JCI Accreditation Mock Survey for Blackrock Health Hermitage Clinic

“Blackrock Health Hermitage Clinic requested HCI to conduct a Mock Survey against the JCI Accreditation Standards for Hospitals, 7^th Edition. HCI were our providers of choice for this review as they have supported us through previous JCI accreditation cycles and are clear experts at interpreting the JCI Accreditation Standards. HCI conducted a comprehensive review and provided us with a detailed report which we used to identify areas of focus and develop action plans. HCI’s support gave us reassurance as we prepared for the JCI survey and we are delighted to have successful achieved JCI Accreditation.”

Gordon Dunne

CEO, Blackrock Health Hermitage Clinic

Background

Blackrock Health Hermitage Clinic (BHHC) is a private hospital based in Dublin, and is part of the Blackrock Healthcare Group.

As BHHC prepared for their next Joint Commission International (JCI) accreditation cycle, they requested HCI to conduct a mock survey of the hospital’s Quality and Safety Management System (QSMS) against the JCI Accreditation Standards for Hospitals, 7^th Edition. The JCI Accreditation Standards represent the gold standard in the global healthcare community.

Objectives

Complete a mock JCI accreditation survey for Blackrock Health Hermitage Clinic to identify the strengths and weaknesses of the current Quality and Safety Management System.
Provide a report identifying areas of good practice and a listing of areas of non-compliance in relation to the JCI Accreditation Standards for Hospitals, 7th Edition.
Provide JCI support for interview preparation and document review.

Solution

In order to ensure a comprehensive Mock Survey was conducted for Blackrock Health Hermitage Clinic, HCI provided the following service:

Development of Project Plan.

Offsite Document Review prior to conducting onsite review.

System and patient tracers.

Staff Interviews with the Management Team, department leaders and frontline staff.

Onsite Document Review.

Development of Draft Mock Survey Report.

Client Review of Draft Report.

Feedback is provided to HCI.

Mock Survey Report is finalised and presented to the client.

JCI Support for interview preparation and document review.

Challenge

Hospital Managers and specific key staff members were new to their roles within the organisation and had not been involved in the previous JCI surveys.

Outcome

HCI conducted a comprehensive Mock Survey at the Blackrock Health Hermitage Clinic in line with JCI Accreditation Standards for Hospitals, 7th Edition. HCI utilised the tracer methodology to analyse BHHC’s systems by following individual patients through the organisation’s care process in the sequence experienced by the patients. This methodology reflects the JCI surveyors’ methodology during the accreditation survey.

Following the onsite review, HCI presented BHHC with a detailed Mock Survey Report that identified areas of good practice and areas requiring improvement in line with the JCI Accreditation Standards for Hospitals. HCI subsequently provided JCI support days around interview preparation and document reviews.

The Blackrock Health Hermitage Clinic successfully received its sixth accreditation from JCI in line with the JCI Accreditation Standards, 7^th Edition.

Benefits

Comprehensive and independent review of processes.
Mock survey is conducted in the same format as a JCI Survey, which helps prepare and educate staff on the survey process.
A detailed report on the current strengths and weaknesses of the hospital’s QSMS against the JCI Accreditation Standards.
The Report provides a roadmap for improvement, allowing the necessary QIPs to be put in place prior to the JCI Survey.
Provides reassurances to Hospital Management that they have a plan in place to achieve reaccreditation.
Risk areas are identified.
HCI have supported Blackrock Health Hermitage Clinic through previous JCI accreditation cycles, and so HCI understand their systems and processes.
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 your compliance rating with the standards.
Maintain a high standard of continuous quality improvement and patient safety.