Healthcare Accreditation

• Adopted by Dr. Haitham Khatatbeh

• Jerash University- Faculty of Nursing
What is accreditation?
• A government or non-government agency grants recognition to health care institutions
which meet certain standards that require continuous improvement in structures,
processes, and outcomes.
• Usually a voluntary process.
• Accreditation Represents a Risk Reduction Strategy:
• That an organization is doing the right things and doing them well;
• Thereby significantly reducing the risk of harm in the delivery of care; and
• Optimizing the likelihood of good outcomes.
Common Core of Health Care Accreditation
Around the World
1. Administered by a recognized body:
• Establishes and publishes standards,
• Conducts objective on-site evaluations,
• Publishes accreditation decision.
2. Professional involvement:
• Consensus on standards of quality and safety,
• Professionals serve as the external evaluators.
3. Focus is on continuous improvement.
What is Accreditation Intended to Accomplish?
• Maximize quality/minimize safety risk:
Improve patient care processes and outcomes,
Enhance patient safety.
• Strengthen the confidence of patients, professionals, and payors about the organization,
• Improve the management of health services,
• Enhance staff recruitment, retention, and satisfaction,
• Provide education on better/best practices,
Benefits of healthcare
accreditation
Benefits of accreditation for the Hospital
• Improves care and enhances public confidence

• Stimulates continuous improvement

• Demonstrates commitment to quality care

• Raises community confidence

• Comparison with self and other similar organization

Benefits for the Medical and Nursing Staff
• Improves professional staff development

• Provides education on standards

• Provides leadership for quality improvement within medicine and nursing

• Increases satisfaction with working conditions, leadership and accountability

Benefits for Hospital Employees
• Values employee opinions

• Measures employee satisfaction

• Improved employee safety and security

• Clearer lines of authority and accountability

• Promotes teamwork
Benefits for Patients
• Access to a quality focused organization

• Rights are respected and protected

• Understandable education and communication

• Satisfaction is evaluated

• Involvement in care decisions and care process

• Focus on patient safety

The Accreditor’s Tools

STANDARDS EVALUATION PATIENT SAFETY DATA ON EDUCATION

METHODOLOGY GOALS AND TOOLS PERFORMANCE
AND BENCHMARKS
Standards

• The heart of any accreditation program is the standards upon which

all else is based – the evaluation methodology, decision process,
evaluator training, and other operational elements.

• Thus, a standard must be “good”, not just on the day the standard is
written, but on a continuing basis.
Impact of Accreditation
• What is the evidence that:
– Accreditation improves quality and safety of care?
– High quality lowers cost of health care?
– The cost of implementing accreditation standards is worth the
achievable benefit?
Continue..
• The process of Joint Commission International accreditation has set
many of the fundamental principles that guide health care
organizations today.
• Many of these principles are routine in health care today but were
revolutionary in their time
Example 1
• Medical Records:
First required in 1917, many considered the medical record
unnecessary

Today the medical record is inarguably the central point of information

gathering for treatment decisions, research, patient monitoring,
outcomes measurement, and even billing.
Example 2
• Infection Control Programs
• In the mid-1950s, patients, especially surgery patients and
newborns, acquired infections in epidemic proportions.
• So, hospitals were required to appoint infection control committees
to direct activities aimed at curbing epidemics of infections.
• Infection control programs were created that reduced the spread of
devastating infectious agents.
Joint Commission International
• JCI is An independent, non-profit, non- governmental agency – Accredits over 15,000
health care organizations in the United States.

• Mission of JCI:
To improve the safety and quality of care in the international community through the
provision of education, publications, consultation, evaluation, and accreditation services.
Accreditation Process Time Line
Joint Commission International Standards
• Patient-Centered Standards:
• Access to Care and Continuity of Care (ACC)
• Patient and Family Rights (PFR)
• Assessment of Patients (AOP)
• Care of Patients (COP)
• Anaesthesia and Surgical Care (ASC)
• Medication Management and Use (MMU)
• Patient and Family Education (PFE)
Continue..
• Organization Management Standards
• Quality Improvement and Patient Safety (QPS)
• Prevention and Control of Infections (PCI)
• Governance, Leadership, and Direction (GLD)
• Facility Management and Safety (FMS)
• Staff Qualifications and Education (SQE)
• Management of Information (MOI)

• Supplementary file of JCI standards is available

JCI survey
• The purpose of a JCI accreditation survey is to assess the extent of a
hospital’s compliance with applicable JCI standards.
• Assessing hospital compliance is accomplished through a number of
methods, including the following:
✓Receipt of verbal information concerning implementation of standards
or examples of their implementation
✓On-site observation by a JCI surveyor(s)
✓Review of documents that demonstrate compliance and assistance in
orienting the surveyor(s) to the hospital’s operations

• Supplementary file of JCI survey is available

Continue..
• The on-site survey uses tracer methodology to follow a sample of active
patients through their experiences of care in the hospital and to evaluate
individual components and systems of care.

