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Introduction to
the JCI
Standards
Copyright, Joint Commission International

Overview of
Joint Commission
International (JCI)
Acreditation
The Transparent JCI Process
Dr Arjaty W Daud MARS

On-site
Evaluation of
Standards

Accreditation
Certificate

International
Standards
CURICULUM VITAE

Client name/ Presentation Name/ 12pt - 2

Nama
Alamat
Tmpt / tgl. Lahi
Status
Email
Hp

: dr. Arjaty W. Daud, MARS

: Jl Kemang Timur XIV / 56 Jakarta Selatan
: Manado,17 Januari 1969
: Menikah
: arjatydaud19@gmail.com,
: 0812 1830 7169

Copyright, Joint Commission International

Accreditation
Decision
Rules

22

PENDIDIKAN
S-1 Fakultas Kedokteran Universitas Sam Ratulangi - Manado , Lulus 1995
S-2 Fakultas Kesehatan Masyarakat, KARS Universitas Indonesia, Lulus 2005

PELATIHAN / SEMINAR
2015 : Practicum Acreditation JCI 5th edition Singapura
2011 : Practicum Acreditation JCI 4th edition Seoul
Patient Safety Course, Singapura
2010 : Safety in Healthcare, Kuala Lumpur
2009 : Hospital Management Asia, Vietnam
Course Risk Management PRMIA Jakarta
2007 : New Perspektif, Conferrence ASHRM, Chicago USA
Certified Profesional Healthcare Risk Management course, Chicago USA
Risk Management Base Training, Joint Commision Resources (JCR)
Patient Safety Up Date, Joint Commision International (JCI) Singapura
2005 : Lead Audior ISO 9001 2000, International Registered Certificated
Auditor (IRCA)
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PENGALAMAN KERJA
2016 : Konsultan JCI RS Sutomo
2015 : Konsultan JCI RS Islam Cempaka putih Jakarta, RS Advent Bandung, RS JMC Jakarta
2014 : Konsultan JCI RS MMC Jakarta, RS Kanujoso Blkppn, RS Sleman Jogja, RS Tarakan Kaltara
2013 : Konsultan JCI RS kanujoso Blkppn, RS Sleman
2012 : Konsultan JCI RSUP Fatmawati, RSUP Wahidin Sudirohusodo Makasar, RS Medistra
2011 : Konsultan JCI RSCM, Konsultan Manajemen Risiko & Keselamatan Pasien RS Tarakan Kaltim
2010 : Konsultan Manajemen risiko RSUP Fatmawati Jakarta, RS Bieuren, RS Lhoksemawe Aceh
2009 : Konsultan Manajemen risiko & Kes Pasien RS Wahidin Makasar, RS Pelni Jakarta
Konsultan RS Aini, RS Sardjito
2007
: Direktur RS Zahirah
Konsultan Manajemen risiko RS Persahabatan, RS Dharmais
2006
Konsultan Manajemen RS Asri, Konsultan Manajemen RS Medika BSD,
2004 - 2005 : Manajer Operasional Medika Plaza International Clinic
2003
: General Manajer Cempaka Medical Centre
2003 - 2004 : Direktur Operasional RS Sentra Medika
2002 - 2003 : Wakil Direktur Medik & Asist Direktur RS Sentra Medika
2000 - 2001 : Kepala Bagian Humas RS MMC
1999 - 2000 : Kepala Bagian Rehabilitasi Medik RS MMC
1999
: Asisten Konsultan WHO Umbrella Project Depkes
1996 -1999 : Kepala Puskesmas Sindang Barang Kabupaten Cianjur
ORGANISASI
2007 2012 : Ketua Bidang IV (Pelaporan Insiden) KKP RS PERSI , Sterring Committe KKP RS
2005 - Saat ini:Ketua Institut Manajemen Risiko Klinis (IMRK) / ICRMI
Member of ASQ (American Quality Society),
Member of Profesional Risk Management International Association

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Patient-Centered Standards
1. International Patient Safety Goals (IPSG)
2. Access to Care and Continuity of Care
(ACC)
3. Patient and Family Rights (PFR)
4. Assessment of Patients (AOP)
5. Care of Patients (COP)
6. Anesthesia and Surgical Care (ASC)
7. Medication Management and Use (MMU)
8. Patient and Family Education (PFE)
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Health Care Organization and

