In the continuously changing environment of medical care, high quality and patient safety are the key to success. In the case of most healthcare organizations across the globe, this quest ends in Joint Commission International (JCI) accreditation. JCI accreditation is not a mere medal of honor but a thorough, detailed procedure which indicates that a healthcare organization is committed to an international standard of patient care, safety, and organizational management. It promotes the image of a hospital, increases the number of foreign patients, and makes the functioning of a facility more effective and, most importantly, increases the effectiveness of the care given.
However, the journey towards the JCI accreditation is usually a path full of numerous challenges. Hospitals that jump on this bandwagon often face obstacles which may challenge their determination, stretch their resources, and require deep organizational change. It is important to know these typical barriers and prepare active plans to address them in order to achieve success.
The Path of Excellence: Common Challenges in JCI Accreditation
JCI accreditation is a marathon and not a sprint. It must be carefully planned, thoroughly committed, and it needs to be flexible to meet the unexpected challenges. The ten most common challenges a hospital faces and ways to overcome them are listed below:
Challenge 1: Staff Resistance and Lack of Buy-in
The first obstacle can be one of the greatest: the commitment of all personnel levels. Healthcare professionals, who already have busy schedules, might see accreditation as an extra bureaucratic step and unnecessary, which is why they tend to resist, become apathetic to the idea, or even go against it. This buy-in failure may bring down the process before it starts.
Expert Tip: By not having any real involvement of staff, JCI accreditation turns into a top-down requirement instead of a unified organizational objective. This definitely results in the facade compliance that collapses after survey.
Case Study: A big private hospital in Southeast Asia initially experienced the problem of nurses and doctors unwilling to follow new documentation procedures. The response of the leadership was the creation of interdepartmental task forces to find viable solutions.
Actionable Solutions:
- Early and Consistent Communication: Be clear about the why of accreditation, it is about better patient outcomes and safety, not compliance.
- Leadership by Example: Top leadership should become the strong visible proponent of the initiative by taking part in training and showing their compliance with new standards.
- Empowerment and Involvement: Form committees and task forces and include representatives of each of the departments. Permit employees to offer ideas in policy formulation and process enhancement.
Challenge 2: Documentation Overload and Management
JCI standards are extremely elaborate, and they need a lot of documentation of policies, procedures, patient care records, training logs, and quality improvement efforts. To most hospitals, this will amount to a huge task of generating, updating and keeping an uncontrollable amount of paperwork.
Expert Insight: JCI compliance is all about documentation, but not just to have documents, but to be sure that they are up-to-date, accessible, and reflective of the reality on the ground.
Case Study: A Middle East hospital had a mountain of paper-based records which were difficult to maintain. They purchased an electronic document management system (EDMS) and began a gradual process of converting and creating a new digitally-first workflow.
Actionable Solutions:
- Digital Transformation: Introduce electronic health records (EHR) and document management to facilitate the process of creation, storage, and retrieval.
- Standardized Templates: Create clear and concise templates of standard documents to make them consistent and simple to fill.
- Frequent Audits: Carry out in-house audit of documentation to detect gaps, discrepancies and other improvement areas prior to the formal survey.
- Individuals or Designated Documentation Teams: Appoint a specific individual or team to be responsible for managing documentation to various standards, to achieve expertise and accountability.
Challenge 3: Infrastructure Limitations and Facility Upgrades
Most of the existing hospitals, particularly those that are old, might discover that their present infrastructure is not sufficient to meet JCI requirements in terms of patient safety, infection, fire control and management of the environment. This may require a lot of capital and intricate renovation.
Case Study: A Latin American public hospital realized that fire safety arrangements and patient room ventilation had serious gaps. They got government funding and undertook renovations gradually, and they prioritized certain sections and continued patient services.
Actionable Solutions:
- Full Gap Analysis: Perform a thorough evaluation of the facility in comparison to the Environment of Care (EC) standards of JCI.
