Joint Commission International Accreditation Research Articles

Nursing perception towards the impact of JCI accreditation on the quality of care in a university hospital in Palestine: a cross-sectional study

BackgroundThis study investigates nursing staff perceptions regarding the impact of Joint Commission International (JCI) accreditation on the quality of care within a university hospital in Palestine. The research specifically examines how the accreditation process influences nursing practices, patient results, and overall healthcare quality in a challenging environment marked by unique operational and external pressures.MethodsThe study was conducted at An-Najah National University Hospital (NNUH), a university hospital in Palestine, using a cross-sectional survey design. The structured questionnaire employed in the study was based on the Donabedian model, which evaluates the process and outcome dimensions of healthcare quality influenced by JCI accreditation. The questionnaire consisted of 47 items, divided into ten main subsections. These subsections included participants’ demographical information (6 items), quality measurement and analysis (4 items), leadership, commitment and support (4 items), use of data (4 items), strategic quality planning (4 items), human resources education and training (4 items), quality management (4 items), quality results (4 items), staff involvement (5 items), and benefits of accreditation (8 items). The questionnaire was rigorously designed to assess both the quality processes and quality results. The eight subscales evaluated various aspects, such as leadership commitment, strategic planning, and staff involvement. To ensure reliability, the internal consistency of the survey was confirmed with a high Cronbach’s alpha score, demonstrating the tool’s robustness and reliability in capturing the intended data.ResultsThe study of 180 nurses overwhelmingly supported the positive impact of JCI accreditation on hospital quality improvement processes. More than 90% of respondents acknowledged the role of accreditation in improving resource utilization, meeting population needs, and promoting professional standards and values ​​among staff. Statistical analyses, including Pearson correlation and stepwise regression, highlighted strong positive associations between quality process variables and quality results. In particular, leadership commitment, strategic planning, and staff engagement were found to be significant predictors of improved quality results.ConclusionsThis study’s findings demonstrate that JCI accreditation significantly positively impacts nurses’ perceptions of care quality at NNUH. The study underscores the importance of international accreditation in driving quality improvements in healthcare, particularly in settings with unique challenges such as those faced in Palestine. These insights are crucial for policymakers and healthcare administrators aiming to enhance care standards through accreditation in similar environments.

Hospital Employees' Perception of Joint Commission International (JCI) Accreditation: Effect of Re-accreditation.

Joint Commission International (JCI) accreditation is a recognized leader in healthcare accreditation worldwide. It aims to improve quality of care, patient safety, and organizational performance. Many hospitals do not apply for re-accreditation after JCI status expires. Understanding employees' perceptions of JCI accreditation would benefit hospital management. We aimed to examine whether re-accredited hospital employees perceived more significant benefits and were more likely to recommend JCI to other hospitals than ex-accredited employees. This is a prospective cross-sectional study with a comparison group design. Survey questionnaires, developed from a qualitative study, included perceptions of challenges, benefits, and overall rating of JCI accreditation. An electronic-based questionnaire was distributed to physicians, nurses, medical technicians, and administrative staff in 5 private OBGYN hospitals in China, March-April 2023. Descriptive and linear regression analyses were performed. The statistically significant level is P-value < 0.05. Of 2,326 employees, 1,854 (79.7%) were included in the study after exclusions, 1,195 re-accredited, and 659 ex-accredited. Perceptions of JCI accreditation were positive, as both groups reported a mean score higher than 4.0 regarding the overall benefits. Adjusted for covariates, re-accredited employees were more willing to recommend JCI accreditation to other hospitals than ex-accredited employees. Re-accredited employees perceived greater benefits of JCI accreditation and were more willing to recommend it to other hospitals, suggesting that perceived benefits contribute to a desire to maintain and sustain JCI accreditation. Employee participation is vital for its effective implementation. Employees' perceived challenges and benefits may provide insights for healthcare leaders considering pursuing and reapplying for JCI accreditation.

