[Clinic name]
Controlled document
[Address]
[Registration or licence number]
JCI survey checklist
1Twelve months out
- Buy the standards manual and the survey process guide for your programme, and read them as a team.
- Form an accreditation team, with one owner per chapter.
- Run a gap analysis against every measurable element, and an action plan with dates.
- Plan to file the application on JCI Direct Connect 6 to 12 months before you want the survey.
2Patient safety goals
- Two identifiers on every patient, in every system, at every step.
- Critical results communicated, read back and recorded.
- High-alert medications and the checks around them, written and shown.
- Hand hygiene measured, with the numbers on the wall and in the minutes.
3Patient-centred care
- Mock tracers on real patients, from first enquiry to follow-up.
- Consent taken, recorded and explained in a language the patient understands.
- Assessments complete and timed, and handovers on the record.
- Information for international patients in their own language.
4Organisation management
- Staff files complete, with qualifications and training current.
- Quality measures chosen, tracked monthly and acted on.
- Access to records controlled by role, with a log you can show.
- Infection control and facility safety rounds, with actions that close.
5After the survey
- Read the SAFER Matrix and start the Strategic Improvement Plan the same week.
- Submit the plan within 60 days of the official findings report.
- Keep evidence current for the Continuous Engagement touchpoints.
- Treat reaccreditation in three years as the next survey, starting now.
6What a JCI surveyor may ask
- How do you identify this patient, and how do you know it is her result? What to show, two identifiers, used every time, and the result on the right record.
- Show me the consent for this procedure, and what she was told. What to show, what the patient was told, in which language, and when she agreed.
- How was this patient's care handed over? What to show, the handover, the referral or the letter, signed and timed.
- How do you communicate with patients who do not speak English or Arabic? What to show, conversations and information in the patient's own language.
- How do you know this note was written at the time? What to show, notes made during care, signed, with any change visible.
- Who can see this record, and how would you know? What to show, roles, access controls and an access log.
- What quality measures do leaders review, and what changed? What to show, the measures, the trend and the decision it led to.
AAppendix, One row per chapter
- A.1Chapter ______ Owner ______
- A.2Elements scored Met ______ Partially Met ______ Not Met ______
- A.3Where the evidence lives ______
- A.4Last mock tracer on ______ Patient traced ______
- A.5Highest-risk gap ______ Fixed by ______
- A.6What improved in the last six months ______