An Exploratory Study on Adherence to Joint Commission International Standards on Facility Management and Safety at a Tertiary Care Hospital in Dubai, United Arab Emirates

Abstract

Introduction: According to the International Society for Quality in Healthcare, accreditation is a process in which "trained external peer reviewers evaluate a healthcare organisation's compliance with pre-established performance standards. Unlike licensure, accreditation focuses on continuous improvement strategies and achievement of optimal quality standards, rather than adherence to minimal standards intended to assure public safety".^1,2 This study aims to observe and identify gaps in adherence to Facility Management and Safety Standards as prescribed by the Joint Commission International (JCI). Methodology: A time-bound single-centre observational study was carried out using the JCI Accreditation Standards for Hospitals (Sixth Edition). Questionnaires were shared with 20 purposively and conveniently (based on consent) selected participants after obtaining signed informed consent. Following the questionnaire examination, one-on-one interviews with management were held to acquire the necessary data for the study, including the reasons for non-compliance with specific requirements. This research closely examined JCI-recommended policies (Chapter: Facility Management and Safety) and the hospital's compliance with them. Results and Conclusion: Based on the study, it can be concluded that the hospital has complied with most of the standards on Facility Management and Safety Standards of the Sixth Edition of JCI. However, the clauses FMS.2:ME.3, FMS.6:ME.4, FMS.9.2.1:ME.3, and FMS.9.2.1:ME.4 were not met.