The transformation of Jordan’s healthcare system in an area of conflict

BackgroundThe Jordanian healthcare system has evolved over the past decades expanding its services, technological, and educational resources. A comprehensive view of this system is lacking. The objective of this report is to describe the structure of the Jordanian healthcare system, the challenges facing it, and the current and recommended health policies.Materials and methodsThis study reviewed the current status of the Jordanian healthcare system. The following parameters were analyzed: health indicators, infrastructure, human resources, insurance system, pharmaceutical expense, health education system, and medical tourism. Data were collected from various relevant official institutions and related published literature.ResultsJordan has a young population with a median age of 23.8 years. Life expectancy is 78.8 years for females and 77.0 years for males. The Jordanian healthcare system is divided into three major categories: (1) Governmental Insurance (i.e., the Ministry of Health (MOH), the Royal Medical Services (RMS) and semi-governmental insurance); (2) Private Insurance; and (3) Refugee Insurance, including the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and the United Nations High Commissioner for Refugees (NHUR). The Governmental Insurance covers 64.30% of the total population. Health expenditure is 6.37% of the gross domestic product (GDP). Pharmaceutical expenses make up 26.6% of the total national healthcare budget. Human resource assessment shows a high ratio of medical staff per 10.000 inhabitants, especially concerning physicians (31.7), dentists (7.9), and pharmacists (15.1). However, the ratio of nursing staff per 10.000 inhabitants is considered low (37.5). The Hospital bed/1000 population ratio is also relatively low (1.4). Healthcare accreditation is implemented through the Joint Commission International (JCI) accreditation which was achieved by 7 hospitals and by the National Health Care Accreditation Certificate (HCAC) achieved by 17 hospitals and 42 primary healthcare centers. Postgraduate medical education covers almost all medical and surgical fields. Medical tourism is currently well-established.ConclusionsAssessment of the Jordanian healthcare system shows high ratios of physicians, dentists, and pharmacists but a low ratio of nursing staff per 10.000 inhabitants. The hospital bed/1000 population ratio is also relatively low. Pharmaceutical expenses are significantly high and medical tourism is well-developed.

Evolución de la percepción de la cultura de seguridad de los profesionales sanitarios en una urgencia pediátrica

Background and aimSafety culture (SC) is a fundamental tool for minimizing adverse events and improving safety and quality of care. Our objective, therefore was to analyze the evolution of the SC of healthcare professionals in a pediatric emergency department (PED) after the implementation of a risk management system for patient safety based on the UNE:EN:ISO 179003 Standard and the execution of new safe practices for Joint Commission International accreditation. At the same time describe the current strengths and weaknesses. MethodsQuasi-experimental, single-center study. All PED professionals participated in the study. An initial measurement of SC was performed through the Hospital Survey on Patient Safety Culture (HSOPS) questionnaire of the Agency for Healthcare Research and Quality adapted to Spanish in 2014. Pro-patient safety strategies were implemented between 2015 and 2022. A subsequent measurement was performed in 2022. ResultsThe response rate in 2014 was 55% and 78% in 2022. On both occasions the group with the highest participation was nurses with 35.1% and 34.8%, respectively.Five dimensions improved after the interventions: frequency of adverse events (25.2%, p<0.001), organizational learning (25%, p<0.001), feedback and communication about errors (22.3%, p<0.001), non-punitive response to errors (6.5%, p = 0.176), and management support (4%, p = 0.333). ConclusionsThe actions carried out had a positive influence on organizational learning and the frequency of adverse events reported and communication within the team. In contrast, the perception of SC did not increase.

The Effects of Quality Assurance System Implementation on Work Well-Being and Patient Safety: Protocol for a Mixed Methods Study.

Systematic monitoring of work atmosphere and patient safety incidents is a necessary part of a quality assurance system, particularly an accredited system like the Joint Commission International (JCI). How the implementation of quality assurance systems affects well-being at work and patient safety is unclear. Evidence shows that accreditation improves workplace atmosphere and well-being. Thus, the assumption that an increase in employees' well-being at work improves patient safety is reasonable. This study aims to describe the protocol for monitoring the effects of implementing the quality assurance system of JCI at Orton Orthopedic Hospital on employees' well-being (primary outcome) and patient safety (secondary outcome). Quantitative (questionnaires and register data) and qualitative (semistructured interviews) methods will be used. In addition, quantitative data will be collected from register data. Both quantitative and register data will be analyzed. Register data analysis will be performed using generalized linear models with an appropriate distribution and link function. The study timeline covers the time before, during, and after the start of the accreditation process. The collected data will be used to compare job satisfaction, as a part of the well-being questionnaire, and the development of patient safety during the accreditation process. The results of the quality assurance system implementation illuminate its possible effects on the patient's safety and job satisfaction. The repeatability and internal consistency reliability of the well-being questionnaire will be reported. Data collection will begin in May, 2024. It will be followed by data analysis and the results are expected to be published by 2025. The planned study will contribute to the evaluation of the effects of JCI accreditation in terms of well-being at work and patient safety. PRR1-10.2196/45200.

