Ms.

Sajida Chagani
Senior Instructor
AKUSONAM
09th June 2022
 Unit X: Accreditation for Institutions

the historical background of the accreditation of

Describe
institution.

Define accreditation.

the importance of accreditation in growth of the

Discuss
institutions.

Differentiate between ISO 9001:2015 and JCIA.

Discuss its implementation in other hospitals

Discuss
/organization.

Apply Learnt knowledge in case-based scenario

Connection time

Why to go for
Can this accreditation accreditation?
be for specific
departments or
services?

Who is eligible for

accreditation?

Is it only for
Hospitals

Who are the

regulatory bodies
authorized to
accreditation?

3
 The act of granting credit or recognition

Accreditation
• The action or process of officially recognizing someone as having
a particular status or being qualified to perform a particular
activity.

• The official review process that allows organizations to

demonstrate their ability to meet official regulatory requirements
and standards.
• Requirements differ per accreditation organization,
BUT
the intent remains the same:
to prove that your healthcare organization’s commitment to meeting
accreditation standards results in a higher level of performance and
a greater focus on patient care.
 Impact of accreditation on quality in
healthcare

Accreditation ensures that organization meets regulations and

standards set by a recognized, external organization.

Accreditation acts as an external stamp of approval for

organization, showing that industry follow standards and best
practices.

Accreditation process helps streamline operations, improve the

quality of care, and build trust with patients and the community.
ACR CARF
American College of
Safe care • Commission on
Radiology accreditation Accreditation of
Rehabilitation Facilities

CAP
• College of
Standards JCIA
• Joint Commission
American
pathologists
of care International
Accreditation

OSHA Magnet
certification
• Occupational ISO 9001 & 9002
Health and Safety
Administration
Acknowledgement Dr. Mairaj Shah
 Differentiate between ISO 9000 and JCIA.

The ISO 9001 standard is more process driven and is better

for back-end departments, such as accounting, human
resources, etc.,
and JCI are clinically-oriented standards that directly affect
patient care
AKUH JCIA Journey 2006-2021

2018
Forth
2012 Reaccreditat
ion
Second
2015 06 edition
th
Reaccreditati .
2006 on
Third 2021
Initial 05th edition
accreditation 3rd Reaccreditatio Forth
.
edition n Reaccreditation
05th edition 07th edition
. .
2009
First
Reaccreditation
04th edition
 Joint Commission International
Mission
• The mission of Joint Commission
International (JCI) is to improve the safety
and quality of care in the international
community through the provision of
education, publications, consultation, and
evaluation services
• JCI is the world’s largest health care
accreditor. JCI’s Gold Seal of Approval® is
a widely recognized benchmark representing
the most comprehensive evaluation process
in the health care industry
Joint Commission International (JCI)

JCI is part of a global enterprise of dynamic, nonprofit

organizations that address all dimensions of accreditation, quality
care and patient safety.

It provides accreditation for hospitals, ambulatory care facilities,

clinical laboratories, care continuum services, medical transport
organizations and primary care services, as well as certification
for disease or condition-​specific care.

JCI standards were developed by international healthcare experts

and set uniform, achievable expectations.
Connection time

Can you recall

eligibility criteria for
enrollment in BSCN
program

Do you know eligibility

criteria for RN

13
Which Hospitals Are Eligible for a JCI Accreditation
Survey?
• The hospital is located outside of the United States and its territories.
• The hospital is currently operating as a health care provider in the country, is
licensed to provide care and treatment as a hospital (if required), and, at
minimum, does the following:
• Provides a complete range of acute care clinical services—diagnostic, curative,
and rehabilitative.

• In the case of a specialty hospital, provides a defined set of services, such as

pediatric, eye, dental, and psychiatry, among others.

• For all types of hospitals, provides services that are available 365 days per year;
ensures that all direct patient care services are operational 24 hours per day, 7
days per week; and provides ancillary and support services as needed for
emergent, urgent, and/or emergency needs of patients 24 hours per day, 7 days
per week (such as diagnostic testing, laboratory, and operating theatre, as
appropriate to the type of acute care hospital)
 JCI accreditation benefits
Helps organize and strengthen improvement efforts:
Performance improvement:

Continuously improve quality and standardize your

processes of care, treatment, and services.

