Before even going into JCI accreditation standards a
hospital must look into these essential conditions or requirements, if it is
planning to go for JCI accreditation. Hospitals not fulfilling any of these
conditions are at risk of accreditation being denied. JCI assesses these
conditions, in addition to standards, for both first time applicant
hospital as well as already-accredited hospitals. For first time applicant
hospitals, these conditions are assessed during the initial survey and for
already accredited hospitals, it is assessed throughout the accreditation period,
through on-site surveys, the Strategic Improvement Plan submitted by hospital,
and through periodic updates that JCI receives from these hospitals.
The requirements given below are referred from 'JCI accreditation standards for hospitals, 6th Edition'
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1.
Data and
information required by JCI must be submitted in timely manner by the hospital.
There are many data and information, which
includes things like information asked in application (electronic application),
annual updates to be made in application, Strategic Improvement Plan, major
changes in hospital etc. These must be submitted within the agreed time-frame.
2.
Data and
information submitted to JCI are accurate and complete.
Hospitals are expected to be engaged with
JCI with honesty, integrity and transparency. Under this condition,
data/information provided to JCI in any form (written or verbal) are included.
3.
Any
change in hospital’s profile or information provided in electronic application
must be reported to JCI within 30 days
These changes may be anything that affects
the information submitted in electronic application to JCI. They include,
change of name, ownership, additional or removal of any clinical offerings,
changes made in hospital’s building, increase/decrease in hospital’s bed capacity,
merger, acquiring of any unaccredited site etc.
4.
Hospital
must allow JCI to conduct on-site evaluation at its own discretion.
JCI can conduct on-site evaluation for a
number of things like assessing compliance to standards, policies, verification
of quality and safety concerns, regulatory sanctions, major complaints etc. The
onsite evaluation can be informed or surprise, as decided by JCI.
5. Hospital
must allow JCI, access to original or authenticated copy of results/reports by
external evaluation conducted by any publicly recognized bodies.
If the hospital has undergone any other
external assessment, like by NABH or ISO, JCI will have right to review the
reports of them.
6.
The
quality improvement programme of the hospital should be based on data and valid
measurement method.
JCI focuses very much on collection,
analysis and use of data. Hospitals are expected that hospital collect and use
data for quality improvement programme. JCI also recommends various types of
measurements through its International
Library of Measures, which the hospitals can refer.
7.
The accreditation status of JCI should be
accurately represented by the hospital
The hospital while representing its
accreditation status should clearly specify the programmes and services to
which JCI accreditation applies. This should be taken care of at all places
like hospital’s website, advertising and promotion, and in any other form in
which information is made available to public.
8.
Any staff
of hospital can directly report to JCI about quality and patient safety related
concerns.
Hospital must allow and inform all staff
that they are permitted to report such concerns to JCI. There should not be any retaliatory action from hospital against that
staff.
9.
At the
time of the survey and if required, hospital must arrange for a qualified translator
and interpreter, who has no relationship to hospital
The translator and interpreter, if
required, should not be a staff of the hospital and should be qualified to
undertake that task.
10.
The
hospital must notify the public whom it serves about the method of contacting
hospital’s management and to JCI, if they have quality or patient safety
concerns
Methods such as display, printed
communication materials, website etc. must be employed
11.
The
environment in the hospital must not pose any risk of an immediate threat to
patient safety or staff safety
The building, space and facility from inside and
outside should be safe for its occupant. Things like no availability of
emergency exit, risk of collapse of building or a part of it etc. should not be
found in hospital.
