Quality and Safety Management System Gap Analysis for St. Michael’s Hospital

“HCI supported St Michael’s Hospital with a Gap Analysis of our Quality and Safety Management System in line with the JCI Accreditation Standards for Hospitals. HCI were our providers of choice for this review due to their reputation and extensive knowledge of the JCI Standards. HCI provided us a comprehensive report which will support us in implementing a QSMS in line with international best practice”.

Anne Coleman

CEO, St Michael’s Hospital

Background

St Michael’s Hospital is a 130-bed acute hospital providing a range of specialised clinical services to the people of South Dublin and Wicklow. In order to ensure that St Michael’s Hospital’s Quality and Safety Management System (QSMS) operated in line with international best practice, St Michael’s Hospital requested HCI undertake a GAP Analysis to determine the current status of the QSMS in line with the requirements of the JCI Accreditation Standards for Hospitals. The JCI Accreditation Standards represent the gold standard in the global healthcare community.

Objectives

Identify the strengths and weaknesses of St Michael’s Hospital’s current QSMS in line with JCI Accreditation Standards for Hospitals, 7^th
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, 7^thedition.

Solution

In order to ensure a comprehensive GAP Analysis was completed in line with the JCI Accreditation Standards for Hospitals, HCI provided the following service:

Development of project plan.

Offsite document review prior to conducting onsite review.

Staff interviews with hospital management team, department leaders and frontline staff.

System and patient tracers.

Post onsite documentation review.

Development of Draft Gap Analysis Report and QIP list.

Client review of Draft Report and feedback is provided to HCI.

Gap Analysis Report is finalised and presented to the client.

Challenges

Some areas of the hospital were restricted due to COVID-19.
As St Michael’s Hospital isn’t an accredited hospital some of the JCI specific programmes and policies had not been developed.

Outcome

HCI presented the St Michael’s Hospital with a detailed GAP Analysis Report that identified areas of good practice and areas requiring improvement in line with the JCI Accreditation Standards for Hospitals, 7^th Edition. Compliance levels allocated during the review were reflective of the JCI compliance rating. St Michael’s Hospital will use this report as a roadmap to implement a QSMS that is based on international best practice.

Benefits

Comprehensive and independent review of processes.
Establish the current baseline of the QSMS.
A detailed report on the current strengths and weaknesses against JCI Accreditation Standards.
Risk areas are identified.
Generate awareness among staff on the JCI Accreditation standards and inspection process.
Implementing a QSMS in line with the JCI Accreditation Standards will increase patient safety and drive quality improvement.
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.