• A competitive advantage:

A visible demonstration to patients and the community

by providing the highest-quality, safest care and
services.
 Importance of accreditation in growth of the institutions

• Ensure a safe • Stimulate and

environment that • Offer quantifiable demonstrate
reduces risk for care benchmarks for quality continuous, sustained
recipients and and patient safety improvement through a
caregivers reliable process

• Improve outcomes • Reduce costs through

• Enhance efficiency
and patient experience standardized care
 Frequency of Standards Updates
• The standards are revised and published
approximately every three or four years.

• JCI informs accredited organizations of

changes made to standards.

• New and revised standards are published at

least six months in advance of the effective
date of re-certification.
• Standards (also known as requirements) are statements
that define the performance expectations and/or structures
or functions that must be in place for an organization to be
accredited by JCI.

• Standards are evaluated for compliance during the on-

site survey
Examples of Standards
• Patient Safety: Standards might include protocols for
preventing medical errors, reducing infections, and ensuring
the safety of medications.
• Clinical Care: Standards could involve guidelines for diagnosing
and treating various medical conditions, ensuring that patients
receive evidence-based care.
• Staffing and Training: Standards may address the qualifications
and training of healthcare staff to ensure they are competent
and capable of providing quality care.
• Facility Management: Standards might cover the cleanliness
and maintenance of the healthcare facility to create a safe and
comfortable environment for patients.
• Emergency Preparedness: Standards could include plans and
procedures for handling emergencies and disasters to ensure
the safety of patients and staff.
 Icons:

• Some standards are followed by icon.

• Such standards require the hospital to have

a written policy, procedure, program, or
other written document for specific
processes.
An intent helps explain the full meaning of a
standard by providing additional background,
justification, or other information.

The intent describes the purpose or reason for the

standard and how it fits into the overall program,
setting parameters for what is required by the
standard.
Measurable elements (MEs):
MEs are statements that detail the specific
performance expectations, structures,
functions, or processes that must be in
place for an organization to meet the
standard and provide high-quality care,
treatment, and services.
Example from pg 25
Standards and measurable element
Overview on JCIA Standards
Three major categories are:

Patients–Centered Standards

Health Care Organization and Management

Standards

Academic Medical Center Hospital Standards

JCIA Standards for Hospitals – 7th Edition
Accreditation Survey process

• Section I: Accreditation Participation

Requirements
Section II: Patient-Centered Standards

2. International Patient Safety Goals (IPSG)

3. Access to Care and Continuity of Care (ACC)
4. Patient Centered Care (PCC)
5. Assessment of Patients (AOP)
6. Care of Patients (COP)
7. Anesthesia and Surgical Care (ASC)
8. Medications Management and Use (MMU)
Section III: Health Care Organization
Management Standards

9. Quality Improvement and Patient Safety (QPS)

10. Prevention and Control of Infection (PCI)
11. Governance, Leadership and Direction (GLD)
12. Facility Management and Safety (FMS)
13. Staff Qualifications and Education (SQE)
14. Management of Information (MOI)
Section IV: Academic Medical
Center Hospital

• 15. Medical Professional Education (MPE)

• 16. Human Subjects Research Programs (HRP)
Tour to JCIA website at AKUH

Pages - Joint Commission International (aku.edu)

JCIA Chapters Videos

• https://one.aku.edu/PK/akuh/qps/Pages/JCIA-Chap
ters---Video-Series.aspx
Connection time

Any Idea about

CAP accreditation

Which Hospital
services are
accredited

33
 SafeCare Accreditation

• SafeCare Accreditation is an
independent, affordable,
internationally recognized
certificate of excellence.
• By reaching SafeCare
Accreditation, a facility earns
distinction in service
provision and positions itself
as a center of excellence.
CAP Re-Accreditation of AKUH Clinical Laboratories

• https://one.aku.edu/Apps/News/Pages/Detail-Page
.aspx?title=CAP-Re-Accreditation-of-AKUH-Clinical-L
aboratories&itemID={F3D6F790-1818-401A-A9F8-C
A3AE0504750}
 American College of Radiology (ACR) Accreditation

• A self-assessment and peer review

process focused on diagnostic image
quality, staff qualifications, policies,
protocols, equipment, and therapeutic
treatment.
• It allows facilities to set and surpass
industry-accepted quality standards for
patient care and includes
recommendations for improvement.
 Magnet for nursing

Magnet status is the highest credential for

nursing facilities in the United States and
around the world. To be certified as a Magnet
hospital, a medical facility must satisfy a set of
criteria created by the American Nurses
Credentialing Center (ANCC) to measure
nursing excellence.
Benefits of Institutional Accreditation for Higher
Education
Clinical objectives
Clinical objectives
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