Perceptions of Chinese hospital leaders on joint commission international accreditation: a qualitative study.

Joint Commission International (JCI) accreditation plays a significant role in improving the quality of care and patient safety worldwide. Hospital leadership is critical in making international accreditation happen with successful implementation. Little is known about how Chinese hospital leaders experienced and perceived the impact of JCI accreditation. This paper is the first study to explore the perceptions of hospital leaders toward JCI accreditation in China. Qualitative semi-structured interviews were used to explore the perceptions of the chief operating officers, the chief medical officers, and the chief quality officers in five JCI-accredited hospitals in China. Thematic analysis was used to analyze the interview transcripts and identify the main themes. Fifteen hospital leaders participated in the interviews. Three themes emerged from the analysis, namely the motivations, challenges, and benefits related to pursuing and implementing JCI accreditation. The qualitative study found that eight factors influenced hospital leadership to pursue JCI accreditation, five challenges were identified with implementing JCI standards, and eight benefits emerged from the leadership perspective. Pursuing JCI accreditation is a discretionary decision by the hospital leadership. Participants were motivated by prevalent perceptions that JCI requirements would be used as a management tool to improve the quality of care and patient safety in their hospitals. These same organizational leaders identified challenges associated with implementing and sustaining JCI accreditation. The significant challenges were a clear understanding of the foreign accreditation standards, making staff actively participate in JCI processes, and changing staff behaviors accordingly. The top 5 perceived benefits to JCI accreditation from the leaders' perspective were improved leadership and hospital safety, improvements in the care processes, and the quality of care and the learning culture improved. Other perceived benefits include enhanced reputation, better cost containment, and a sense of pride in the staff in JCI-accredited hospitals.

Examining the Influence of Joint Commission International (JCI) Accreditation Surveys on Medication Safety Practices: A Cross-Sectional Study from Mediclinic Welcare Hospital in Dubai, UAE

Examining the Influence of Joint Commission International (JCI) Accreditation Surveys on Medication Safety Practices: A Cross-Sectional Study from Mediclinic Welcare Hospital in Dubai, UAE

Antimicrobial stewardship programs in seven Latin American countries: facing the challenges

BackgroundStudies have shown that more than 50% of the antibiotics used in hospitals are unnecessary or inappropriate and, that antimicrobial resistance may cost up to 20 billion USD in excess medical costs each year. On the other hand, Antimicrobial Stewardship Programs (ASP) significantly reduce inappropriate antimicrobial use, emergence of antimicrobial resistance, healthcare associated infections, and costs in hospital settings.ObjectiveTo evaluate the development of ASP and antibiotic savings in 7 Latin American hospitals using standardized quantitative indicators in all the participating health care institutions.MethodsAn interventional study was conducted, where pre- and post- evaluations were performed using a standardized score tool adapted from the Joint Commission International accreditation standards and, the Colombian Institute of Technical Standards and Certification. We evaluated ASP from 7 Latin American hospitals between 2019 and 2020. A pre-intervention evaluation was done in each hospital to quantify the degree of development of the ASP (ASP Development score). Based on these results, tailored on-site training was implemented in each hospital, followed by a post-intervention evaluation to quantify improvement of ASP-development indicators. In addition, monetary savings in antimicrobials derived from the ASP intervention were estimated.ResultsIn the pre-intervention evaluation, the average ASP development score for the 7 institutions was 65.8% (40-94.3%). The items with the lowest development score were those related to monitoring and communicating the ASP progress and success. For the post-intervention evaluation, 2 institutions couldn’t participate due to the pressure imposed by the COVID-19 pandemic. For the remaining 5/7 hospitals, the average ASP development score was 82.3% with an increase of 12.0% when compared to the pre-intervention measurement of the same institutions (average pre-intervention score 70.3% (48.2%-94.3%) The items with a significant increase were key performance indicators, AMS education and training of the prescribers. Three of the seven (3/7) hospitals reported antibiotic monetary savings associated to the ASP intervention.ConclusionsThe use of the tool described shown to be useful to evaluate specific areas of ASP-development that were lacking and tailor interventions for the participating hospitals, consequently, it helped improve ASP-development in the institutions that underwent pre- intervention and post-intervention analysis. In addition, the strategies showed monetary savings on antimicrobial costs when measured.

Using the SLIPTA checklist to assess laboratory readiness for Joint Commission International accreditation.

The Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) helps prepare laboratories in low- and middle-income countries to achieve international accreditation aligned with the ISO 15189:2012 standards. Accreditation by the Joint Commission International (JCI) is among the highest sought by hospitals worldwide. While the readiness of laboratories with a five-star SLIPTA score to undergo ISO 15189:2012 accreditation was recently assessed, the compliance of the SLIPTA checklist with JCI is still unknown. The study evaluated the SLIPTA checklist's utility in assessing laboratories to meet the JCI standards. We conducted a detailed gap analysis between SLIPTA and JCI laboratory standards from January 2021 to January 2022. We cross-matched the JCI standard requirements to SLIPTA clauses and categorised each standard into 'met', 'partially met', and 'not met'. We highlighted similarities, discrepancies, and improvement areas. A total of 109 JCI standards were included. The SLIPTA checklist completely met 61 standards, partially met four, but did not meet 44. The unmet JCI standards focused on the quality planning, control, and improvement sections. Healthcare organisation management and quality control processes, including selecting an accredited reference laboratory, collecting quality management data, creating of post-analytical policies and procedures, and validating monitoring systems, constitute the basis of this preparation. The SLIPTA checklist covers major quality management system elements of the JCI standards for laboratories. However, some components should be addressed to assure readiness for JCI accreditation. This study identified additional areas not covered by the SLIPTA checklist that are required for JCI accreditation.

An Exploratory Study on Adherence to Joint Commission International Standards on Facility Management and Safety at a Tertiary Care Hospital in Dubai, United Arab Emirates

Introduction: According to the International Society for Quality in Healthcare, accreditation is a process in which "trained external peer reviewers evaluate a healthcare organisation's compliance with pre-established performance standards. Unlike licensure, accreditation focuses on continuous improvement strategies and achievement of optimal quality standards, rather than adherence to minimal standards intended to assure public safety".1,2 This study aims to observe and identify gaps in adherence to Facility Management and Safety Standards as prescribed by the Joint Commission International (JCI). Methodology: A time-bound single-centre observational study was carried out using the JCI Accreditation Standards for Hospitals (Sixth Edition). Questionnaires were shared with 20 purposively and conveniently (based on consent) selected participants after obtaining signed informed consent. Following the questionnaire examination, one-on-one interviews with management were held to acquire the necessary data for the study, including the reasons for non-compliance with specific requirements. This research closely examined JCI-recommended policies (Chapter: Facility Management and Safety) and the hospital's compliance with them. Results and Conclusion: Based on the study, it can be concluded that the hospital has complied with most of the standards on Facility Management and Safety Standards of the Sixth Edition of JCI. However, the clauses FMS.2:ME.3, FMS.6:ME.4, FMS.9.2.1:ME.3, and FMS.9.2.1:ME.4 were not met.

Assessing the Presence of the Joint Commission International Accreditation Requirements in Western Saudi Arabia Hospital Pharmacies: A Cross-sectional Study.

The Central Board of Accreditation for Healthcare Institutions (CBAHI) the national Saudi accreditation body accredited most hospitals in Saudi Arabia whereas, the Joint Commission International (JCI) a well-known international accreditation body accredited some hospitals. We assessed Western Saudi Arabia hospital pharmacists' knowledge, opinions, and observations about pharmacy-related JCI accreditation criteria needed for hospitals. This was a cross-sectional survey-based study conducted among pharmacy personnel working in the Ministry of Health (MOH), Military, and private hospitals in the Makkah region in western Saudi Arabia. The present report represents the findings of descriptive and comparative analyses. Comparative analyses were tested by Student's t-test, analysis of variance, and Chi-square when applicable and a P ≤ 0.05 was considered statistically significant. One hundred and one pharmacists completed the survey; most of them were from Taif (53.5%) and Jeddah (37.6%) and fewer from Makkah (8.9%). The highest proportions were from MOH (55.4%), private (29.7%), and some from military (14.9%) hospitals. They worked mostly in hospitals accredited with CBAHI (93.1%) than JCI (58.4%) and only (41.6%) worked with quality units. Correct answers on knowledge items ranged from 14.9% to 65.3%. On five-point Likert Scale, they showed supportive ratings on how they perceived the importance of JCI statement provided (overall average score: 3.78) and on how statement criteria are implemented in their hospitals (overall average score: 3.76). Higher proportions of those working in quality units compared to their counterparts were aware that accreditation cycles for JCI and CBAHI are identical (66.7% vs. 55.9%, P = 0.009) and that JCI criteria are more concise than CBAHI (59.5% vs. 52.5%, P = 0.007). Higher proportions of those working in JCI-accredited hospitals compared to their counterparts were aware that JCI criteria are clearer than CBAHI (55.9% vs. 33.3%, P = 0.021) and that JCI criteria are more concise than CBAHI (61% vs. 47.6%, P = 0.012). To a high extent, pharmacists were supportive of JCI criteria and considered the criteria to be implemented in their hospitals. There is a room for improvement to enhance awareness and support of JCI quality criteria among pharmacists.

The Expansion of Turkey’s Medical Tourism Industry

The Expansion of Turkey’s Medical Tourism Industry

Hospital accreditation processes in Saudi Arabia: a thematic analysis of hospital staff experiences

BackgroundHospital accreditation by an international organisation can play an important role in health quality and safety. However, little is known about how managers and front-line employees experience and perceive the...

A case study exploring the impact of JCI standards implementation on staff productivity and motivation at the laboratory and blood bank.

Background and AimsQuality of care has transformed to become an essential element of healthcare service delivery, which caused decision makers in Health Care Organisations (HCOs) to seek methods to evaluate the level of care provided. The field of accreditation is under massive development, especially in healthcare organizations. Joint Commission International (JCI) accreditation is one of the accreditation bodies that require a lot of documentation and quality improvement to guarantee proper standard application. The process of accreditation is known to be demanding and requires staff involvement to guarantee successful implementation.MethodsThis study focuses on the impact of JCI standards implementation on staff productivity and motivation in a 350‐bed hospital. An interpretive approach was used to collect empirical data by interpreting the population's behavior, which is represented in this study by the questionnaire. The study is considered an emergent study that identified, explained, illustrated, and developed a model of staff motivation. In this type of study, the process of inquiry, supporting arguments, and questions of interest is developed after the launching of the study and during the process of data collection. Thus, the researcher relied on the social constructive paradigm, whereby the grounded theory (GT) is used to build the research model of staff motivation during the process of accreditation.ResultsBy studying the Turn Around Time (TAT) performance indicator, the study showed that TAT of tests decreased by 3% after JCI standards implementation, which was reflected at two different laboratory sections. The trainings conducted throughout the process of standards implementation also resulted in enhancing the quality of samples, which was demonstrated by the decrease in the percentage of rejected samples.ConclusionStaff productivity increases when JCI standards are implemented. However, staff motivation is dependent on their involvement with management decisions and the smooth transition through change management, which ensures staff retention and therefore increase productivity.

Lean Six Sigma Redesign of a Process for Healthcare Mandatory Education in Basic Life Support-A Pilot Study.

Healthcare staff are required to undertake mandatory training programs to ensure they maintain key clinical competencies. This study was conducted in a private hospital in Ireland, where the processes for accessing mandatory training were found to be highly complex and non-user friendly, resulting in missed training opportunities, specific training license expiration, and underutilized training slots which resulted in lost time for both the trainers and trainees. A pilot study was undertaken to review the process for accessing mandatory training with a focus on the mandatory training program of Basic Life Support (BLS). This was chosen due to its importance in patient resuscitation and its requirement in the hospital achieving Joint Commission International (JCI) accreditation. A pre- and post-team-based intervention design was used with Lean Six Sigma (LSS) methodology employed to redesign the process of booking, scheduling, and delivery of BLS training leading to staff individual BLS certification for a period of two years. The redesign of the BLS training program resulted in a new blended delivery method, and the initiation of a pilot project led to a 50% increase in the volume of BLS classes and a time saving of 154 h 30 min for staff and 48 h 14 min for BLS instructors. The success of the BLS process access pilot has functioned as a platform for the redesign of other mandatory education programs and will be of interest to hospitals with mandatory training requirements that are already facing healthcare challenges and demands on staff time.

Needs and Strengths Assessment for Radiotherapy Centers in Africa Transitioning to IMRT

Multiple centers globally are interested in implementing intensity-modulated radiotherapy (IMRT) programs, however little data exists comparing granular center-specific needs and strengths of radiotherapy (RT) centers interested in establishing an IMRT program, in low-resource countries in this position. In conjunction with up-scaling training, methods are needed to assess multiple centers efficiently. Using a novel approach, we assess centers' needs and strengths to tailor a multi-institutional remote training program.To assess strengths and needs of centers interested in establishing an IMRT program. Core RT leaders from 16 RT centers in 7 African countries (Ghana, Ivory Coast, Kenya, Nigeria, Senegal, Morocco, Zambia and one sister center in Pakistan) were individually invited to complete a 30-minute, 55-question electronic survey followed by 60-75-minute video conference with 2-4 lead members of a non-profit global health radiation oncology organization prior to participating in a remote IMRT training program.14 centers responded and were surveyed, and interviewed, including 11 public, 3 private and 1 hybrid institutions. Among centers 4 (28.6%) and 1 (7.1%) are currently treating patients with IMRT and both, IMRT and VMAT, respectively. In terms of strengths all 14 (100%) centers emphasized high energy and commitment to learning potential research collaboration, 1 (7.1%) center is a designated International Atomic Energy Agency training center and 1 (7.1%) is the only center in East Africa with Joint Commission International Accreditation. All 14 (100%) centers emphasized the need for education and training in advanced treatment planning procedures and techniques, 4 (28.6%) centers reported major gaps (including CT simulators, linear accelerator) in equipment, 5 (35.5%) minor gaps (including in-room image guidance, multi-leaf collimator) in equipment, and 5 (35.7%) gaps in physics QA devices (including film/array detectors, dose calculation software, phantoms for machine output checks). Using benchmark recommended staffing levels from Health Economics in Radiation Oncology data (HERO), 14 (100%) centers were well-staffed with physicists, 8 (57%) well-staffed with radiation oncologists and 8 (57%) well-staffed with radiation therapists.Among a motivated group of African RT centers with demonstrated interest in commissioning an IMRT program, we noted gaps in equipment for safe IMRT treatment delivery. Staffing met recommendation for physicists but not radiation oncologists and therapists. Combined survey and video interview assessment can help guide curriculum design for training programs and other areas for improvement.

Effect of Joint Commission International Hospitals Accreditation on quality of Health care as Perceived by Nurses

Background: Joint commission international hospitals accreditation aims to improve quality of health care in the international community by providing worldwide accreditation system that include highest standard of quality. Health care organizations can seek accreditation as a self-regulated step for upholding standards in healthcare system, in addition to ensuring compliance and improvement The study aimed to identify the effect of joint commission international hospitals accreditation on quality of health care as perceived by nurses. Study design Descriptive design was utilized to meet the aim of this study. Setting this studywas conducted in all inpatients departments at El Araby hospital at Menofia Governorate. The study sample was composed of 206 staff nurses from the above mentioned setting. Two tools were used for data collection;Perceived impact of hospital accreditation outcomes questionnaire and Quality of health care questionnaire. Results The majority of study subjects (97.6%) perceived positive outcomes of joint commission international hospitals accreditation, the majority of study subjects (84%) perceived satisfactory level of quality of health care and total mean score , standard deviation regarding total quality of health care was(90.05±21.71) that represented (85.8 %) of the total score. Conclusion This study concluded that there was a significant positive correlation between outcomes of joint commission international hospitals accreditation and total level of quality of health care. The study recommended that increase nurse participation in decision making process to enhance their confidence, patientsꞌ satisfaction should be involved as a tool to measure quality.

