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HCM 620 Final Exam(A) Answer Script

GBS 2018
Course Code:
MBA 602 - Healthcare Management
Course Title:
Healthcare Accreditation
Student Name:
Student ID:
Ritthu Anshar
Final Exam - Individual Assignment 60%
1. Study one of the hospital’s journey of healthcare Accreditation in UAE
2. What changes did the accreditation bring to that organization?
3. What was the impact of Accreditation on the performance of the organization?
The case Study should have the following
Cover Page
Table of Contents
Conclusions & Recommendations
References (Using Harvard Referencing)
Appendix (if any)
Joint Commission International (JCI) is the recognized leader in international health care accreditation
which identifies, measures, and shares best practices in quality and patient safety with the world. JCI
provides leadership and innovative solutions to help health care organizations across all settings to improve
their outcomes and achieve peak performance in patient care. JCI accreditation is considered the gold
standard in global health care.
JCI enables organizations to help themselves through:
 Earning JCI accreditation and certification, recognized as the global Gold Seal of Approval
 Providing leading education
 Delivering evidence-based advisory services
JCI focuses on the highest patient care standards and results-oriented process improvement and has earned
the respect of health care leaders from around the world.
The mission of JCI is to improve the safety and quality of care in the international community through the
provision of education, publications, consultation, and evaluation services.
Zulekha Healthcare Group
Zulekha Healthcare Group is one of the foremost brands providing the highest quality healthcare in the
Zulekha Healthcare Group was the first to receive the largest International Quality accreditation for their
high quality healthcare services from Joint Commission International (JCI), USA for both multi-specialty
hospitals in Dubai and Sharjah in 2007. As an endorsement of their consistent commitment to high quality,
both hospitals received JCI re-accreditations on December, 2010.
Zulekha Healthcare group is proud to have various accreditations/awards to its credit in various sectors like
IT, Engineering, CSR and Healthcare. Some of the awards/ accreditations include, Joint Commission
International Accreditation, ISO 20000, Best Sustainable Hospital Project Award, Best Technology
Initiative award, Dubai Chamber CSR Label award, ISO 15189, College of American Pathologists (CAP)
Laboratory Accreditation Program among others.
 Zulekha Hospital Vision:"To be the most efficient, competent and courteous providers of comprehensive healthcare in
the world."
 Zulekha Hospital Mission:"To provide easy accessibility to high quality healthcare"
 Zulekha Hospital Values
 Honesty & Integrity
 Privilege & Responsibility
 Planning & Implementation
 Quality Service & Continuous Improvement
 Courtesy & Compassion
 The Zulekha Hospital Philosophy
 Quality healthcare at affordable costs.
 Continuous improvement in terms of infrastructure and patient care.
 Meticulously adhered to our focus - "Your health matters"
Zulekha Healthcare Group is a healthcare conglomerate with two multi-specialty hospitals in Dubai and
Sharjah, three UAE medical centres and three pharmacies. The Group today has over 1,700 personnel that
include more than 200 qualified doctors, staff nurses and a host of paramedical staff.
Today, Zulekha Healthcare Group symbolizes comprehensive healthcare that is easily accessible to anyone
in need of any kind of medical attention.
In 2005, the Zulekha Healthcare Group decided to embark on the journey of JCI accreditation to provide
quality and safe services to patients.
The following steps outline Zulekha Hospital’s journey of JCI Accreditation:1. Becoming familiar with JCI’s Accreditation Standards and Survey Process
Leadership reviewed JCI’s Accreditation Policies and Procedures, the ‘JCI Hospital Accreditation Manual’
and the ‘JCI Survey Process Guide for Hospitals’ in order to prepare for the survey. All relevant
information was shared with team members.
2. Conducting Gap Analysis and Building Action Plan
Leadership then identified a team to perform a baseline assessment of the hospital’s performance against
JCI standards in order to check the compliance.
Staff responsibilities were assigned, a primary accreditation contact was created and the organization
commenced the JCI electronic application (E-App).
An accreditation action plan was created to respond to the gaps in the self-assessment and achieve
compliance with the JCI standards.