Management Standards
1. Quality Improvement and Patient Safety
(QPS)
2. Prevention and Control of Infections (PCI)
3. Governance, Leadership, and Direction (GLD)
4. Facility Management and Safety (FMS)
5. Staff Qualifications and Education (SQE)
6. Management of Information (MOI)

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Academic Medical Center Standards*

1. Medical Professional Education
(MPE)
2. Human Subject Research Programs
(HRP)

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Accreditation
A Definition
Usually a voluntary process by which a
government or non government agency
grants recognition to health care institutions
which meet certain standards that require
continuous improvement in structures,
processes, and outcomes.
Sukarela - Penghargaan

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STANDARD
(STRUKTUR, PROSES,
OUTCOME)

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The Accreditation Journey

The Basics
Evaluate the commitment of leadership
(Board, CEO, and clinical leaders) to a never
ending journey.
Assess the purpose safe, high quality
organization.
Set a clear understanding that the process
will require significant leader time.
Assigning accreditation only to the quality
department will not work.

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The Transparent JCI Process

ON
ATI

RM
SFO Y
N
RA ALIT
YT
NE O QU
R
T
JOU

ST
CO

ACREDITATION
CERTIFICATE

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Accreditation Preparation Process

nal
atio
aniz ent
g
r
O
esm
Ass

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e yo
luat
Eva nt
e
r
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u
n
c
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to d
cr
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stru vemen
o
r
imp

cy &
Poli dure
ce
o
r
P
t
men polices
elop
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Dev lop new res tha
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Dev rocedu JCI
p
h
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an
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com arts
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JCI

to
erts sistant
exp
r
Use ess pe
r
add ifficult
or d lems
b
pro

s.
plan

Moc

rvey
k Su

t
rren onths
s cu
ses nce 6 m allow
s
a
Re orma vey to o
r
f
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per r to su time
h
prio enoug inutes
m
u
t
o
s
y
e la
s
mak tment
JCIA y
s
e
adju
Surv

Create New Processes

Monitor progress and Adjust

Develop and implement new

policies, plans, and
procedures

Evaluate effectiveness of processes and

refine ad necessary

18-24 Months

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ROAD MAP

Mock
Survey
Implementasi

Tindak AKREDITASI JCI

lanjut hasil
Mock
Survey

Sosialisasi
& Simulasi

Pra
Sosialisa
si
Gap
Analysis
Review
Dokume
n

Scheduling your Mock Survey

Jika and ingin disurvey dipertengahan November)
Track record period
July

Aug

Sept

Oct

Nov

Survey
Start of 4 month track record

Track Record Period: the period of time prior to your survey within
which surveyors will examine compliance. (Track record period :
periode waktu sebelum survey untuk menilai kepatuhan anda)
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12

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Scheduling your Mock Survey

Fix issued identified
during the Mock Survey

Feb

March

April

Schedule your
Mock survey

Mei

Juni

Mock
survey

July

Aug

Sept

Oct

Start of 4 month
track record

Nov

Survey

Schedule your Mock Survey at least two months before the start of your
track record to give you time to fix identified issues (jadwalkan Mock survey
minimal dua bulan sebelum waktu mock survey yg diinginkan untuk
membenahi isu yg ada)
.
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13

The Last 10 Moths

Fix issued identified
during the Mock Survey

Feb

March

Schedule your
Mock survey

April

Mei

Juni

Mock survey

July

Track record period

Aug

Sept

Oct

Start of 4 month
track record

Nov

Survey

Scheduled Actual survey

4 months before survey: Track Record Starts

6 months before survey: Schedule your survey
6 - 8 months before survey: mock survey
10 months before survey: schedule your mock survey.
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Make Final Modifications

Make any final improvements using the
information from your Mock Survey. (buat
perbaikan final dengan menggunakan informasi
dari hasil mock survey)
Dont make improvements just to pass the
survey, your improvements should be durable
improvements to patient safety. (jangan buat
perbaikan hanya untuk lulus akreditasi,
PERBAIKAN ADALAH UNTUK
MENINGKATKAN KESELAMATAN PASIEN)
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15

PENGORGANISASIAN AKREDITASI
Core Team

Direktur Utama

WALI 1
Wadir Yan
Medik

WALI 2
wadir.

