JCI Accreditation and Specialized Consulting

JCI Accreditation and Specialized Consulting

PROPOSAL FOR SERVICES JCI ACCREDITATION OVERVIEW Preparation Joint Commission International (JCI) accreditation and certification is the proven process your organization needs to help ensure a safe environment for your patients, staff and visitors. This voluntary process demonstrates your organization s commitment to continuously improving patient safety. We are dedicated to helping international healthcare organizations evaluate, improve and demonstrate their quality of patient care while accommodating country specific legal, religious, and cultural factors. For a hospital that is dedicated to clinical excellence for all its patients, the most important benefit of JCI accreditation is its enhanced reputation among stakeholders and the domestic and international communities. Making a decision to obtain JCI accreditation is a journey, a culture shift, and a visible commitment to improve the quality of patient care and services. Benefits of JCI accreditation and certification Improve public trust as an organization that values quality and patient safety Involve patients and their families as partners in the care process Build a culture open to learning from adverse events and safety concerns Ensure a safe and efficient work environment that contributes to staff satisfaction Establish collaborative leadership that strives for excellence in quality and patient safety Understand how to continuously improve clinical care processes and outcomes The key to success in your journey to accreditation is the commitment to the process by the board of directors, president/general director and the clinical leaders in your organization. Because senior leaders are accountable for the overall system s processes to ensure quality and patient safety, their support and commitment are essential to your organization being successful. Accreditation preparation must be a priority in your organization.

Assessment The assessment will cover the entire organization and include all the chapters related to patient-focus and organizational management standards. The assessment will also cover the International Patient Safety Goals and identify gaps in the organizations performance and expectations of the goals. In your baseline assessment, we will also look at quality data currently available in the organization and compare that data to the requirements of the quality monitoring standards. Results of your baseline assessment, guide the development of a detailed action plan. The Baseline Assessment will be arranged according to the JCI standards and arranged to demonstrate your organizations status according to the standards, including findings and recommendations to achieve compliance. Implementation Plan Before you can get started, your organization s leader should designate an individual to be responsible for coordinating the accreditation activities. This individual needs to be a full-time employee of your organization who will be responsible for all accreditation preparation activities prior to the survey, as well as monitoring continuous compliance once the survey is over. This individual is designated as the JCI Survey Coordinator and will be your organization s key contact to the JCI accreditation program. In addition to working closely with AHMC during the preparation phase and the application process, your JCI Survey Coordinator will also coordinate activities with JCI surveyors. For most organizations, the process of preparing for a JCI accreditation survey will take between 12 and 24 months. In some cases, achieving compliance with the standards may require allocation of resources, which could include enhancements to your facility, recruiting and training staff, and redesigning care delivery processes and systems. The availability of these resources will affect the time it will take. The quest for quality and patient safety never ends, however. Once your organization is accredited and as your journey continues, your organization must still focus on maintaining continuous standards compliance. JCI Accreditation will be available to offer guidance, as well as provide important standards interpretation information, newsletters, and tools to assist you in your continued compliance and readiness throughout the three-year accreditation cycle. Organizations that incorporate the continuous readiness activities as an ongoing strategy within their daily life can, and do, move toward achieving some of the highest levels of quality and patient safety. Before you know, it s again time for JCI to visit your organization. Experience first-hand the achievement in providing the best to your patients and their families, your staff, and the organization as a whole. AHMC will work closely with the organization to achieve success at accreditation and provide continuous support. This includes periodic site visits for mock surveys and teaching opportunities on processes, providing guidance to overcome obstacles encountered, providing supplemental resources such as tools and templates as required/requested.

JCI Accreditation Process Time Line 12-24 months prior to survey 6-9 months prior to survey 4-6 months prior to survey 2 months prior survey Survey dates 6-9 months prior to resurvey due date Within 2 months of survey 6-9 months prior to resurvey due date Submit revised application and schedule JCI accredtation resurvery every 3 years Within 2 months of survey Receive accreditation decision and official survey findings report from JCI Survey dates JCI accreditation survey occurs 2 months prior survey JCI survey team leader contacts your organization to determine survey agenda 4-6 months prior to survey Receive and complete JCI service contract and travel instructions form 6-9 months prior to survey Submit application for survey to JCI and schedule survey dates with JCI 12-24 months prior to survey Obtain JCI standards manual and begin preoaring for JCI accreditation

AHMC Preparation Process Time Line 20 months prior to survey 24 months prior to survey - journey to accreditation begins 22 months prior to survey Prior to 24 months - as soon as the decision to move to accreditaton is made 20-1 month each monthprior to survey 20-1 months prior to survey 6-12 months prior to resurvey 24-2 months prior to resurvey 24-2 months prior to resurvey Ensure all documents are translated into English 6-12 months prior to resurvey Mock Survey by AHMC team 20-1 months prior to survey Begin scheduling the monthly web conferencing sessions 20-1 month each month prior to survey AHMC JCI Team Leader contacts your organization to determine progress and troubleshoot obstacles faced 20 months prior to survey Tools, suggestion, and action plan developed with team 22 months prior to survey Baseline assessment report submitted to the facility 24 months prior to survey - journey to accreditation begins Assessment of healthcare facility readiness - preliminary results given Prior to 24 months - as soon as the decision to move to accreditaton is made Dialogue and pre-assessment activites begin to streamline process

Resources You will need to purchase a standards manual for the particular program for which you are preparing. These official standards manuals contain all the program standards, the intent or rationale for each standard, and the measurable elements for each standard. 3-5 persons will spend one week at the facility to perform the baseline assessment. Web access to schedule the monthly web conferencing sessions. Deliverables The accreditation preparation and survey experience will give your organization and staff the knowledge and tools for measuring and sustaining enhancements in the areas of process improvement, patient safety, and quality improvement: Process Improvement Developing comprehensive, patient-centered processes throughout the organization Establishing a structured and transparent process to monitor continuous compliance to the IPSGs and various types of risk management activities Enhancing interdisciplinary communication Improving documentation of processes to ensure care continuity, patient safety and continuous improvement Patient Safety Adhering to the IPSGs to create a culture of safety for staff and patients Adopting a holistic approach to involve patients, families, staff, and visitors Establishing a transparent reporting system for complaints and suggestions from employees, patients and families Quality Improvement Developing a quality management system based on the JCI Standards Improving monitoring systems and processes to measure enhancements to quality and patient safety in clinical and managerial areas Establishing a periodic review of data analysis to sustain quality improvements Designing an effective and efficient surveillance system to monitor, analyze and address data-driven, sustainable improvements in infection control

AHMC SCOPE OF WORK Introductory Consultation For organizations considering accreditation, this service explains JCI's preparation process and provides a high-level analysis of your organization s strengths and weaknesses, as well as a plan to move forward. Organizational Assessment For organizations in the early stages of their preparation process, this service provides an in-depth analysis of your organization's current ability to meet JCI standards. At the end of the assessment, our experts will provide you with a report prioritizing the standards which need improvement. Ongoing Assistance For organizations in any stage of the preparation process, continuous off- site advice and support through email, phone and video conference communications. On-site support and education programs are also available. Simulated Survey For organizations 6 to 8 months away from their actual survey, this service provides a comprehensive practice survey to assess your organization s accreditation readiness. Organizations have found this to be the most critical and invaluable step in their preparation process.

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