Quality Management Systems against JCIA Standards

What We Offer

• Provision of “Consultancy” for the development of Quality Management Systems [QMS] against Joint Commission International Accreditation [JCIA] Standards,
• Awareness training on JCIA Standards,
• development of documentation aligned with JCIA Standards,
• Risk assessment and management through tools including FMEA etc.,
• Performance monitoring and measurement through KPI’s etc.,
• Performance Improvement Project by using Different Quality Models such as PDCA, FMEA, Lean philosophy, Six sigma methodology, total quality, 
• Gap analysis and mock survey, and
• Incident investigation and reporting.

Target Clients

• Home Care,
• Ambulatory Care,
• Clinical Laboratory,
• Hospitals,
• Long-Term Care,
• Medical Transports, and 
• Primary Care.

Why Choose ADIQC 

• We provide enough time to our prestigious client to discuss and clarify issues & concerns, as needed, during our meeting sessions,
• We provide enough training to our prestigious client to develop competencies in order to be able to maintain the management systems in a way that bring value to it through continual improvement initiatives,
• We are flexible and work according to customer convenience, to the extent possible,
• you can call us anytime during working hours if needed our expertise &/or assistance, and 
• we are target oriented by keeping on track through developed & agreed “Action Plan”.

Benefits of JCI Accreditation

Nowadays, when selecting healthcare facilities, one of the criteria that people are looking for is the delivery of quality services. When you are accredited by JCI, your facility will be in their list or might as well the first-choice healthcare provider in your service area by the people who are seeking healthcare assistance. JCI ensures that all their accredited organizations meet highest quality standards for patient safety, delivery of clinical care, overall patient support, etc. Your clients will be confident that your facility has met strict criteria of JCI through thorough, in-depth and independent evaluation of various technical and managerial organizations processes, facilities, equipment etc.

Process Flow

1. Initial assessment/gap analysis with report submission

ADIQC will provide initial assessment program according to scope of services. This initial assessment will cover the management office and the patient sites. A comprehensive written report of initial assessment will be presented to the top management on the status of the facility against JCI standards’ requirements. The presentation will be provided to the management on the Non-conformities and action plan will be developed in liaison with the client to work on the gaps identified.

2. Awareness of Quality and JCI standards

ADIQC will provide Quality awareness and JCI standards training to the Management and to all other staff, who will involve in JCI accreditation preparation process of the facility.100% of the total staff must get the training.

3. Development stage

Management structure

• Assistance will be provided to the Management in the review or development of the facility’ management structure as per the JCI Standards,
• Vision, mission, and values,
• Objectives, targets, and programs,
• Organization charts,
• Management structures,
• Medical staff privileges,
• job descriptions for all other staff, 
• Strategic plan, both short & long & term,
• Ethical framework, and
• Financial management.

Development of committees structure

ADIQC Consultants will provide expertise for the establishment of Standing and Subcommittees (Admin & Clinical Committees) for the facility with the terms of Reference [ToR] for each committee which includes the purpose, members, and function of the committee

The list of committees includes

• Senior Management Committee,
• Quality and Patient Safety Committee,
• Infection Control Committee,
• Patient Education Committee, and
• JCIA Steering Committees which will be responsible for JCI all (Clinical and Management) chapters’ review, development, and provision of orientation to staff and implementation afterward.

4. Development of documentation

ADIQC Consultants will provide the full assistant for the development of documents according to the requirements of JCI Standards & the facility practice. These documents will be:

1. Policies, procedures &gGuidelines (PPGs), both clinical and non-clinical,
2. Satisfaction survey questionnaire for staff, patients, and suppliers and any other stakeholder,
3. Operational plans e.g. Fire & safety, emergency preparedness, disaster plan, evacuation plan, staff recruitment & retention plan etc.,
4. Medical staff privileges,
5. Quality performance indicators [KPI’s],
6. Performance improvement projects [PI projects],
7. Risk management program,
8. Establishing medical records system, and
9. Establishing complaint management system.

5. Review of documents

ADIQC Consultant will review each and every provided document prior to finalization. After review by ADIQC Consultants, the management shall also review the document prior to approval.

6. Approval of documents

Manuals, Policies, Procedures, Plans, Key Performance Indicators, etc. according to the requirements of JCI will be formally approved by the management of the Facility.

7. Distribution of the documents

The management will ensure the distribution of the documents in all areas and to make sure the availability of the most recent approved copy of the documents.

8. Training on developed documentation 

ADIQC will provide training on 

• Departmental policies, procedures and guidelines,
• The fire & safety plan,
• Waste management,
• Key performance indicators (KPI),
• Risk management, and
• Performance improvement projects etc.

9. Implementation stage

• All the developed policies, procedures, guidelines will be distributed to all the relevant areas for the purpose of implementation. The different manuals will be developed on practice and each Head of the Area will be responsible for the implementation of these manuals,
• Implementation of medical record system – ADIQC Medical record expert will provide assistance for the development and implementation of medical record system for the facility,
• Development of mandatory documents (Forms),
• Development of medical record review process (audit checklist), and
• Open & closed chart review audit.

10. Risk & safety assessment & management

ADIQC consultants will provide complete support and expertise for the Risk & Safety Assessment and Management of the facility by assessing, analyzing, evaluating, categorizing, prioritizing, and developing the corrective &/or preventive action plan using tools such as FMEA etc. Our Consultants will also provide assistance for the development of

• Safety plan.
• Facility disaster plan.
• Disaster/emergency preparedness and evacuation plan.
• Material safety data sheet.
• Management of medical waste.

11. Implementation of customer complaint system

ADIQC will provide assistance for the development of process for written and verbal customer complaints for the facility for the handling, analyzing, outcome, providing feedback to customers and if required, development of corrective preventive action. The track and trend for all complaints will be maintained also for improvement purposes.

12. Customer & staff satisfaction survey

• ADIQC will provide assistance in the development of the questionnaire for customer satisfaction survey and will conduct the survey with the help of facility personnel, will make the report and submit to facility management.
• Personnel for this task from facility side would be assigned by the management prior to start the “Survey”.
• There will be customer satisfaction survey at least, bi-Annually with data analysis and action for the improvement; also staff satisfaction survey will be conducted and action plan for improvement to be developed and implemented.

13. Audit of implemented documentation 

The developed documents must be audited to review the below

• The treatment plan is reviewed at each session,
• Subjective outcomes are reviewed at each session,
• Objective outcomes are reviewed at each session,
• All changes, subjective and objective, are documented,
• Any changes to the treatment plan are documented,
• The outcome is measured at the end of the treatment program, and
• All policies and procedures are followed and documentation is done, if necessary.

14. Tracers

The tracer should be conducted with the patient home, these tracers will be individual patient experience, medication tracer, infection control tracer, data tracer. These tracers will be conducted as per patient journey from the time patient came under the service until discharge.

15. Mock surveys

• Final assessment by ADIQC team will be performed before JCI survey to assess the preparation,
• ADIQC will provide the report of the survey to the management and will help to rectify the findings/non-conformities/concerns.  The management will ensure rectification of the identified concerns within the time frame as agreed between ADIQC team and the client project team, and
• There should be a multidisciplinary team to do these tracers. All the nonconformities should be noted in the action plan for improvement.

Deliverables by ADIQC

• Gap analysis report and action plan,
• Training on JCIA Standards [awareness], KPI’s, developed PPG’s, infection control, health & safety, leadership & management,
• Documentation that includes Job Descriptions, Forms, Flow-charts, List, Registers and Checklists, Terms of Reference, Agenda & meeting minutes, Policies, Procedures and Manuals, Plans, Programs,
• Satisfaction surveys & evaluation (staff, customer, supplier etc.),
• Training on developed documentation,
• Tracer and mock survey reports, and
• Assistance on rectification on JCIA’ survey report.