KA PANITIA AKREDITASI
Sekretariat
Koord Dokumen
Koord sosialisasi
Koord Telusur

WALI 3
Wadir

WALI 4
Wa Dir ..

ACC

IPSG

SQE

AOP

PFE

MPE

FMS

COP

PFR

HRP

QPS

ASC

PCI

MMU

MOI

GLD

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Standards Content
Each JCI standard contains three
components:
1.The standard represents the principle
2.The intent describes the rationale of the
standard
3.The measurable elements are the detailed
requirements from the standard and
intent that are scored

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What is a Standard?
A statement of the safety and quality expected
Types of Expectations in Standards
Inputs (Structures) : Resource
Processes
: Activities
Outcomes
: Results

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CHAPTER STANDAR
12
APR
10
IPSG
19
PFR
38
AOP
26
COP
16
ASC
19
MMU
5
PFE
12
QPS
20
PCI
33
GLD
23
FMS
24
SQE
16
MCI
7
MPE
10
HRP

290

ME

30
76
162
107
54
77
17
53
72
184
91
99
63
30
42

CHAPTER STANDAR
6
IPSG
23
ACC
30
PFR
44
AOP
22
COP
14
ASC
21
MMU
7
PFE
23
QPS
24
PCI
27
GLD
27
FMS
24
SQE
28
MCI

1.157

320

ME

24
103
100
184
74
51
84
28
89
83
98
92
99
109

1.218

arjaty/JCI/2011
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Adaptable Standards Example

STANDARD PFR.5.4
The hospital establishes a process, within the context of existing law and
culture, for when others can grant consent. (RS -- Proses General Consent )
INTENT STATEMENT
Informed consent for care sometimes requires that people other than (or in
addition to) the patient be involved in decisions about the patients care. This is
especially true when... culture or custom requires that others make care
decisions...
MEASURABLE ELEMENTS
1. The hospital has a process for when others can grant informed consent.
( RS Proses general consent diberikan oleh selain pasien)
2. The process respects law, culture, and custom.
(Proses sesuai hukum, budaya dan adat)
3. Individuals, other than the patient, granting
consent are noted in the patients record.
(Pemberi General consent selain pasien tercatat dlm RM)
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Contoh Komponen Standar

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Scoring of Lists in Intent Statements

Note that there are two ways the lists in the Intent Statements are
scored. ( 2 cara skoring intent)
Lists that are designated by letters (e.g. a h) or numbers (e.g.
1 11) are mandatory, and are referenced in MEs
(list dgn huruf : mis a-h atau nomor 1-11 wajib)
Lists that are marked by bullet points () are advisory in nature
(list dgn bullet dianjurkan
The mandatory elements are reflected in the Measurable
Elements and full compliance with them is required
( Elemen yg wajib - ME kepatuhan)
The bulleted elements are not scored as such, but ignoring them
completely will lead surveyors to drill down and ask what else
was considered in compliance with the standard
(Elemen bullet tidak di skoring, tapi dapat
menjadi pertanyaan surveyor untuk menilai kepatuhan standar)
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11

abuse and neglect are shaped by the culture of the patient population. These assessments are not intended to be
proactive case-finding processes. Rather, the assessment of these patients responds to their needs and condition
in a culturally acceptable and confidential manner. The assessment process is modified to be consistent with
local laws and regulations and professional standards related to such populations and situations and to involve
the family when appropriate or necessary. (Also see AOP.1.2 and AOP.1.2.1)

Measurable Elements of AOP.1.6

1. The hospital identifies, in writing, those special patient groups and populations it serves that require
modifications to its assessment.

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2. The assessment process for special-needs patient populations is modified to reflect their needs.
3. The modified assessment process is consistent with local laws and regulations and incorporates
professional standards related to such populations.

Standard AOP.1.7

Dying patients and their families are assessed and reassessed according to their individualized needs.

