What is JCI Accreditation?

Joint Commission International Accreditation is a voluntary process in which an entity separate and distinct from the health care organization which assesses the health care organization to determine if it meets a set of requirement (standards) designed to provide a visible commitment by an organization to improve the safety and quality of care which is optimal and achievable. It is an effective quality evaluation and management tool for ensuring a safe care environment which helps continuous improvement process to reduce risk to patient and staff.

Who are JCI?

Joint Commission International is a U.S. based not for profit accreditation body which sets and designs standards and processes to create a culture of ethics, safety and quality within an organization that strive to continually improve patient care processes and results.

Benefits of JCI Joint Commission International teaches and leads us to:

  1. Improve patient trust by improving patient safety, quality and care.
  2. Provide a safe and efficient work environment that contributes to staff satisfaction
  3. Listen to patients and their families, respect their rights, and involve them in the care process as partners; and
  4. Helps establish collaborative leadership that sets priority for and continuous leadership for quality and patient safety at all levels.

What is Tracer Methodology?

Tracer methodology is an evaluation method in which a surveyor selects a patient and uses that individual’s record as a roadmap to assess and evaluate an organization’s compliance with selected standards and the organization’s system for providing care and services.


What is the role of the staff in the survey/during a tracer?

As surveyors move around the hospital, they will ask to speak with the staff members who have been involved in the tracer patient’s care, treatment and services. Assume they will want to talk with you, so have confidence in yourself—you provide awesome care, so let them see it! Remember that you are prepared to answer their questions.


Consider the following recommendations:

  • Be certain to greet the surveyor (good morning/ good afternoon) with a smile, introduce yourself, including your title, and accompany the surveyor to your area and/ or to you department head/ supervisor/ in-charge
  • Be confident and remain calm, don’t attempt to hide, ignore or run from them.
  • Answer their questions directly (keep your answers short and sweet) and ask the surveyor to repeat or rephrase the question if you don’t understand it.
  • Be polite and smile—do not let the questions make you feel defensive or angry.
  • Be honest—if you do not know the answer, do not make one up; tell them you don’t know but you will ask your senior staff or your colleague who knows the answer.
  • Be specific, provide examples for an answer and refer to policies or procedures whenever possible
  • Be enthusiastic about what you do.


To serve the healthcare needs of the region by giving comprehensive care.

To treat and to prevent illness.

To provide advanced procedures & modern technology combined with the traditions of caring & compassion.


Our CORE VALUES as healthcare providers

RESPECT: We interact professionally with others and affirm that each person has special value, unique talents and varied gifts. We offer open mindedness, recognition a rid appreciation to the perspectives and experiences that others bring to the table and are willing to share.

TEAMWORK: We work together to achieve our goals. We make effective teams through respectful interpersonal communication dynamics building a supportive teamwork environment and camaraderie with our co-workers.

INTEGRITY: We do the right thing. We Act ethically arid responsibly in all services we do.

EXCELLENCE: We do the best thing. The best service, best experience and best practices to provide the highest quality care for our patients and their families.

COMPASSION: We are advocates for a compassionate and just society through our actions and our words. Be empathic by listening, reflecting and accepting people and where they are in life, conscientiously care for our environment, be with those most vulnerable and recognize that not only patients, but also their families and our co-workers need help from time to time.

JCI Standards (5th Edition)

Accreditation Participation Requirements (APR): 12 Chapters Total Number: 16

  • Patient Centered Chapters: 8
  • Organization Management Chapters: 6
  • Academic Medical Center Hospital Chapters: 2

Standards: Total Number: 304

Standards are set around the important functions; they are common to all healthcare organizations.

Intent statement: Easy explanation of the standards

Measurable Elements: 1218 (total number), measurable elements are those requirements of standards which are reviewed and assigned a score during survey.

Survey: Assesses the hospitals compliance on JCI standards

Chapters Details

  • Accreditation Participation Requirements
    Accreditation Participation Requirements (APR)-Introductory
  • The Patient Centered Standards are:
    • International Patient Safety Goals (IPSG)
    • Access to Care and Continuity of Care (ACC)
    • Patient and Family Rights (PFR)
    • Assessment of Patients (AOP)
    • Care of Patients (COP)
    • Anesthesia and Surgical Care (ASC)
    • Medication Management and Use (MMU)
    • Patient and Family Education (PFE)
  • The Organization Management Standards are:
    • Quality Improvement and Patient Safety (QPS)
    • Prevention and Control of Infections (PCI)
    • Governance, Leadership, and Direction (GLD)
    • Facility Management and Safety (FMS)
    • Staff Qualifications and Education (SQE)
    • Management of Information (M01)
  • The Academic Medical Center Hospital Standards are:
    • Medical Professional Education (MPE)
    • Human Subjects Research Programs (HRP)

JCI addresses the following issues very intensively:

  1. International Patient Safety Goals
  2. Patient & Family Education
  3. Patient & Family Rights & Responsibilities
  4. Pain Management
  5. Quality Indicators & Monitoring
  6. Hand Hygiene & Prevention and Control of Infection
  7. Fire Safety and Emergency Codes
  8. Removal of Barriers to Care
  9. Patient Identifiers
  10. Care of High Risk Patients (Vulnerable patients)
  11. Restraint Order
  12. Rights of Drug administration
  13. Discharge Planning & Components of Discharge Summary
  14. Time Out process
  15. Biomedical Waste Disposal
  16. Personal Protective Equipments (PPE)
  17. HAZMAT, Lab, Radiation, Facility Safety
  18. DNR (Do Not Resuscitate)
  19. End of Life Care
  20. Hospital Mandatory Trainings