Accreditation support

Reference models

Quality improvement projects in healthcare organizations are usually based on models that outline the areas to address, specific aspects to evaluate, and sometimes the expected level of compliance. Organizations can develop their own models or take existing ones as a reference. Among the most known and widely used external evaluation models, both nationally and internationally, are ISO standards, the EFQM Model (both generic and applicable to organizations of any type and sector), and accreditation (specific for healthcare organizations).

The improvement project presented here is based on the Joint Commission International accreditation model.

• The Joint Commission is currently the organization with the most experience in healthcare accreditation worldwide. It has been dedicated for over 50 years to improving quality and safety in healthcare and social care organizations. Currently, it accredits nearly 20,000 organizations globally. The information and experience obtained from evaluating these organizations are used to update the standards periodically, adapting them to changes in healthcare services.
• In 1996, the Joint Commission International (JCI) was created, a division of the Joint Commission aimed at improving care quality in the international community by providing accreditation services worldwide. To ensure international applicability of the standards, they are agreed upon by a group of experts and opinion leaders from all five continents. The JCI evaluation process is designed to adapt to the legal, religious, and cultural characteristics of each country.

The Joint Commission International accredits over 800 organizations worldwide.

Joint Commission International accreditation always covers the entire healthcare organization; it is not applied to areas or services independently, since it encompasses the organization as a whole. The Accreditation model is based on the key functions of the organization, carried out across all areas. In each of these functions, key processes are identified and best practice standards are established. Additionally, standards considered essential to guarantee patients’ and families’ rights, develop adequate care, and reduce risks in the care process are highlighted.

The model as a whole represents a compendium of good management practices for the entire center.

This system allows moving from structural and service-level evaluation to evaluation of care and management processes across the center.

Contents of the JCI Hospital Standards Manual

Benefits

Choosing an improvement approach based on Joint Commission International accreditation provides the following benefits:

• Patient-centered: develops a care approach focused on the patient as the central element, requiring interdisciplinary care based on patient needs. Evaluates care quality throughout the process.
• Promotes patient safety culture: standards particularly emphasize content focused on patient safety and risk reduction in clinical and care processes.
• Evaluates all management aspects: guides all management phases toward efficiency and best practices, from leadership responsibilities to critical management and strategic planning processes.
• Represents an important improvement tool for the organization: the accreditation preparation process represents a common improvement project for managers and professionals, catalyzing internal changes.
• Provides international recognition for the care provided: Joint Commission International accreditation publicly demonstrates that the center meets the quality requirements of the sector’s most technically competent institution. This accreditation represents an indisputable international recognition of prestige.

Work phases

The work plan to prepare a center for JCI accreditation usually consists of four phases, which gradually introduce the model into the organization and help generate changes in work systems to meet the standards’ requirements. These phases are:

• 1. Training
• 2. Situation diagnosis
• 3. Improvement planning
• 4. Implementation of the improvement project

Phases 3 and 4, focused on planning and implementing improvements, depend on the results of the diagnostic evaluation carried out in phase 2. Occasionally, it may be necessary to adjust the level of support in these phases after reviewing the diagnostic results, although the objectives and activities described for each phase remain stable.