Intent of AOP.1.7
Assessments and reassessments need to be individualized to meet patients and families needs when patients are
at the end of life. Assessments and reassessments should evaluate, as indicated by the patients condition,
a) such symptoms as nausea and respiratory distress;
b) factors that alleviate or exacerbate physical symptoms;
c) current symptom management and the patients response;
d) patient and family spiritual orientation and, as appropriate, any involvement in a religious group;
e) patient and family spiritual concerns or needs, such as despair, suffering, guilt, or forgiveness;
f) patient and family psychosocial status, such as family relationships, the adequacy of the home
environment if care is provided there, coping mechanisms, and the patients and familys reactions to
illness;
JOINT COMMISSION INTERNATIONAL
ACCREDITATION STANDARDS FOR HOSPITALS, 5TH EDITION
g) the need for support or respite services for the patient, family, or other caregivers;
h) the need for an alternative setting or level of care; and
i) survivor risk factors, such as family coping mechanisms and the potential for pathological grief
reactions.

Measurable Elements of AOP.1.7

1. 1.A discharge
summary
is prepared
qualifiedand
individual.
Dying patients
and their
familiesbyarea assessed
reassessed for those elements in a) through i) of the

intent, according to their identified needs.

2. A copy
of the discharge summary is provided to the practitioner responsible for the patients continuing
2.or follow-up
Assessmentcare.
findings guide the care and services provided. (Also see AOP.2, ME 2)
3. Assessment findings are documented in the patient record.

3. A copy of the discharge summary is provided to the patient in cases in which information regarding the
23
practitioner responsible for theArjaty
patients
continuing
or follow-up care is unknown.
/ JCI
Edisi 5/2015
Standard
4. A copy of theAOP.1.8
completed discharge summary is placed in the patient's record in a time frame identified
The initial assessment includes determining the need for discharge planning.
by the hospital.

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Assessment of Patients
(AOP)

Measurable Elements of ACC.4.3.2

69

Access to Care and

Continuity of Care (ACC)

Standard ACC.4.4

The records of outpatients requiring complex care or with complex diagnoses contain profiles of the medical
care and are made available to health care practitioners providing care to those patients.

Intent of ACC.4.4
When the hospital provides ongoing care and treatment for outpatients with complex diagnoses and/or who
need complex care (for example, patients seen several times for multiple problems, multiple treatments, in
multiple clinics, and/or the like), there may be an accumulated number of diagnoses and medications and an
evolving clinical history and physical examination findings. It is important for any health care practitioner in all
settings providing care to that outpatient to have access to information about the care being provided.
The process for providing this information to health care professionals includes
identifying the types of patients receiving complex care and/or with complex diagnoses (such as patients
seen in the cardiac clinic with multiple comorbidities, or patients with end-stage renal failure);
identifying the information needed by the clinicians who treat those patients;
determining what process will be used to ensure that the medical information needed by the clinicians is
available in an easy-to-retrieve and easy-to-review format; and
evaluating the implementation results to verify that the information and process meet the needs of the
clinicians and improve the quality and safety of outpatient clinical services.
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Measurable Elements of ACC.4.4

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24

1. The hospital identifies the types of outpatients receiving complex care and/or with complex diagnoses
who require an outpatient profile.
2. The information to be included in the outpatient profile is identified by the clinicians who treat those
patients.
3. The hospital uses a process that will ensure the outpatient profile is available in an easy to retrieve and
review format.
4. The process is evaluated to see if it meets the needs of the clinicians and improves the quality and safety
of outpatient clinical visits.

12

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Policy Requirements
Some standards require organizations
to have a written policy or procedure
for a specific process.
(Standard RS buat Kebijakan & SPO)
These standards will be marked with
our policy required symbol.

All policies and procedures will be

scored at MOI.9 and MOI.9.1 232
(Kebijakan & SPO di skor di MOI 9, 9.1)
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DOCUMENT REVIEW
Tujuan : survei kepatuhan pada standar.
Peserta :
staf yang paham dokumen yang akan disurvei,
penerjemah yang profesional.
Tim surveyor dapat menunjuk sejumlah staf yg hadir /
(dibatasi ) dalam sesi Dokumen Review.
Sesi adalah wawancara dengan staf tentang dokumen.
Hampir semua chapter membuat Plans, Policies, and
Procedures tertulis.

