A Proven Pathway To Accreditation
A Proven Pathway To Accreditation
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 purchase the JCI Hospital Accreditation Manual in your language.
Rana M. Al Mandil, MD, MHADirector, Quality & Strategic Planning AdministrationKing Fahad
Specialist Hospital-Dammam, Saudi Arabia
Step 2 Plan
Step 3 Process
Update policies and procedures
Duration: 2 months
Step 4 Focus
Target improvements where needed
Duration: 2-3 months
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.
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
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.
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JCI Website
Pathw ay to Accr
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