JCI Accreditation Standards Training Program

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Joint Commission International standards for hospital

“Guide for bridging the gap between knowledge and practice”

What is JCI?

An independent, not-for-profit organization, Joint Commission International (JCI) accredits and certifies health care organizations and programs across the globe. Joint Commission International accreditation and certification is recognized as a global leader for health care quality of care and patient safety.


What is JCI Accreditation Standards?

JCI standards define the performance expectation, structures, or functions that must be in place for a hospital to be accredited by JCI.



What is KASH Enterprise role?

This training program covers all JCI standards in hospital and provide an overview of the process for implementing JCI standards in hospitals , describe each standard, intent and measurable elements in a simple method and also in integrated way which includes learning materials, case studies and workshops.


Training Objectives:

Upon completion of the JCI Training Program, you should be able to

1. Demonstrate an understanding of compliance with each JCI standards and measurable elements included in each chapter.
2. Interpret each measurable element into requirements in practice.
3. Identify policies, procedures and programs component to fulfill standard requirements.
4. Identify guidelines, protocols and clinical pathways required to fulfill standard requirement.
5. Identify templates and forms either medical & non-medical required to fulfill standard requirement.
6. Using certain tools and methods to achieve the requirements “Survey, Checklist, huddles, Flowcharts, etc….”
7. Using Quality improvement tools to achieve standard requirements “PDCA, FMEA, cause & effect diagram, 5 whys, etc…”
8. Select well defined, evidence based key performance indicators that are applicable to patient population and services to comply with JCI standard.
9. Perform a risk assessment through risk identification, risk mapping and risk mitigation plan.
10. Identify different hospital committee’s members, roles and function.
11. Perform Individual Patient tracer and system tracer methodology.


Target audiences:

Quality professionals
Any Healthcare staff interested in JCI accreditation standards


What is the duration of the course?

The course lasts for 65-70 hours, 2 hours/day, 2 days/week.


Details of Lectures’ Times:

All lectures in the form of LIVE Sessions

Days: Every Sunday and Wednsday.
First Lecture: will be held in October (Exactly date will be determined with attendees)
Number of Lectures: 36 Lectures
Time: from 8:30 pm – 10:30 pm (Cairo Time)


Teaching Method:

This course will cover all JCI standards “excluding the Academic medical center hospital standard”, the course is thought through interactive sessions, involving workshops for certain requirements/tools as will be introduced through each session, also self-participation and sharing experience will be encouraged.


Lectures and Studying Materials:

The lectures’ presentations are developed through comprehensive review and collection from different resources:

· JCI Accreditation standard for hospitals, 7th edition
· JCI Survey Process Guide, 7th edition
· Joint Commission international resources
· Institute for healthcare improvement, IHI
· Agency for healthcare quality & Research, AHRQ
· Different websites, reference and organizations


Certificate of Accomplishment is available.


Sara Ahmed Tarek, TQM, HMD, LSSGB, TOT

Diploma in total quality management, AUC
Diploma in hospital management, AUC
Lean Six Sigma Green built, AUC
Former quality manager in different organizations in Egypt
Participated in preparation of several JCI accreditations “initial & triennial“ in “Dar AlFouad, Wadi El Neel, International Medical Center” Hospitals


Nada Elhawary

Infection Control Board (The Egyptian Fellowship)
Professional Diploma of infection prevention & control (AICPD)
Former IC Manager in accredited hospital
Former IC consultant in logistics for healthcare improvement
Participated in many JCI accreditations


Important N.B. 

To increase the value of the course and sharing experience and discussions between attendants, all the lectures will be live sessions and no records available. But you have all the right to attend the same course for unlimited times with the same fees you have already paid.