Document
Review

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13

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Dokumen yang harus di translate ke Bahasa Inggris

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How to Prepare
Banyak dokumen yang diperlukan menjadi bagian dari
dokumen lain. RS tidak perlu fotokopi bagian dokumen2
ini. Sebaliknya, dokumen2 dapat diidentifikasi
menggunakan bookmark / daftar dokumen.
Notulen dan laporan2 dari Komite2, bisa diberikan
dokumen asli / fotokopi. Beberapa contoh dokumen,
seperti Notulen2 komite dari beberapa pertemuan
terakhir.
Jika RS memiliki contoh2 yang banyak pada topik
tertentu, harus dipilih yang paling representatif atau
contoh yang paling relevan. Surveyor tidak ada waktu
untuk meninjau semua dokumen
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Organization of the Materials

Dokumen di buat Daftar agar memudahkan
pencariannya saat dibutuhkan surveyor & harus
tersedia.
Pengelompokan dokumen sesuai dengan tiga daftar
berikut ini:
1. Data Mutu yg dipersyaratkan
2. Program RS yg dipersyaratkan
3. Kebijakan RS yg di persyaratkan
Dokumen2 dapat dikelompokkan dalam binder atau
folder, atau cara lain yang dapat digunakan untuk
memudahkan pencariannya
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15

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Evaluation of the Policies and Procedures

by the Survey Team
Evaluasi Dokumen tujuanya agar Surveyor mendapat gambaran
apa yang diharapkan saat Tracer.
Misalnya, ketika ada SPO baru tentang pembuangan limbah
infeksius :
A P A K A H ???
Staf telah di sosialisasikan tentang SPO baru tsb
(Special skills) keahlian khusus / pelatihan yang dibutuhkan
telah dilakukan
Pembuangan limbah sudah dibuang sesuai prosedur baru
Dokumen2 yang diperlukan sesuai SPO tersedia untuk
direview
The Management and Implementation of Documents bagian
dari chapter MOI akan digunakan untuk mengevaluasi
kepatuhan dalam mengembangkan dan menerapkan kebijakan
31
dan SPO. (MOI 9)
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Kebijakan / SPO saja tidak dapat menentukan skor .

Sebaliknya, skor ditentukan oleh implementasi
terhadap kebijakan atau SPO.
Tim survei akan mencari bukti implementasi terkait
kebijakan / SPO, apakah diterapkan dengan baik, secara
menyeluruh dan konsisten
Tidak adanya satu kebijakan atau kurangnya
implementasi dari salah satu kebijakan kemungkinan
besar tidak dapat di skor..
Jika beberapa kebijakan tidak ada / beberapa kebijakan
belum sepenuhnya dilaksanakan, - indikasi Systemwide problem related to policy .
Scoring dari MOI.9.1 akan didasarkan pada
persentase kebijakan yang tidak dibuat dan / atau
tidak sepenuhnya dilaksanakan
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Penilaian surveyor meliputi :

1. Dokumen : 3P ?
2. Dokumen sesuai standard yg di
syaratkan?
3. Implementasi sesuai dokumen
standard ?
4. Implementasi Konsisten &
menyeluruh di semua are RS ?

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Secara umum, lamanya waktu kebijakan telah

diimplementasikan disebut Track record.
Tim survei akan mencari 4 bulan Track record untuk
standar terkait kebijakan selama survei awal dan
untuk Track record 12- bulan selama survei tiga
tahunan.
Untuk standar terkait kebijakan akan diberi skor fully
met jika persyaratan track record dipenuhi.
Jika waktu track record belum terpenuhi, namun Tim
survei menemukan bahwa kebijakan tersebut telah
dilaksanakan secara berkelanjutan, tim memiliki hak
prerogatif untuk memberi skor fully met
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Track record untuk standar yang baru di hitung dari

"tanggal efektif" dengan tanggal survei.
Sebagai contoh, jika sebuah standar baru / (ME)
efektif pada 1 Januari, dan survei berlangsung pada
1 Juni di tahun yang sama, track record yang
diperlukan untuk standar baru / ME adalah 5 bulan
untuk fully met

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18