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 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, 2 nd 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 actual practice, 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