The Joint Commission International (JCI) had announced the updated Accreditation Decision Rules for Hospitals as was published on their webiste.on 13 March 2014.

By and large a Health Information Management (HIM) / Medical Records (MR) practitioner in a hospital setting will not be briefed about everything hospital accreditation, especially matters like how the decision is made to accredit a hospital. That notwithstanding, If you are working at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for accreditation status, I think it is important to be aware on how all information from the initial or triennial full JCI and any required follow-up focused survey are used to make the decision regarding a hospital accreditation.

The hospital must meet five (5) conditions to be accredited. The conditions requires that the hospital must be able to demonstrate that there is acceptable compliance with each standard, there is acceptable compliance with the standards in each chapter, there is overall acceptable compliance,  the total number of measurable elements (MEs) found to be “Not Met” or “Partially Met” is not above the mean (three or more standard deviations) for a hospital surveyed under the hospital accreditation standards within the previous 24 months, and the ME in the International Patient Safety Goals ( IPSG) is scored “Not Met”.

Since the 5 conditions encompass the relevant standards that HIM / MR practitioners manage in the daily routine management of health information management / medical records management in a hospital setting, he or she must be made aware of by circulars or at least briefed on these 5 conditions to be accredited.

If the HIM / MR practitioners in their practice fail to comply with any relevant standard, any relevant standards in each chapter, and contribute to non-compliance of MEs found to be “Not Met” or “Partially Met” is not above the mean (3 or more standard deviations) for a hospital surveyed under the hospital accreditation standards within the previous 24 months, than he or she would be deemed to be contributing negatively to the overall performance during the hospital survey process and towards accreditation been denied!

The HIM / MR practitioner is advised to be aware of At Risk for Denial of Accreditation conditions, especially the 5 conditions regarding relevant standards and MEs.

Below is a flowchart (click on the flowchart below and it will open in a new tab of your current window; click on the resulting image in this new tab for a larger view of the flowchart image – zoom to see bigger fonts or simply print to read) showing all the decision rules that will be taken by the JCI Accreditation Committee to validate if your hospital meets the criteria for accreditation. From the chart, there are two potential outcomes. The outcomes may be that the hospital meets the criteria for accreditation or does not meet the criteria and is denied accreditation. The charts also shows At Risk for Denial of Accreditation conditions.

References:

1. Joint Commission International, 2013, Joint Commission International Accreditation Standards For Hospitals, 5th edn, JCI, USA
2. Joint Commission International, 2014, JCI Announces Updated Accreditation Decision Rules for Hospitals,  viewed 31 March 2014, <http://www.jointcommissioninternational.org/jci-announces-updated-accreditation-decision-rules-for-hospitals/>