3. Updating Policies and Procedures
The hospital’s existing policies and procedures were reviewed and updated to achieve compliance with the
JCI standards and the measurable elements.
4. Examining Challenges and Targeting Improvements where needed
Initially, the International Patient Safety Goals were reviewed in order to highlight the problematic areas
and describe evidence-based solutions.
The hospital’s risk for adverse events was assessed. Information from reporting systems like incident
reports / occurrence variance reports were analysed to show risk patterns.
The high-risk, high volume and problem-prone issues were prioritized.
5. Working with staff to overcome obstacles.
The organization attempted to create a culture of safety wherein both staff and leadership acknowledge
mistakes, learn from them, identify the root causes and take necessary corrective and preventive action. All
individuals were made to focus on maintaining excellence in performance and accept that safety and
quality of care, treatment and services are a personal responsibility.
The hospital staff were given training on the new JCI Policies and Procedures.
6. Assess the organization’s readiness at the midpoint
The staff were prepared for a mock survey which stimulated the JCI on-site accreditation process and
addressed the hospital adherence to JCI standards in day-to-day operations. A dedicated quality department
was created involving a few clinicians in this process.
Staff were involved and Patient tracers (a foundational element of JCI on-site surveys) were implemented
to follow the course of a patient’s treatment within the hospital, allowing staff to assess the hospital’s
compliance with JCI standards in multiple departments by many caregivers and assess the safety and
quality of care at the organizational level.
7. Continuing training for sustainable changes.
The hospital staff were introduced to the JCI accreditation philosophy and approach. They were educated
about how accreditation can be used as a risk reduction strategy.
The mock survey planning was completed and tracer findings were communicated to the staff so as to
brain-storm for solutions.
8. Evaluating and Refining Processes
The accreditation team spotted process deficiencies and staff were encouraged to undertake corrective
9. Conducting the Mock Survey to assess readiness
The Multidisciplinary Audit Team conducted the mock survey to evaluate everything including proposed
steps in action plans. The hospital then began to resolve the non-compliance issues prior to actual survey.
Areas of non-compliance were identified and specific problems were brought to the attention of the staff so
as to plan corrections, consider new methods for achieving hospital goals and make improvements.
10. Making final preparations for JCI survey
The leadership communicated with JCI Accreditation and the JCI Surveyor team during the scheduling and
planning periods that preceded the hospital’s on-site survey.
The JCI survey process involved: an opening conference, leadership interviews, staff qualification and
education, facility tour and a leadership conference among other key interactions.
The survey was completed and JCI accreditation was successfully achieved for Zulekha Hospitals in 2007
and reaccreditation was achieved in 2010, 2014 and 2017.
In the year 2015, two of the newly added services in Sharjah, Chemotherapy and Dialysis Treatments had
also undergone the JCI extension survey and became successfully accredited.
Zulekha Hospital Sharjah was the first hospital to be accredited by JCI in the Northern Emirates.
In 2017, JCI expert surveyors visited Zulekha Hospitals in Dubai and Sharjah to evaluate the hospital’s
standards in various areas and were truly impressed with the degree of compliance of the Hospital policies
and procedures with the JCI 5th edition Hospital Standards.
JCI Accreditation helped the organization to achieve standardization of their processes and systems,
improve patients’ trust that the organization is concerned for patient safety and quality of care and provide
a safe and efficient work environment. Through the process of JCI accreditation, the organization was able
to ensure that the hospital policies and procedures were in compliance with the JCI Hospital standards
related to a variety of areas including the International Patient Safety Goals, patient assessment and care,
anaesthesia and surgical care, medication management, patient and family education, quality improvement,
infection prevention and control, governance and leadership, facility management, staff qualifications and
education, and information management.
It motivated the organization to build a culture of quality within the organization and contributed to the
establishment of a dedicated quality department in the organization involving a few clinicians in the
process resulting in the development of efficient and effective quality systems.
Earning the JCI Accreditation also provided credibility and external validation of Zulekha Hospitals and
created a favourable impression of the organization amongst the general public, existing customers and
other stakeholders.
Subsequently, Zulekha Hospital implemented the European Foundation for Quality Management (EFQM)
Excellence Model and received the Dubai Quality Appreciation Award and Dubai Quality Award by Dubai
Economic Development Department in the year 2007, 2011 and 2014 respectively. This helped the
management to measure and improve many of the processes within the organization which led to
improvement in satisfaction of both patients as well as other stakeholders.
Earning the JCI Accreditation also paved the way for the organization to successfully achieve the
Mohammed Bin Rashid Al Maktoum Business Excellence Award (MRM) in February 21st 2017.
The organization was further motivated to improve their laboratory services so as to help the doctors in the
diagnosis of patients. This led to the implementation of the College of American Pathologists (CAP’s)
Laboratory Accreditation Program which is an internationally recognized program designed for laboratory
services. Zulekha Hospital Dubai Laboratory achieved CAP accreditation in 2012 and reaccreditation in
2014 and 2016. Zulekha Hospital Sharjah Laboratory also achieved CAP accreditation in 2016. The
confidence of Zulekha Hospital doctors on the laboratory reports has increased many folds with this
accreditation. It helped the hospital laboratories to achieve the highest standards of excellence to positively
impact patient care.
After achieving JCI accreditation, Zulekha Hospital continued its efforts in ensuring full compliance with
the JCI hospital standards at all times. The accreditation process helped the organization to identify critical
components of patient safety, build systems and processes to ensure safety and constantly be on the lookout
and adopt the best practices in healthcare.
Implementation of the JCI accreditation standards considerably improved the patient satisfaction scores,
decreased the number of patient falls and medication errors, encouraged the reporting of incidents / errors
and streamlined the processes related to admission, referrals, discharge, medication management etc.
In 2015, the continued compliance with the JCI accreditation standards achieved the following:
 Zero sentinel events which testified the safe practices and environment of the hospital
 Zero Ventilator associated pneumonia (VAP) cases due to the implementation of VAP bundle
 Zero Catheter associated infections
 Improvement of Hand hygiene compliance by 2.5%
 Consistent Increase in the number of Incident Reports / Occurrence Variance Reports reported by staff,
thus providing the hospital ample opportunities for improvement.
 Implementation of a ‘Just Culture’ wherein the management focuses on the processes, policies and
systems and staff are not punished unless some gross negligence is found.
 Only 3 patient identification errors were identified compared to 8 in the previous year with no
significant impact on patient outcomes. All were identified and corrected before providing care to
 Decrease in the number of needle stick injuries since 2011 with the introduction of butterfly needle,
small sharp bins which can be carried to patients’ bed side and continuous education of staff.
 0.84% Surgical site infections were reported which was well below the benchmark of 2%
 15 Patient falls were reported with no injuries to almost 26000 admissions done
 A cross match to transfusion ration of 1.65 well below the benchmark of 2
 Lower segment caesarean section rate of 49.1%, less than the previous year
 Improved performance in terms of the patient volume (both inpatients and outpatients) which increased
by 20%
 Hospital discharged about 85% of patients within 2 hours of writing discharge orders, thus allowing
patients to leave quickly and ensure that patients waiting for treatment are being taken off
 Average door to balloon time for Angioplasties achieved was 80.4 minutes against the benchmark of 90
minutes which shows quick care to patients in need
 The turnaround time for STAT samples in Laboratory improved by 1.95% in 2015 when compared to
previous year.
 Communication of critical values compliance improved by 1.31% in 2015 when compared to previous
After successfully earning the JCI Accreditation, Performance Improvement became the highest priority of
Zulekha Hospitals. This led to the development of the performance improvement model called
“ZULEKHA” PERFORMANCE IMPROVEMENT MODEL which created a sense of belongingness
and pride in the organization. A plan was made for the hospital wide implementation of this model as
• The process improvement will run once every year
• Each department will have to take up at least one project each year
• Participation is mandatory
• A 5 member multidisciplinary team “Project Steering Committee” was formed to approve, guide and
monitor the status of all projects
1. Deployment of Approach –
The poster of the ZULEKHA model was made (Refer to Appendix – Figure 1). A workshop was held for
all the staff of various departments to introduce the model and explain the process of implementation.
