Any hospital may
apply for Joint Commission International (JCI) accreditation if it meets all
the following criteria:
• The hospital is located outside of
the United States and its territories.
• The hospital is currently operating
as a health care provider in the country, is licensed to provide care and
treatment as a hospital (if required), and, at minimum, does the following:
• Provides a complete range of acute
care clinical services—diagnostic, curative, and rehabilitative.
• In the case of a specialty hospital,
provides a defined set of services, such as pediatric, eye, dental, and
psychiatry, among others.
• For all types of hospitals, provides
services that are available 365 days per year; ensures all direct patient care
services are operational 24 hours per day, 7 days per week; and provides
ancillary and support services as needed for emergent, urgent, and/or emergency
needs of patients 24 hours per day, 7 days per week (such as diagnostic
testing, laboratory, and operating theatre, as appropriate to the type of acute
care hospital).
• The hospital provides services
addressed by the current JCI accreditation standards for hospitals.
• The hospital assumes, or is willing
to assume, responsibility for improving the quality of its care and services.
• The hospital is open and in full
operation, admitting and discharging a volume of patients that will permit the
complete evaluation of the implementation and sustained compliance with all
current JCI accreditation standards for hospitals.
• The hospital meets the conditions
described in the current Accreditation Participation Requirements (APRs).
Academic medical
center hospital applicants must meet each of the criteria above in addition to
the following three criteria:
1) The applicant hospital is
organizationally or administratively integrated with a medical school.
2) The applicant hospital is the principal
site for the education of both medical students (undergraduates) and
postgraduate medical specialty trainees (for example, residents or interns)
from the medical school noted in criterion 1.
3) At the time of application, the
applicant hospital is conducting medical research with approval and oversight
by an Institutional Review Board (IRB) or research ethics committee.
Definitions
Full
operation
• The hospital accurately identifies
the following in its electronic application (E-App) at the time of application:
• All clinical
services currently provided for inpatients and outpatients. (Those clinical
services that are planned and thus not identified in the E-App and begin
operations at a later time will require a separate extension survey to evaluate
those services.)
• Utilization statistics for clinical
services showing consistent inpatient and outpatient activity levels and types
of services provided for at least four months or more prior to submission of
the E-App
• All inpatient and outpatient clinical
services, units, and departments identified in the E-App are available for a
comprehensive evaluation against all relevant JCI standards for hospitals
currently in effect, consistent with JCI’s normal survey process for the size
and type of organization (see, for example, the current JCI hospital survey
process guide), such as
• patient tracer activities, including
individual patient and system tracers;
• open and closed medical record
review;
• direct observation of patient care
processes;
• interviews with patients; and
• interviews with medical
students/trainees.
Contact JCI
Accreditation prior to submitting an E-App to discuss the criteria and validate
whether the hospital meets the above criteria for “in full operation” at least
four months or more prior to submitting its E-App and at its initial survey.
JCI may request documentation of the hospital’s utilization statistics prior to
accepting the E-App or conducting the on-site survey. In addition, JCI will not
begin an on-site survey, may discontinue an on-site survey, or may cancel a
scheduled survey when it determines the hospital is not “in full operation.”
Principal
site
Principal site means
the hospital provides the majority of medical specialty programs for
postgraduate medical trainees (for example, residents or interns) and not just
one specialty, as in a single-specialty hospital (for example, an
ophthalmologic hospital, dental hospital, or orthopedic hospital).
Medical
research
Medical research
conducted at the academic medical center hospital represents varied medical
areas or specialties within the institution and includes basic, clinical, and
health services research. Such research may include clinical trials,
therapeutic interventions, development of new medical technologies, and
outcomes research, among others. Hospitals that primarily conduct non–human
subjects research and/or research exempt from review by an IRB or research
ethics committee, such as medical record review studies, case studies, and
research involving data/specimens without individually identifiable
information, do not meet criterion 3 of the academic medical center hospital
eligibility criteria.
Note: If in its
reasonable discretion JCI determines that the applicant does not meet the
eligibility criteria for the Hospital/Academic Medical Center Hospital
accreditation program, JCI will not accept the application or will not process
the application for accreditation from the hospital and will notify the
hospital of its decision.
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