Dr. Joel Roos

Accreditation: A key step on the road toward high reliability

The JCI surveyors are the “heart and soul” of JCI

Before Dr. Joel Roos joined Joint Commission International (JCI) as Vice President of International Accreditation, Quality Improvement and Safety two years ago, he served for 30 years in the U.S. Navy, where he spent a lot of time on the receiving end of the Joint Commission surveys. Now that he’s on the other side of the table—observing people getting ready for surveys and conducting analysis—he’s uniquely positioned to share what he knows about the journey toward high reliability.  “Hospitals” magazine sat down with Dr. Roos to learn what organizations need to know about the accreditation process.  

Does JCI work only with major hospitals and academic medical centers, or can smaller or newer systems achieve accreditation, too?

The size and age of your health system really doesn’t matter. Whether you’re large or small, new, or well established, we’re ready to work with any organization committed to excellence. 

While accreditation is an important tool in setting the groundwork for high reliability and zero harm, to achieve it an organization must have a certain level of quality improvement and patient safety standards, infrastructure, skills, and resources in place. In terms of actual types of healthcare organizations, there’s a wide spectrum – Academic Medical Centers, Hospitals, Ambulatory clinics, Home Healthcare organizations, Laboratories, etc..

What advice would you give organizations considering pursuing accreditation?

First, I would urge any organization to seriously consider what’s required to achieve accreditation. After all, it is a commitment of time and money. The results are worth it, though. JCI has also worked hard to create products and tools to support healthcare organizations throughout the accreditation process. JCI Evaluate, for example, is a tool that helps organizations conduct patient safety and quality self-assessments, so they can get a feel for whether they’re truly ready for accreditation right now or need to work on some areas first in order to get there.

When you speak with organizations considering JCI services, what are some of the key points you stress about how they can develop a culture of quality and safety?

A culture of quality and safety is a leadership initiative. Until leadership commits, the rest of the organization will not follow. And it’s more than just a commitment of financial resources.  Healthcare systems also need to demonstrate a dedication to improving care for everyone who walks through the door. In fact, as part of the accreditation process, organizations must take a hard look at where their problems are—and have a true desire to fix them. When they learn about things they aren’t doing well, or have a bad outcome, they must ask questions like “What did we learn from this?” and “How do we make it better?”

Will you please provide a brief overview of the JCI standards, the survey process, and the value that the surveyors bring to it?

Joint Commission International (JCI) standards define the performance expectations, structures and functions that must be in place for a healthcare organization to be accredited by JCI. The survey process is really based on evaluating against these standards, which span across patient-centric and organizational management functions. For example, our standards focus on access to care and continuity of care, anesthesia and surgical care, infection control and prevention, medication management, leadership and governance, information management, and facility management to name a few of the areas.  The survey process, itself is a very robust and rigorous process.  When a healthcare organization successfully completes the survey, it signals patients and the community it is serving that the organization has undergone an exacting performance assessment and met a robust series of qualifications in patient safety and quality of care, resulting in the Gold Seal of Approval^® symbolizing the commitment to excellence. The standards and the processes we use are basically our intellectual property. However, they come to life with the surveyors. The JCI surveyors are the “heart and soul” of JCI, the surveyors come from a variety of backgrounds. We have nurses, physicians, healthcare administrators—all very seasoned people who are dedicated to teaching and improving quality and patient safety. They’re experienced. They’re passionate about what they do. And they bring that passion for improvement, day in and day out, to every healthcare organization they evaluate.

Thank you, Dr. Roos for this insightful discussion. Where can people get more information about JCI and your services?

My pleasure. Thank you for giving me the opportunity to share these perspectives. The JCI website (www.jointcommissioninternational.org) has a wealth of trusted resources, designed to help any health system looking to improve quality of care and patient safety. It’s our hope that the information you need to keep your organization moving toward continuous improvement is just a few clicks away.