Along with that various other quality tools needed for process improvement like prioritization matrix, team
building, project charts, flow charts, data collection and analysis tools, bar diagrams and control charts,
root cause analysis (fishbone and five why techniques), lean, value stream mapping etc. were explained and
exercises conducted.
A timeline for the project cycle was also presented.
A project steering committee comprised of Managing Director, Director of Quality, Director of Finance,
Deputy Director of Nursing and Deputy Director of Administration was formed.
Deputy Director of Quality was identified as the responsible person for supervising the projects and
coordinating with the teams and steering committee.
2. Zoom –
The teams were asked to look at their KPIs data, complaints and feedback from end users and identify at
least 3 topics with the prioritization matrix and the reason why they want to select a particular process for
improvement using the ZULEKHA model.
A total of 48 projects were approved for the year 2015 across Zulekha Hospital, Sharjah and Dubai.
3. Unite and Understand –
The next update meeting with the Steering committee was held 20 days later where the teams presented the
project charter explaining the objectives of the projects, team composition and budgets required. Based on
the recommendations of the steering committee, the project charters were amended and budgets allocated.
4. Learn and Lookout –
In the next meeting held after 20 days, the teams presented the existing process flows, data and what
aspects would they like to improve and how. The steering committee give inputs related to the processes
and suggested few ideas and system changes which could be done. The parameters to monitor the
effectiveness of solutions were identified.
5. Execute –
For the next one and half month, the teams implemented the solutions approved by the steering committee
and collected the data. An update meeting was held to review the progress of the implementation of the
corrective actions and data was reviewed by the steering committee.
6. Know –
The teams implemented further improvements and recommendations as suggested by the steering
committee. The committee insisted on Health Management Information Systems (HMIS) changes for
better and permanent solutions and also for easy monitoring of the process through data retrieval.
7. Hasten and Honour –
A ceremony was held in the month of December 2015 to congratulate and recognize the departments and
its members who have achieved improvements in their processes.
8. Assign –
For projects which are completed, departmental staff were assigned responsibilities to monitor the
improved / new process through KPIs and report quarterly.
9. Assessment –
Within the projects selected, the objectives set were monitored on a continual basis with the project
steering committee. A total of 15 projects were completed so far and a revenue generation or savings of 5
Million achieved.
The approach of the implementation of “ZULEKHA” model is being continuously reviewed through
conducting meetings on time, completion of agreed on projects, compliance to the timeframes set etc.
10. Refinement –
Decision was made to approve either one or a maximum of 2 projects only for each department, prioritize
the implementation of IT solutions based on need and assign coordinators from quality department for each
project to provide more support.
From the above case study, it can be concluded that JCI Accreditation helps to organize and strengthen
patient safety efforts. Achieving accreditation makes a strong statement to the community and strengthens
community confidence about an organization’s efforts to provide the highest quality and safety of care,
treatment and services. Accreditation may provide a marketing advantage in a competitive health care
environment and improve the ability to secure new business.
Implementation of Joint Commission accreditation standards tends to attract qualified personnel, who
prefer to serve in an accredited organization. Accredited organizations also provide additional opportunities
for staff to develop their skills and knowledge.
Joint Commission standards focuses on state-of-the-art performance improvement strategies that help
health care organizations continuously improve the safety and quality of care, which can improve risk
management and reduce the risk of error or low quality care.
Accreditation involves preparing for a survey and maintaining a high level of quality and compliance with
the latest standards. Joint Commission accreditation hence provides a framework for organizational
structure and management as well as guides an organization’s quality improvement efforts.
It is strongly recommended that organizations should implement JCI accreditation standards because it is a
globally recognized achievement in quality improvement and patient safety. Achieving JCI accreditation
can have a profound impact on your performance, culture, image, and business operations.
 https://www.jointcommissioninternational.org/
 http://zulekhahospitals.com/
 http://www.dubaided.ae/PublicationsDocument/ShareBestPracticesBooklet2016.pdf
 http://zulekhahospitals.com/uploads/files/GRI%20Annual%20Report_2015_V9_opt_S2.pdf
 https://www.jointcommission.org/benefits_of_joint_commission_accreditation/
Figure 1
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