11 Conditions that a hospital must fulfil in-order to

participate in JCI accreditation process

Before even going into JCI accreditation standards a hospital must look into these essential
conditions or requirements, if it is planning to go for JCI accreditation. Hospitals not fulfilling any of
these conditions are at risk of accreditation being denied. JCI assesses these conditions, in addition
to standards, for both first time applicant hospital as well as already-accredited hospitals. For first
time applicant hospitals, these conditions are assessed during the initial survey and for already
accredited hospitals, it is assessed throughout the accreditation period, through on-site surveys, the
Strategic Improvement Plan submitted by hospital, and through periodic updates that JCI receives
from these hospitals.

The requirements given below are referred from 'JCI accreditation standards for hospitals, 6th
Edition'

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1. Data and information required by JCI must be submitted in timely manner by the hospital.

There are many data and information, which includes things like information asked in application
(electronic application), annual updates to be made in application, Strategic Improvement Plan,
major changes in hospital etc. These must be submitted within the agreed time-frame.

2. Data and information submitted to JCI are accurate and complete.

Hospitals are expected to be engaged with JCI with honesty, integrity and transparency. Under this
condition, data/information provided to JCI in any form (written or verbal) are included.

3. Any change in hospital’s profile or information provided in electronic application must be

reported to JCI within 30 days

These changes may be anything that affects the information submitted in electronic application to
JCI. They include, change of name, ownership, additional or removal of any clinical offerings, changes
made in hospital’s building, increase/decrease in hospital’s bed capacity, merger, acquiring of any
unaccredited site etc.

4. Hospital must allow JCI to conduct on-site evaluation at its own discretion.

JCI can conduct on-site evaluation for a number of things like assessing compliance to standards,
policies, verification of quality and safety concerns, regulatory sanctions, major complaints etc. The
onsite evaluation can be informed or surprise, as decided by JCI.

5. Hospital must allow JCI, access to original or authenticated copy of results/reports by external
evaluation conducted by any publicly recognized bodies.

If the hospital has undergone any other external assessment, like by NABH or ISO, JCI will have right
to review the reports of them.

6. The quality improvement programme of the hospital should be based on data and valid
measurement method.

JCI focuses very much on collection, analysis and use of data. Hospitals are expected that hospital
collect and use data for quality improvement programme. JCI also recommends various types of
measurements through its International Library of Measures, which the hospitals can refer.

7. The accreditation status of JCI should be accurately represented by the hospital

The hospital while representing its accreditation status should clearly specify the programmes and
services to which JCI accreditation applies. This should be taken care of at all places like hospital’s
website, advertising and promotion, and in any other form in which information is made available to
public.

8. Any staff of hospital can directly report to JCI about quality and patient safety related
concerns.

Hospital must allow and inform all staff that they are permitted to report such concerns to JCI. There
should not be any retaliatory action from hospital against that staff.

9. At the time of the survey and if required, hospital must arrange for a qualified translator and
interpreter, who has no relationship to hospital
The translator and interpreter, if required, should not be a staff of the hospital and should be
qualified to undertake that task.

10. The hospital must notify the public whom it serves about the method of contacting hospital’s
management and to JCI, if they have quality or patient safety concerns

Methods such as display, printed communication materials, website etc. must be employed

11. The environment in the hospital must not pose any risk of an immediate threat to patient
safety or staff safety

The building, space and facility from inside and outside should be safe for its occupant. Things like no
availability of emergency exit, risk of collapse of building or a part of it etc. should not be found in
hospital.