A COMPARATIVE STUDY OF EVIDENCE BASED PRACTICES BEFORE AND AFTER INTERNATIONAL ACCREDITATION AND PERCEPTION OF EMPLOYEES

Purpose: To compare the availability of evidence based practices before and after joint commission international accreditation as well as to assess employee perception about the impact of accreditation. Method: Conducted a cross sectional study in 11 health centers belong to Dubai health authority. Prepared a checklist and questionnaire to assess the processes improvements as well as the perception of employees respectively. Studied perception by recruiting physician (n=106) and nurses (n=194) using convenience sampling technique. Done content validity of the tools with clinical quality experts. Conducted pilot study for the questionnaire and checked the reliability using Cronbach alpha (0.924). After obtaining ethical clearance and consent from subjects, the researcher personally visited the health centers and administered validated questionnaire to the participants. To study processes improvements , the researcher audited documents for availability of evidence based practices before and after accreditation using the validated checklist with 17 processes reecting various domains of quality in healthcare . Results: Observed tremendous improvement in the availability of evidence-based practices. The proportion of practices before and after the accreditation was statistically signicantly different (p &lt;.001). Majority (96.3%) of doctors and nurses perceived improvements in practices after accreditation. Statistical signicance was noted between qualication and perception of employees about the impact of accreditation (p &lt;.001). Similarly there was also positive association between length of service and perception (p &lt;.001) Discussion: Observed processes improvements ensuring quality of health care after accreditation. Likewise, majority of employees perceived that the accreditation has improved quality of patient care

Challenges for Joint Commission International accreditation: performance of orthopedic surgeons based on International Patient Safety Goals.

ABSTRACTThe Joint Commission International (JCI) is a US-based organization that accredits and certifies hospitals worldwide. Among the requirements for accreditation, the JCI emphasizes continuous quality improvement (CQI) with regard to international patient safety goals (IPSGs). Our university hospital treats about 26,000 hospitalized patients and 600,000 outpatients annually, and our goal is patient safety in compliance with IPSGs. The purpose of this study is to examine the activities of orthopedic surgeons in preparation for JCI accreditation, including clear identification of patients, preoperative timeout and marking to ensure correct surgery, timely approval of CT/MRI reports, care with pain management, prevention of infection, setting of quality indicators and daily monitoring, and teamwork. Examiners from the JCI visited our hospital to review medical records and documents, and to interview patients, nurses and doctors. There were 1270 evaluation items covering 16 fields, including reviews of IPSGs, patient evaluation and care, infection prevention and control, and governance and leadership. Most importantly, the efforts of all the medical staff in our hospital in obtaining the first JCI accreditation among national university hospitals in Japan have promoted the safety and quality of medical care from the perspective of the patient.

The Effectiveness of the Joint Commission International Accreditation in Improving Quality at King Fahd University Hospital, Saudi Arabia: A Mixed Methods Approach.

IntroductionSaudi Arabia has one of the highest numbers of health organizations accredited by the Joint Commission International. This study aimed to measure this process’s effectiveness in improving quality at King Fahd Hospital of the University in Khobar, Saudi Arabia. Additionally, the study investigated health providers’ perceptions of this process.Materials and MethodsThis research utilized a convergent parallel mixed method. For the quantitative analysis, an interrupted time series was conducted to assess the changes in a total of 12 quality outcomes pre- and post-accreditation. Thematic analysis was utilized to collect and analyze qualitative data from hospital employees and health providers.ResultsThe quantitative results indicated that pursuing accreditation positively impacted nine out of 12 outcomes. The improved outcomes included: the average length of stay, the percentage of hand hygiene compliance, the rate of nosocomial infections, the percentage of radiology reporting outliers, the rate of pressure ulcers, the percentage of the correct identification of patients, the percentage of critical lab reporting, and the bed occupancy rate. The outcomes that did not improve were the rate of patients leaving the ER without being seen, the percentage of OR cancelations, and the rate of patient falls. The qualitative analysis suggested that the accreditation process was perceived positively by participants. Nevertheless, participants also highlighted some of the drawbacks of this process, including: the potential bias in observation-based key performance indicators, the focus on improving process without enhancing the hospital structure, and the increased workload.ConclusionInternational accreditation had a positive impact on quality and was received positively by providers. However, several issues need to be addressed by hospital administrators in future accreditation cycles. According to participants, the most notable issue during the first two accreditation cycles was the increased workload and paperwork, which can potentially distract from patient care.