- Phased Renovation Plan: Create a multi-year renovation plan that focuses on areas that are the most at risk and have the longest lead time.
- Involve Professionals: Work with architects, engineers and construction companies that have experience in designing healthcare buildings in accordance with JCI standards.
Challenge 4: Post-Accreditation Compliance
Although the process of obtaining accreditation is a herculean endeavor, compliance may also be a frustrating undertaking in the long run. Unless there is constant vigilance, policies may become obsolete, training staff may be allowed to lapse, old habits may re-emerge, and standards may start drifting before the next survey.
Expert Insight: Accreditation is not an end-state. The true challenge is to make quality and safety part of the hospital DNA to the point that compliance becomes continuous, part of the way the hospital functions.
Case Study: A large academic medical center experienced a decrease in specific quality measures a year after an initial JCI success. They also introduced a strong internal auditing program and factored in JCI standards into regular performance evaluation and annual competencies of the staff.
Actionable Solutions:
- Continuous Readiness Program: Create a permanent program of internal audits, mock-surveys and performance monitoring to maintain a state of constant preparedness.
- Incorporation in the Daily Processes: Incorporate the JCI standards into everyday processes, job descriptions, evaluations as well as orientation of new hires.
- Periodic Review and Update: Maintain a regular review and update of all policies, procedures and training materials.
- Quality and Safety Teams: Have a team that is well-staffed and dedicated to ensuring continuity of compliance and quality-related initiatives.
Challenge 5: Limitations and Resources Distribution
The JCI accreditation is a momentous financial process, which implies the payment of surveyors, the training of staff, the modernization of technology, the enhancement of infrastructure, and the cost of special staff. In the case of most hospitals, particularly those in developing economies or those in the public sector, sufficient financing may be a significant obstacle.
Case Study: A non-profit hospital had issues with getting modernized healthcare facilities because of finances. The hospital established a special fundraising group and used its better quality story to gain charitable contributions and grants to be used specifically in accreditation-related activities.
Actionable Solutions:
- Detailed Budgeting: Prepare a detailed budget by taking into consideration all the elements of direct and indirect costs involved during the whole process of accreditation.
- Cost-Benefit Analysis: Provide a definite business case to the stakeholders, and outline the long-term advantages and ROI of accreditation.
Challenge 6: Bridging Cultural Gaps and Communication Barriers
The JCI accreditation may reveal the cultural differences in the communication style, hierarchy, and patient care approaches in the multicultural healthcare context. It may be difficult to have uniformity in understanding and application of the standards in varied staff populations.
Expert Insight: It is all about cultural competence. The JCI standards are universal, yet their application has to be responsive to the local cultural peculiarities and communication patterns.
Case Study: In a hospital where the international workforce is highly diversified, they introduced compulsory cultural sensitivity training and a multilingual communication plan, such as translated documents and interpreters in the most important meetings.
Actionable Solutions:
- Cultural Competency Training: Offer training that deals with various cultural norms, methods of talking and expectations of patients.
- Multicultural Communication: Translate important policies, patient education resources and signage to the common languages of the staff and patients.
- Cross-Cultural Teams: Establish accreditation teams where team members represent different cultures by diversifying their views.
Challenge 7: Performance Measurement and Data Management
JCI focuses on evidence-based decisions and constant quality enhancement. Hospitals have to ensure that they have strong mechanisms for gathering, analyzing, and responding to data regarding patient outcomes, safety events, and efficiency of processes. Fragmented data systems or inability to develop analytical capabilities are some of the challenges faced by many organizations.
Case Study: A hospital in South Korea is having challenges analyzing data, it combined its disparate clinical and administrative databases in a central data warehouse so that real-time dashboards and automatic reporting could be provided on JCI-required performance indicators.
Actionable Solutions:
- Integrated Data Systems: Invest in or merge current IT systems to form a single data collection and reporting system.
