The Joint Commission International Accreditation Process: A Rare and Challenging Experience of Hamad Medical Corporation in Its Strive for Re-Accreditation

Wednesday, 15 July 2009: 3:45 PM

Dora Maria Carbonu, EdD, RN1
Badriya Sulaiman Al Ali, PhD, RN2
Salama Dokhis Sultan Al Rumaihi, BScN, RN1
1Regulatory and Accreditation Section, Quality Management Department, Hamad Medical Corporation, Doha, Qatar
2Quality Management Department, Hamad Medical Corporation, Doha, Qatar

Learning Objective 1: describe the purposes and goals of Joint Commission International (JCI)accreditation initiatives for Hamad Medical Corporation as a health care organization

Learning Objective 2: appreciate HMC's experience in mobilizing its workforce in collaboration with a JCI Consultant to revise core policies within three weeks toward re-accreditation in 2009

Purpose: Hamad Medical Corporation (HMC), the major health care provider in the State of Qatar, gained a Joint Commission International (JCI) accreditation in 2006, and has been striving to meet the standard requirements for the triennial re-evaluation in 2009. The Quality Management Department collaborated with JCI in the conduct of mock surveys, tracer methodology, on-site observations, review and revision of policies and procedures, and other related accreditation activities, as preparatory measures toward the re-accreditation process. Evidence from the various results suggested that the Corporation lacked in preparedness in several standards-related functions for a successful re-accreditation within the scheduled time frame. Methods: The organization embarked on an ambitious and challenging exercise of assigning its Corporate Clinical Committee, under the direction of the Quality Management Department, in mobilizing all the staff, including corporate and facility administrative and managerial leadership, in all five (5) accredited facilities – to work in collaboration with an assigned JCI Consultant, from October 26 to November 13, 2008, in reviewing and revising all the priority JCI- and HMC-required policies, developing new policies, merging duplicates, and deleting obsolete ones. Results: This demanding yet challenging project resulted in several rewarding experiences for the staff, organizational leadership, and all sectors of HMC; it promoted, enhanced and enriched (1) staff awareness, understanding and appreciation of policies and procedures as requirements unique to the organization’s vision, mission and values; (2) multidisciplinary team approach and commitment to policy and procedure-related issues; quality care, safe care and services, continuous improvement, and external recognition of HMC as a reputable international health care organization. Conclusion: The outcome of this project was the demonstration of a positive staff attitude to organizational preparedness toward a successful triennial re-accreditation in 2009.