• An important characteristic of the JCI survey process is on-site education

conducted by the surveyor(s). This support occurs throughout the survey
as the surveyor(s) offers suggestions and strategies that may help the
hospital better meet the intent of the standards and, more importantly,
improve performance.
The on-site survey consists of several steps
such as:
1. Orientation to the Hospital’s Services and the Quality Improvement Plan
2. Surveyor Planning Session
3. Document Review
4. Daily Briefing
5. Facility Tour
6. System Tracer: Medication Management
7. System Tracer: Infection Control

Tracer methodology: https://www.youtube.com/watch?v=GH5OGjxIUBU

1. Orientation to the Hospital’s Services and the Quality
Improvement Plan
• Purpose
✓ 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 activities.

• Issues Addressed
✓ Overview of the hospital’s services
✓ Overview of the quality improvement and patient safety program and process
✓ Overview of medical education (for academic medical center hospitals only)
✓ Overview of research programs (for academic medical center hospitals only)
2. Surveyor Planning Session
• Purpose
✓ During this session, the surveyor(s) reviews data and information about the hospital and plans
the survey agenda. The surveyor(s) also selects initial tracer patients/clients.

• Hospital Participants
✓ The hospital should provide space for this activity, usually the room designated as the “surveyor
headquarters.”
✓ This space should have the following items: Conference table, Power outlets, Telephone, High-
speed Internet connection/access for each surveyor, Printer, Document shredder.

• Hospital Participants
✓ Hospital survey coordinator (as needed by team)
✓ Translators (as needed by team)
3. Document Review
• Purpose
✓ The objective of the Document Review session is to survey standards that require some written
evidence of compliance, such as an emergency preparedness plan or a patient’s rights document.
✓ In addition, this session orients the survey team to the structure of the hospital and management.

• Hospital Participants
✓ Participants should include hospital staff members who are familiar with the documents that will be
reviewed, can translate these, and are able respond to questions the surveyor(s) may have during the
session.

• Examples of Documents/Materials Needed

✓ A list of clinical practice guidelines
✓ An accurate list of the patients currently receiving care in the hospital
✓ A current map of the hospital campus
✓ A sample of all medical record forms
continue
• What Will Occur
✓ The documents should be made available to the survey team
✓ one staff person should briefly orient the survey team to the organization of the documents.
✓ a staff member who can respond to any questions the surveyor(s) may have should be readily available (in
person or by telephone).
• Evaluation of the Policies and Procedures by the Survey Team
✓ The documents reviewed by the survey team provide an overview of what they expect to see in actual
practice during the survey process.
• For example, they would expect to find the following when a new procedure on the disposal of infectious
waste is developed:
✓ That appropriate staff have been educated about the new procedure
✓ That any special skills or other needed training has taken place
✓ That waste is actually being disposed of according to the new procedure
✓ That any documentation required by the procedure is available for review
4. Daily Briefing
• Purpose
✓ To facilitate understanding of the survey process and the findings that contribute to the accreditation
decision.
• What Will Occur
✓ The daily briefing occurs every morning of a multiday survey with the exception of the first day.
✓ The session is intended to be brief; 60 minutes is suggested depending on the number of surveyors on the
team.
✓ When multiple surveyors are on site, the briefing is conducted jointly, with the survey team leader serving
as the facilitator.
• During the daily briefing with the hospital, the surveyor(s) will perform the following actions:
✓ Offer a concise summary of the survey process activities completed on the previous day
✓ Note any specific positive findings
✓ Emphasize patterns or trends of significant concern that could lead to noncompliance determinations. The
surveyor(s) may report minor, one-time, or single observations that might not impact final scoring
4. Continue..