- Define Key Performance Indicators (KPIs): Define specific performance measures that need to be implemented as required by JCI and set the baselines and targets.
- Staff Training on Data Literacy: Train employees on collecting data and interpreting reports, and making decisions through data.
- Frequent Data Reviews: Have regular meetings to review performance data, determine trends and take corrective actions.
Challenge 8: Adapting to Evolving Standards
JCI standards are not fixed; they are constantly upgraded to include recent developments in medical science, best practices in patient safety and emerging global health issues. Remaining updated on these changes and applying them throughout the organization may be an ongoing struggle.
Case Study: A hospital wants to earn JCI accreditation. In order to bypass the challenges, it appointed a special task force to keep track of JCI changes, share the information with the rest of the employees, and spearhead the change of impacted policies and procedures. They also read JCI newsletters and joined webinars.
Actionable Solutions:
- Committed Standards Observation: Designate a person or a team that monitors regularly the official publications of JCI, to ensure changes and amendments.
- Internal Communication Protocol: This should develop a clear procedure for communicating information about standard changes to all the departments concerned.
Challenge 9: Disaster Management and Emergency Preparedness
JCI puts a lot of emphasis on the capacity of a hospital to respond effectively in case of emergency, disaster, and mass casualty. This needs detailed planning, frequent drills and effective liaisons with the outside agencies. Few hospitals are equipped or have the expertise to create and trial these far-reaching plans.
Expert insight: A hospital is the last resort in a society during a crisis. JCI guarantees that this important infrastructure is robust and prepared to save lives when it is needed the most.
Case Study: One of the hospitals in an earthquake-hazardous area collaborated with the local emergency services to organize combined disaster exercises, where gaps in communication and distribution of resources were discovered and then filled.
Actionable Solutions:
- Hazard Vulnerability Assessment (HVA): Perform a thorough HVA to determine the possible emergencies and probable effects they will have on the hospital.
- Comprehensive Emergency Management Plan: Design elaborate plans on different scenarios, protocols of communications, the role of staff, management of resources, and evacuation procedures.
Challenge 10: Maintaining a Patient Safety Culture
On the most fundamental level, JCI accreditation is the culture of patient safety. This implies going beyond compliance to integrate safety into values, establish open reporting on incidents without fear of being blamed and learning all the time from mistakes. The most significant and challenging task can be a change of an ingrained culture.
Expert Insight: True patient safety culture can be defined as psychological safety, where employees feel encouraged to voice their concerns and mistakes are considered as educational experiences.
Case Study: A hospital adopted a system of Just Culture, where the faults were examined in order to find the failures of the system and not only to punish individuals. This saw a great improvement in the reporting of incidents and active risk prevention.
Actionable Solutions:
- Leadership Commitment: Leaders should be seen as leading advocates of patient safety and as providers of resources, and as those responsible for achieving a safe environment.
- Just Culture Implementation: Embrace a Just Culture which separates the line between human error, those at risk in their behavior and those who engage in reckless behavior and encourages learning over blame.
- Open Reporting Systems: Establish an open and confidential reporting system of adverse events and near misses, with well-defined feedback measures.
- Patient and Family Engagement: Engage patients and their families in safety efforts, getting them to speak up regarding concerns.
How to Convert Obstacles into Opportunities: Strategic Perspective
Every obstacle met on the way to the JCI accreditation is a frightening experience, but an individual growth and development. A strategic, resilient mindset may enable healthcare administrators to turn such barriers into stepping stones to real organizational excellence.
Summary: The Sustainability of JCI Accreditation
The JCI accreditation process is indeed vigorous, and it entails tremendous commitment, resources, and the readiness to experience a drastic change in organization. The issues found in JCI accreditation may include staff resistance, documentation overload and infrastructure problems, which require well-thought-out solutions that are strong.
By overcoming these obstacles in advance, healthcare facilities will not only become accredited but also integrate sustainable quality and patient safety in their daily activities.
