ICORP GROUP · INSIGHTS
APR in JCI 8: Accreditation Participation Requirements Hospitals Should Not Overlook
Time speaks to JCI. Many hospitals often think about Clinical Care, Patient Safety or Facility Management first, but the JCI 8th Edition still emphasizes Accreditation Participation Requirements or APR which is in the main structure of the standard and reflects that the availability for certification does not only measure the quality of the service system but also includes how the organization participates and lies for the certification process.
APR should be considered as a Governance matter.
From a management perspective, APR asks how responsibly the organization handles accreditation information, processes and conditions. It is not the quality department's responsibility alone: accreditation information comes from leadership, doctors, nurses, human resources, facility and other support units.
Information exported from the organization must be reliable.
Certification requires a large amount of information. If each agency provides the data uncompatible or the information presented does not reflect the practical, it will pose a risk for both reliability and internal administration. Therefore, Hospital Governance should have a way to review the accuracy of the data before being used in the process of an investigation or official reporting.
The team must understand their role on the Survey Day.
Survey readiness should not mean just answering questions, but it should make people understand why one system is designed so. What data is used and when Gap is found, how to report or correct. The person who understands the system will answer questions more naturally than the person who remembers the answers.
Important changes must be managed systematically.
Hospitals are changing over time, such as opening new services, changing the structure, changing the IT system or adjusting the facility. These issues can affect Scope and quality system availability. There should be a channel for the quality department to recognize and evaluate the impact. Not waiting until close. Survey will come to a subsequent review.
Checklist that the administrator should take review
- Who owns the key information used in certification?
- How is the accuracy and conformity of data verified?
- The management team understands the scope of accreditation.
- Are the change of service or facility sent to the quality team?
- Is there a Gap tracking system found from internal and external assessments?
Good APR reduces “specific preparation” work.
If the organization builds good Governance, preparation JCI will become part of normal administration. No urgent project before the day Survey. This concept is in line with Continuous Readiness which allows quality and safety to be traced all the time.
ICORP can help hospitals make Gap Assessment, Readiness Review, Management Workshop and Improvement Roadmap to ensure the roles of the various administrations and agencies are connected before entering the real survey process.
Note: This article describes the administrative concepts from the JCI 8th Edition standard structure and does not replace the specifications in the administrative guide.