Do not expect the surveyor(s) to perform the following actions:

✓ Repeat observations made at a previous Daily Briefing unless it is in the context of
identifying a systemic issue.
✓ Discuss, in detail, each survey activity, specific records, suggestions, and conversations held
with individuals during tracers.
✓ Delay scheduled activities for the current day to have an in-depth discussion of issues from
the previous day.
1
5. Facility Tour

• Purpose
✓ The purpose of the Facility Tour is to address issues related to the following:
The physical facility, Utility systems, Fire safety, Medical technology and other nonmedical equipment,
Patient, visitor, and staff safety and security, Infection prevention and control, Emergency preparedness,
Hazardous materials and waste & Staff education.

• Location
✓ Selected patient care settings, inpatient and ambulatory units, treatment areas, and other areas, including,
but not limited to, admitting, kitchen, pharmacy, central storage, laundry, morgue, and power plant (if
applicable).
✓ The tour is designed to cover high-risk areas for safety and security. Any and all areas of the hospital’s
campus may be surveyed, so the hospital must be prepared to provide JCI surveyors with access to any
area(s) upon request.
continue
• Standards/Issues Addressed
✓ Facility Management and Safety (FMS)
✓ Prevention and Control of Infections (PCI)
✓ Staff Qualifications and Education (SQE)
✓ Assessment of Patients (AOP); laboratory and radiology standards
✓ Management of Information (MOI)
✓ Medication Management and Use (MMU); storage of medication
✓ Access to Care and Continuity of Care (ACC); admission to hospital, transportation
✓ Patient and Family Rights (PFR); privacy, confidentiality, and security
continue
• What Will Occur during the Facility Tour
✓ After the surveyor( review the documented, current, accurate inspection of the hospital's physical facilities
✓ They will then visit different areas of the facility to check the implementation of these programs.
✓ The surveyor(s) will visit patient care areas as well as non–patient care areas of the facility.
✓ The non–patient care areas visited by the surveyor(s) include the following: The boiler room, The emergency
power generator, Central sterile supply department, Laboratory, The IT control room, The laundry, Food
service/kitchen, Medical gas storage areas, Hazardous materials storerooms, etc.
✓ surveyor(s) will observe the facility and interview staff to learn how the hospital manages the facility to
accomplish the following:
➢ Reduce and control hazards and risks
➢ Prevent accidents and injuries
➢ Maintain safe conditions
➢ Maintain secure conditions
➢ Implement emergency response plans
6. System Tracer: Medication Management
• Purpose
✓ To explore the hospital’s medication management process as well as potential risk points in the system.

• During the focused-tracer activity, the surveyor(s) will visit areas relevant to medication management processes,
talk with available staff in these areas about their roles in medication management, visit unit medication storage
locations, review documentation, and possibly interview a patient.
• Standards/Issues Addressed
✓ All Medication Management and Use (MMU) standards
✓ IPSG.3 and IPSG.3.1
• What Will Occur:
• Most important part is a practical medication tracer that extends from the point of order entry to patient
administration and monitoring. It is similar to a patient tracer, but traces a medication rather than a patient.
The medication chosen for the tracer is generally a high-risk/high-alert medication.
7. System Tracer: Infection Prevention and Control
• Purpose
✓ Identify strengths and potential areas of concern in the infection prevention and control program
✓ Begin determining actions necessary to address any identified risks in infection prevention and control
processes
✓ Begin assessing or determining the degree of compliance with relevant standards

• Process
✓ The tracer may begin with a short group meeting with individuals responsible for the hospital’s infection
prevention and control program or in a patient care area identified by the surveyor(s) for the focused-tracer
activity.
✓ During the group meeting, the surveyor(s) will gain a better understanding of the infection prevention and
control system.
✓ The surveyor(s) may move to other settings as appropriate and applicable to tracing infection prevention and
control processes across the hospital.
✓ The surveyor(s) will observe staff and engage them in discussion focused on infection prevention and
control practices in any setting that is visited during this system tracer activity.
Questions?
References

• Joint Commission International. International Library of Measures.

https://www.jointcommissioninternational.org
• Agency for Health Research and Quality. Resources for health care quality
measurement. https://www.ahrq.gov
• https://www.definitivehc.com/blog/history-of-quality-improvement-in-healthcare
• http://squire-statement.org/
• https://www.who.int
• https://www.cdc.gov
• https://www.ihi.org
• https://www.ahrq.gov/