What is JCI?

 

JCI, the acronym of Joint Commission International, recognized by World Health Organization (WHO), is the authority in global hospital quality evaluation.

 

What is the core idea of JCI standards?

 

The idea of JCI standards is to meet patients’ need maximally, establish related policies, systems and processes to encourage continual quality improvement, regulate hospital management, and provide patients with thoughtful and quality services.

 

What is the difference between JCI and ISO?

 

Both JCI and ISO are international accreditation standards, the difference is that ISO international general standards are applicable to companies, factories and enterprises that manufacture and sell products, and JCI is the special medical field international standards for medical organization accreditation, and requires accredited organizations to have tri-annual re-surveys.

 

JCI organization and JCI standards

 

JCI organization is composed by international experts of medical, nursing, administration, public policy and other fields, and they are from Latin America and Caribbean, Asia and Pacific Rim, Middle Ease, Middle Europe and East Europe, and Africa. JCI has guided and surveyed public and private medical organizations and governments in more than 100 countries. JCI hospital accreditation could help hospital to establish uniform, standard-based and practical organization management framework, policies and working processes. Chinese government has decided to take JCI standard as main reference for hospital accreditation in our country in the future, and “safety”, “quality”, “service” will be the core of accreditation, which means all hospitals in the country will be focusing on the continual improvement of medical quality, service quality and patient safety.

 

Why does our hospital carry on JCI accreditation?

 

JCI accreditation standards are the globally accepted medical service standards, representing the highest level of hospital service and hospital management, meanwhile they could help hospital to establish reasonable, appropriate organization structure, policies and working processes. Our hospital, in order to meet the needs of Shenzhen’s development towards international city, to improve hospital safety and standardized management, to improve hospital management, to meet the basic requirements of international commercial insurance organizations to pay medical insurance, to fit the current market and internal and external environments, decides to take JCI standards as hospital working guidance to achieve hospital strategic development target during the current critical period.

 

What benefits may hospital bring to patients by having JCI accreditation?

 

       Obtaining JCI accreditation indicates that the quality of medical services provided in the hospital has reached global accepted level.

 

   Obtaining JCI accreditation indicates hospital has made a solemn promise on continual improvements on medical quality and patient safety.

 

   JCI is the sign of hospital safety and standardized management, also the basis for commercial insurance company to make reimbursements.

 

 

JCI accreditation process

   

      Preparation   It may cost more than one year or more to prepare for JCI accreditation, because there are many strict steps to be completed, including: research and accumulate current material; make gap analysis; design, implement, evaluate and run new system; and have survey finally. JCI requires at least four months of successful running of the whole system before survey.

 

  JCI survey    In order to get accreditation, there will be a JCI survey (or investigation) in the hospital. A team composed of three surveyors (usually a physician, a nurse and an administration person) will be sent to the hospital for three to five days.

 

   Hospital survey   During survey, JCI surveyors will use tracer method (or system method) to make investigation, and they will interview eight or more than eight patients on spot by using this method. By using this method, surveyors could determine the quality of the nursing service the patients have and determine how every department works together to provide nursing service. In this process the surveyors have to make judgment based on more than 300 standards and more than 1000 measurable elements and grade.

 

   Withdraw interview   Before leaving hospital, the surveyors will have a withdraw interview with the managerial personnel in the hospital and submit a preliminary report to them.

 

  Award accreditation   60 days after completing formal survey, the hospital will be informed officially if it is accredited.

 

 

How to carry on a JCI accreditation?

 

Survey team is composed of one physician surveyor, one nurse surveyor and one administration surveyor, in rotation. They are the experts in their own field, having international working experience. Each surveyor is responsible for surveying if the standards were met and make corresponding scoring.

 

The survey time is not fixed, about 3 ~ 5 days, usually contains the following steps:

    

        Policy review (usually in the morning)   Review the related policies, meeting minutes and other documents in the hospital, and there are eight written documents are required to be translated before survey.

　

    Meeting with leadership   Give survey feedbacks of the observations every day, discuss the opportunities and steps for improvement.

 

   Visiting medical and nursing units     Usually after visiting hospital facilities, environment, surveyors will review inpatient medical records with medical and nursing staff, usually 8~10 records will be reviewed; meet frontline staff randomly, sometimes talk with patients to know the quality of medical service in some departments; check hospital infection control, quality improvement, patient safety and etc. when surveying hospital function departments; make inspection tour to check environment and hospital facilities, including kitchen, equipment department and etc.

 　　

   Other evaluation activities

 

The accreditation processes mentioned above will help surveyors to know the structure of hospital operating; meeting with leadership will help to know the overall strategy planning; during accreditation, they will also meet hospital physicians, nurses and directors of departments, and talk with them on how to guarantee patients’ rights and safety. During survey, OPD, OR, obstetrics dept., anesthesia dept., ER, radiology dept., IPD, pathology dept., clinical lab dept., rehabilitation dept. and other departments will be inspected, however the inspection methods and times may be different.

 

The inspection to function departments will mainly focus on evaluating staff qualification and education, hospital infection control, quality improvement, patient safety and other issues.

 

The survey team doesn’t determine whether or not a hospital will be accredited or not, however, it makes a preliminary report and submits it to JCI principle and standard committee, and the 16 experts in the committee will decide if the hospital will be accredited.

 

Working target of JCI accreditation in our hospital   Our target: try to meet JCI accreditation standards within two years, and try formal survey at the beginning of 2011.

 

 

The JCI accreditation process in our hospital