The Royal Victoria Eye and Ear receives Joint Commission International Accreditation

“RVEEH have been long term partners with HCI. Their expertise in interpreting and implementing the JCI standards is outstanding and HCI’s guidance has been an instrumental support from the very beginning of our JCI Accreditation Journey. As our accreditation cycle came up in 2020, we had every confidence that HCI would ensure we were best prepared for our JCI Survey. HCI provided us with a detailed quality improvement plan that addressed all the areas we needed to focus on. HCI guided and supported both the Management Team and staff throughout the process. With HCI’s ongoing support, extensive knowledge and guidance, we are delighted to have achieved JCI Accreditation.”

Tommy Bracken

Executive Support, RVEEH

Background

Founded in 1897, The Royal Victoria Eye and Ear Hospital (RVEEH) Dublin is a public teaching hospital and the National Referral Centre for both Eye and Ear, and Nose and Throat disorders. RVEEH have partnered with HCI since 2012. During this time HCI have supported the RVEEH through each JCI accreditation cycle. With the RVEEH’s most recent JCI accreditation survey scheduled in late 2020, the RVEEH asked HCI to assess the hospital’s current status against the JCI Accreditation Standards for Hospitals and create a plan for quality improvement.

Objectives

Identify the strengths and weaknesses of RVEEH’S current Quality and Safety Management System (QSMS) in line with JCI Accreditation Standards for Hospitals.
Review and finalise Quality Improvement Plans (QIPs) from a previously conducted GAP Analysis.
Provide RVEEH with a structured plan and support for achieving JCI accreditation.

Solution

In order to support the RVEEH to successfully prepare for their JCI Accreditation Survey, HCI provided the following services:

Quality and Safety Co-ordinator.

Project plan and work plan.

Gap analysis review.

Development of QIP list.

Virtual patient and system tracer audits.

Defined Key Performance Indicators (KPIs).

Departmental and document reviews.

Review of data analytics.

Staff education and training on the International Patient Safety Goals.

Weekly review meetings with Senior Management.

Mock interviews with staff.

Expert JCI support and guidance for staff.

Document preparation for JCI Survey.

Challenges

Due to COVID-19, some staff were working from home which resulted in slower response times in closing out QIPs and approving policies and procedures.
The COVID-19 pandemic resulted in the need for a new virtual survey format.
WIFI connection was poor so boosters had to be put in place throughout the hospital to enable a smooth virtual survey experience.

Outcome

The RVEEH successfully achieved JCI Accreditation in line with the requirements of the JCI Accreditation Standards for Hospitals, for the third time in November 2020. HCI’s long-term partnership with RVEEH has meant that HCI really understand their requirements and have built a trusting relationship with RVEEH to effectively support them in embedding the JCI practices within their hospital. With HCI’s ongoing support, achieving JCI Accreditation has promoted a culture of continuous improvement at the RVEEH and it serves as a recognition of RVEEH’s commitment to the public to provide the highest standards of quality and patient safety.

Benefits

Provides reassurance to Hospital Management that there is a structure in place and dedicated resources to manage the preparation for the JCI Survey.
Staff are educated and effectively prepared for the new virtual format of the accreditation survey.
The ongoing and dedicated support from HCI ensures that JCI practices are embedded fully at the hospital.
The JCI accreditation allows RVEEH to benchmark themselves internationally against other JCI Accredited Hospitals.
Risk areas are identified and discussed weekly with Senior Management.
Demonstrate to all stakeholders a commitment to continuous improvement.
Comprehensive and independent review of processes.
HCI’s extensive regulatory, quality and patient safety knowledge is transferred to staff during the project.