The Joint Commission International (JCI) accreditation is a globally recognized standard for healthcare quality and patient safety. It provides an objective assessment of healthcare organizations to ensure they meet rigorous standards of care. Achieving JCI accreditation is a significant milestone for any hospital, but it also comes with numerous challenges, especially in a multi-specialty setting. In this article, we will explore some of the common challenges faced by multi-specialty hospitals in obtaining JCI accreditation and discuss strategies to overcome them.
Multi-specialty hospitals are often characterized by complex organizational structures with numerous departments, services, and specialties. Coordinating and aligning these various units to meet Joint Commission International (JCI) standards can be a daunting task.
Implementing a robust governance structure that involves representatives from all departments and specialties is crucial. This allows for effective coordination, collaboration, and communication throughout the accreditation process. Few examples are structures like “Accreditation Executive committee” Senior Management Team for Accreditation etc
Further down Hospitals can create chapter teams for 13 chapters of JCI, bringing leads from various functional areas to lead implantation at their own areas/departments. Regular meetings, clear reporting mechanisms, and designated individuals responsible for different aspects of compliance can help streamline the process.
JCI accreditation requires hospitals to develop and implement standardized policies and procedures across all departments. Most of chapter policies required implementation across various departments in a uniform manner, There are several policies which are interdisciplinary in nature. for an instance sedation management outside operation room, required certain unform practice across areas giving sedation such as endoscopy, ICU, Radiology or dental etc In a multi-specialty hospital, where each department may have unique workflows and practices, achieving this standardization can be a significant challenge. Ensuring consistent implementation and adherence to policies becomes even more complex.
Conduct a comprehensive gap analysis to identify areas where policies and procedures need to be standardized. Engage representatives from each department in the development and review of these policies to ensure they are practical and feasible in different clinical settings. Regular training and education sessions should be conducted to familiarize staff with the updated policies and encourage their adherence. This should be done with the guidance of a accreditation expert who can understand and align interdepartmental process and thorough understanding on JCI standards.
Obtaining JCI accreditation requires a careful allocation of human resources. In multi-specialty hospitals, allocating these resources appropriately can be challenging, as each department may have its own priorities and budget constraints. The competition for resources can lead to delays and compromise the accreditation process.
Prioritize JCI accreditation as a hospital-wide goal and secure buy-in from all stakeholders. Identify champions and volunteers who have passion to such task within department, Involve department heads and key staff members in resource allocation decisions to ensure fairness and transparency. Consider seeking external partnerships to supplement the available resources.
Effective collaboration between different departments is essential for successful JCI accreditation. However, in multi-specialty hospitals, where each department has its own goals and priorities, fostering collaboration and teamwork can be a challenge. Siloed approaches hinder the sharing of information, best practices, and learning opportunities.
Establish interdepartmental committees or task forces dedicated to hospital accreditation. These
committees should
include representatives from all departments and meet regularly to share progress, challenges,
and success stories.
Quality department staff shall act as catalyst in these groups and bring consensus when there is
a conflict.
As the months passes, we can see highly collaborative team get formed and functional
Hospital accreditation is not a one-time achievement but an ongoing process. Hospitals are required to demonstrate continuous quality improvement and sustained compliance with JCI standards. This can be particularly challenging in a multi-specialty hospital with diverse services and a large number of staff members.
Develop a robust quality improvement framework that involves all departments and specialties. Establish Key Performance Indicators (KPIs) to monitor and measure progress. Regularly review and analyse data to identify areas for improvement and implement targeted action plans. Encourage a culture of quality and safety by promoting staff involvement, conducting regular audits, and sharing best practices across departments.
Managing the vast amount of documentation required for accreditation can be overwhelming. Maintaining up-to-date records, policies, procedures, and evidence of compliance across various departments and specialties can be a significant challenge.
Adopt accreditation software’s to provide a smart and secure digitalizing Accreditation preparedness, Quality Management system and help you manage your day-to-day complex processes/workflows in a digital platform. Document management, KPI data, Physician performance data, Incident management, audit etc are few examples of areas a hospital can digitize and manage hassle free.
Achieving hospital accreditation often requires significant changes in processes, workflows, and organizational culture. Resistance to change can be a major obstacle in a multi-specialty hospital, where staff members may be accustomed to established routines and practices.
Implement a structured change management approach that includes clear communication, staff engagement, and education. Involve staff members in the planning and decision-making processes to foster ownership and reduce resistance. Provide training and support to help staff members adapt to new processes and workflows. Celebrate small wins along the way to maintain motivation and momentum. Presence of an external guide like a group manager, or consultant can ease the frictions.
JCI accreditation involves engagement with external experts who have experience with number of projects in similar capacity, which helps it building trust and involving stakeholders in the accreditation process This experts can be members formed from the same hospital group if they had other units accredited or a hired consulting company with good track records.
Obtaining JCI accreditation is a challenging but rewarding endeavour for any multi-specialty hospital. By addressing the complexities of organizational structure, standardizing policies and procedures, allocating resources effectively, fostering interdepartmental collaboration, and embracing continuous quality improvement, hospitals can overcome the challenges and achieve the desired accreditation. Partners Consultants International specializes in providing comprehensive consulting services to hospitals across the globe and proven their methodology over 140 successful JCI accredited organizations.
By Admin | Posted on April 7, 2021
