Services
Quality Improvement Program
The hospital orients the surveyor(s) to the
services, programs, and strategic activities the
hospital provides and its quality improvement
process. This information provides the
surveyor(s) with baseline information about the
hospital and its quality and patient safety
program that can help focus subsequent survey
During this session, the surveyor(s) reviews
information about the hospital and plans
surveyagenda. The surveyor(s) also selects
The objective of the Document
session is to survey standards that
some written evidence of
compliance, such as an emergency
preparedness plan or a patient’s
document. In addition, this session
the survey team to the structure of
hospital and management.
To facilitate understanding of the
process and the findings that
The purpose of this session is to
hospital leadership selects the
be used to measure,
assess, and improve quality and
safety and the process for
hospitalwide strategic priority
Leadership for Quality and
Patient Safety Interview
The purpose of this tracer is to
quality measurement to
improve patient care and services
provided by their area. In addition,
surveyors will evaluate how clinical
are selected and implemented for
The purpose of this session is to
the quality program staff support
program for quality and patient
the use of tools for data collection,
analysis, and response to
sentinel events, adverse events, and
The purpose of this session is to
hospital’s development and
of an ethical framework and how
leadership, through its vision and
shapes the culture of safety in the
Ethical Framework and
Culture of Safety
The purpose of this session is to identify
hospital leadership uses evidence to
decisions related to purchasing and the
technical and human resources. As part
decision making, it is important to have a
understanding of the supply chain for
technology, and supplies. Discussion will
leadership knowledge and
integrity of the supply chain.
Supply Chain Management
An individual patient tracer follows the experiences of an
patient to evaluate the hospital’s performance against
standards. One approach to conducting a tracer is to
the course of care, treatment, and services received by the
preadmission through post-discharge.
During an individual tracer, the surveyor(s) will do the
Follow the course of care, treatment, and services
patient by and within the hospital using current records
Assess the interrelationships between and among
departments, programs, services, or units and the
in the care, treatment, and services being provided
Evaluate the performance of relevant processes, with
on the integration and coordination of distinct but
Identify potential concerns in the relevant processes
Individual Patient Tracer
The purpose of the Facility Tour is to address
related to the following:
• The physical facility
• Utility systems
• Fire safety
• Medical technology and other nonmedical
• Patient, visitor, and staff safety and security
• Infection prevention and control
• Emergency preparedness
• Hazardous materials and waste
• Staff education
The purpose of this session is to provide
the surveyor(s) in his or her evaluation of
hospital’s facility management and safety
system and the effectiveness of the
programs in managing risk. The surveyor(s)
hospital will do the following:
• Identify areas of strength and
improvement in the hospital’s FMS
• Assess or determine the hospital’s actual
System Tracer: Facility
Management and Safety
This session explores the hospital’s
management process as well as potential
points in the system.
Note: When a separate Medication
System Tracer is not noted on the
example, on shorter surveys), the
address medication management
individual patient tracers and during the
quality activities, such as the Leadership
System Tracer: Medication
During the discussion of the infection prevention and
program, the surveyor(s) and hospital will be able to
• Identify strengths and potential areas of concern in
prevention and control program
• Begin determining actions necessary to address any
risks in infection prevention and control processes
• Begin assessing or determining the degree of
• Identify infection prevention and control issues
Note: When a separate Infection Prevention and
Tracer is not noted on the agenda (for example, on
surveys), the surveyor(s) will address infection
System Tracer: Infection
Prevention and Control
Tracer methodology is used as the primary tool to
standards compliance. However, other tools or a
approach can be used to gather additional
evaluate standards compliance that is not directly
specific patient tracer. Each of these focused
on the survey agenda as an “Undetermined
Undetermined Survey Activities are broadly
encompass a variety of activities customized to
needs of each hospital. Undetermined Survey
selected by the survey team to allow a more
assessment of a targeted area when information
survey activity, such as tracers or discussions,
Note: In past years, this session was called the Staff
Qualifications and Education Session."
The objective of this interview session is to address
the hospital’s processes to recruit, orient, educate,
and evaluate all hospital staff. In addition, the session
addresses the hospital’s process for evaluating the
credentials of the medical, nursing, and other health
care professional staff and their ability to provide
clinical services consistent with their qualifications.
Staff and Medical Professional
Education Qualifications Session
This session is held to validate the hospital’s
compliance with the documentation track record (4
months for initial surveys and 12 months for triennial
Purpose of the Form
The purpose of using the Closed Patient Medical
Record Review Form (see page 99) is to gather and
record continuous evidence of compliance with
standards that require documentation in the patient’s
Closed Patient Medical Record
For surveys conducted by more than
surveyor, scheduled team meetings
opportunity for surveyors to share
and observations, plan for upcoming
activities, and plan for communication
coordination with the hospital.
Surveyor Team Meetings
The surveyor(s) will use this time to compile,
and organize the data collected throughout
into a report reflecting the hospital’s
The purpose of this conference is to report
findings of the survey to hospital leadership