A proven pathway to accreditation

Here are 10 steps that hospitals and academic medical centers typically follow toward
accreditation success.
Average duration 18-24 months.

Step 1 Start-up
Become familiar with JCI's accreditation
standards and survey process
Duration: 2-3 months

Follow this link to review JCI's policies and procedures.

Follow this link to purchase the JCI Hospital Accreditation Manual in your language.

Click to view a pdf about

how JCI accreditation can benefit your organization

Rana M. Al Mandil, MD, MHADirector, Quality & Strategic Planning AdministrationKing Fahad
Specialist Hospital-Dammam, Saudi Arabia

Step 2 Plan

Conduct gap analysis and build action plan

Duration: 2-3 months

Click to read about

helpful questions for assessing compliance

John WocherExecutive Vice PresidentKamada Medical Center, Japan

Step 3 Process
Update policies and procedures
Duration: 2 months

Namsik Chung MD, PhD, FAHA, FASEGeneral Director, Severance HospitalProfessor of

Cardiology, Younsel University College of Medicine, South Korea

Step 4 Focus
Target improvements where needed
Duration: 2-3 months

Use infographics to educate staff about challenges. Click to view.

Inspect all areas of your hospital, as this infographic indicates. Click to view.

The San Francisco Veterans Association Medical Center used this tool to address handoff risks and
gaps. Click to view.
Kieran McNamaraHealth and Safety OfficerBon Secours Hospital Cork, Ireland

Step 5 Fix
Barriers
Work with staff to overcome obstacles
Duration: 2-3 months

Drs. Mark Chassin and Jerod Loeb explain how to achieve a safety culture in this Milbank Quarterly article.

Abdullah Assiri MD, FACPDirector, Infection Prevention and ControlMinistry of Health, Saudi
Arabia

Step 6 Readiness
Assess your readiness at the midpoint
Duration: 2-3 months

Learn about tracer methodology using this document and others like it. Click to view.

Communicate tracer findings to staff and promote brainstorming for solutions, as described in this
article. Click to view.
Dr. Mahesh VakamudiChief Operating OfficerProfessor & Head Anesthesiology, Sri Ramachandra
Medical Centre, India

Step 7 Training
Continue training for sustainable changes
Duration: 2-3 months

Use this resource to determine your staff's educational needs. Click to view.

Hung Choon ChuaCEOInstitute of Mental Health, Singapore

Step 8 Monitor and Adjust

Evaluate and refine processes
Duration: 2-3 months

Learn how the Weinburg Surgical Suite at The Johns Hopkins Hospital utilized "Good Catch"
awards. Click to view.

Learn how the Memorial Herman Health System in Texas got its entire organization "from
boardroom to bedside" excited about the journey towards high reliability health care. Click to view.
Dr. Abdulla Al KhayaCEOLatifa Hospital, United Arab Emirates

Step 9 Mock
Survey
Use a mock survey to assess your readiness
Duration: 2-3 months

Prioritize improvements based on mock survey.

Takaaki Kameda MD, PhDChairman of the Board, Kameda GroupCEO, Kameda Medical Center,
Japan

Step 10 Final
Stage
Make final modifications
Duration: 6-7 months

After a successful accreditation survey, your hospital can proudly display the Gold Seal of
Approval.

Follow this link to visit World Hospital Search.

Tsuguya Fukui, MD, MPH, PhDPresidentSt. Luke's International Hospital, Japan

We commend you on considering JCI accreditation.

It is a globally recognized achievement in quality
improvement and patient safety. Our team is ready to
assist you at every step of your journey.
The use of Joint Commission International (JCI) advisory services is not necessary to
obtain a JCI accreditation award, nor does it influence the granting of such awards.

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