The Hermitage Medical Clinic receives Joint Commission International Accreditation

“To prepare for our JCI Accreditation Survey, we asked HCI for support in undertaking a thorough and independent GAP Analysis of our Quality and Safety Management System to identify any gaps in our compliance with the revised JCI Accreditation Standards for Hospitals. Subsequently we requested HCI provide us with specific JCI support on a monthly basis to ensure we were prepared for our JCI survey. HCI were our providers of choice for this project due to their reputation and extensive knowledge of the JCI Standards. We are delighted to have received JCI Accreditation for the 4th time.”

Martina Rosser

Quality and Risk Manager, Hermitage Medical Clinic

Background

The Hermitage Medical Clinic (HMC) is a 112 bed private hospital in Dublin. In preparation for their upcoming Joint Commission International (JCI) Accreditation Survey, the HMC requested HCI carry out a GAP Analysis to determine the current status of the Quality and Safety Management Systems (QSMS) in line with the requirements of the JCI Accreditation Standards for Hospitals, 7^th Edition.

As the JCI Accreditation Standards were due to be revised since HMC’s previous accreditation cycle, they were keen to address any potential areas for improvement in order to be as prepared as possible for the release of the new standards and their upcoming accreditation survey. Subsequently, they requested HCI provide them with JCI support on a monthly basis in the lead up to their accreditation survey.

Objectives

Identify the strengths and weaknesses of HMC’s current QSMS in line with JCI Accreditation Standards for Hospitals.
Review the new edition of standards to identify new requirements in order to prepare for the upcoming JCI Accreditation Survey.
Provide a structured plan and support for achieving JCI accreditation.

Solution

In order to support the Hermitage Medical Clinic to successfully prepare for their JCI Accreditation Survey, HCI provided the following solution:

Quality and Safety Specialist.

Project Plan and Work Plan.

Gap Analysis.

Virtual Patient and System Tracer Audits.

Departmental and documentation reviews.

Review of data analytics.

Mock interviews with staff.

Expert JCI support and guidance to staff.

Document preparation for JCI survey.

Challenges

The HMC had a very well developed QSMS, however the challenge was to identify the gaps within the QSMS that needed to be addressed in order to meet the new set of JCI Standards.
The revised JCI Standards included new measurable elements and had an increased focus on risk.
There was no draft process guide in place for the revised standards.
The COVID-19 Pandemic resulted in the need for a new virtual survey format.
Patient Feedback was limited as the team could not interact with patients due to COVID-19.

Outcome

The Hermitage Medical Clinic successfully achieved JCI Accreditation in line with the requirements of the JCI Accreditation Standards for Hospitals, 7^th Edition. The JCI Accreditation Standards for Hospitals, 7^th Edition came into effective in January 2021, which made the Hermitage Medical Clinic one of the first hospitals to be accredited against these revised standards.

Benefits

A detailed report on the current QSMS strengths and weaknesses against JCI Standards.
The roadmap for improvement provides reassurance to Hospital Management that there is a structure in place and dedicated resources to manage the preparation for the JCI Survey.
Risk areas are identified.
Generate awareness among staff on the revised JCI Accreditation standards.
Conducting mock interviews and tracer audits in the virtual format helps to identify and address any issues prior to the JCI Survey.
HCI’s extensive regulatory, quality and patient safety knowledge is transferred to staff during the project.
HCI has extensive knowledge of the JCI Accreditation Standards and can expertly interpret the Standards and identify the necessary QIPs in order to become compliant.
JCI accreditation serves as a recognition of Hermitage Medical Clinic’s assurance to provide the highest standards of care and patient experience.
Increased focus on patient safety and continuous improvement.