Campus Bio-Medico University Hospital is accredited by the Joint Commission International (JCI), an independent international organization that ensures compliance with standards of excellence in the health care sector.
JCI is called in by hospitals on a voluntary basis to assess their level of compliance with pre-established standards of safety for patients, staff and other persons in the hospital and of quality of health care, both from a medical and infrastructural perspective. Joint Commission International is the largest and most experienced health care accreditation body in the world.
The standards established by Joint Commission International are defined by objective requirements for hospital safety and quality of health care. They are described in a manual published and periodically updated by JCI. New standards are added and existing ones improved in each new edition. Accredited facilities must implement the updates to maintain their accreditation.
A committee for international standards, composed of 12 experts including doctors, nurses, administrators and public policy experts from around the world, deals with the development and revision process for the standards.
UCBM Hospital’s accreditation renewal in 2017 refers to the 5th edition of the JCI Standards Manual. The enforcement of each standard is verified through a number of specifically defined, measurable elements. Accreditation involves the verification of 1,300 elements. Because UCBM Hospital is a university hospital, the university also had to be accredited, in compliance with specific standards for teaching and research. The university received the Academic Medical Centre Hospital Accreditation.
Patient-related standards cover safety, access to and continuity of health care, the rights and education of patients and their families, patient assessment and care, anesthetic and surgical care, and the management and use of drugs, especially high-risk drugs.
Standards for hospital organization and management concern quality improvement and patient safety, infection prevention and control, internal governance, leadership and management, infrastructure management and safety, staff qualification and training, and communication and information management.
The final phase of the Joint Commission International evaluation is a visit to the medical facility (survey). A team of experts, including at least one physician, one nurse and one administration expert sent from the JCI Chicago headquarters, ensures that all standards have been met. The team of experts checks the measurable elements one by one and attributes a rating to each of them (compliant, non-compliant, or partially compliant). Based on the number of measurable elements rated compliant, the experts then calculate which standards have been met and send the results and a report to the Chicago headquarters, where the JCI Accreditation Committee issues the final verdict: accreditation granted or rejected.
During the period when the survey is taking place, members of the evaluating team are free to walk around the facility and interview health care professionals and patients, directly observe the processes of access to services within the facility, from admission to discharge, and review documents, procedures and guidelines for clinical practices adopted by the hospital. They also verify the safety of the hospital infrastructures and the management of medications. During the visit, they are accompanied by an interpreter, since respondents are required to speak in their mother tongue.
In order to ensure a safe, high quality health care environment, UCBM Hospital pays careful attention to all concerns expressed by patients and employees regarding the quality and safety of health care and the work environment. Patients can communicate their concerns, suggestions or complaints to us in several ways: