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Healthcare Quality & JCI Accreditation Standards Training Course

Prepares healthcare organisations for JCI accreditation by turning its standards into daily practices that improve patient safety, governance and performance.

HQP · Healthcare Quality, Patient Safety & Patient ExperienceAll Levels#2621ClassroomEnglish , Arabic
Duration
5 Days
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Free substitution at any time · 30+ days' notice: full refund minus 10%. Cancellation policy

Course Overview

This advanced training course provides a practical framework for strengthening healthcare quality systems and preparing healthcare organisations for Joint Commission International (JCI) accreditation. It focuses on translating accreditation requirements into operational practices that improve patient safety, clinical effectiveness, governance, and organisational performance. The programme examines the key principles of healthcare quality management, patient-centred care, safety practices, clinical governance, risk management, performance measurement, and continuous improvement. Participants explore how accreditation standards can be integrated into daily operations rather than treated as a standalone compliance exercise. Particular attention is given to accreditation readiness, policy and procedure management, documentation, tracer methodology, quality indicators, incident reporting, medication safety, infection prevention and control, patient rights, staff competencies, and leadership responsibilities. Practical approaches are used to identify gaps and establish sustainable corrective actions. Through case studies, mock tracer activities, gap assessments, indicator analysis, and improvement exercises, participants develop the practical capability to assess organisational readiness, address compliance gaps, strengthen quality systems, and support successful accreditation preparation.

Learning Objectives

  • Develop an integrated understanding of healthcare quality management and JCI accreditation principles.
  • Interpret accreditation requirements and translate them into practical operational controls.
  • Assess organisational readiness for accreditation through structured gap analysis.
  • Strengthen patient safety, clinical governance, and risk-management practices.
  • Develop effective quality indicators and performance-monitoring mechanisms.
  • Apply tracer methodology to evaluate compliance across clinical and support processes.
  • Improve documentation, policy management, and evidence of compliance.
  • Strengthen systems for incident reporting, investigation, corrective action, and learning.
  • Integrate quality improvement principles into clinical and administrative operations.
  • Establish effective governance and accountability structures for accreditation readiness.
  • Develop sustainable corrective and preventive action plans for identified gaps.
  • Prepare an integrated roadmap for continuous quality improvement and JCI accreditation readiness.

Who Should Attend

Healthcare Quality and Patient Safety Managers Hospital Quality Improvement Professionals Accreditation and Compliance Officers Clinical Governance Professionals Hospital Administrators and Operations Managers Medical and Nursing Leaders Department Heads and Clinical Supervisors Risk Management Professionals Infection Prevention and Control Professionals Healthcare Auditors and Internal Review Teams Performance Improvement and Patient Safety Teams Healthcare Policy and Procedure Coordinators Professionals preparing healthcare organisations for JCI accreditation Consultants supporting healthcare quality and accreditation programmes

Learning Outcomes

  • Assess healthcare quality systems against accreditation expectations.
  • Conduct structured organisational gap assessments and prioritise compliance risks.
  • Map accreditation requirements to clinical and operational processes.
  • Apply tracer methodology to identify weaknesses across patient care pathways.
  • Develop measurable quality and patient safety indicators.
  • Analyse performance data and identify opportunities for improvement.
  • Evaluate policies, procedures, records, and supporting evidence for compliance.
  • Strengthen incident reporting, investigation, root cause analysis, and corrective action.
  • Integrate risk management and patient safety into quality improvement programmes.
  • Develop practical action plans for closing accreditation gaps.
  • Coordinate multidisciplinary teams throughout accreditation preparation activities.
  • Establish a sustainable framework for continuous improvement beyond the accreditation survey.

Course Outline

Day 1

Healthcare Quality Management & Accreditation Readiness

  • Principles and dimensions of healthcare quality
  • Quality, patient safety, clinical effectiveness, and patient experience
  • Healthcare quality management systems and organisational governance
  • Overview of JCI accreditation and its role in healthcare performance
  • Accreditation structure, requirements, and organisational responsibilities
  • Leadership commitment and accreditation governance
  • Quality and patient safety programme development
  • Accreditation readiness assessment
  • Organisational self-assessment and evidence review
  • Identifying critical compliance gaps and high-risk areas
  • Policy, procedure, and document control
  • Building an accreditation culture across clinical and support departments
  • Practical Application: Conduct a structured JCI readiness assessment and prioritise key organisational gaps.
Day 2

Patient Safety, Clinical Governance & Risk Management

  • Patient safety principles and high-risk processes
  • Clinical governance structures and accountability
  • Patient identification and safe care processes
  • Communication and information management across care transitions
  • Medication management and medication safety
  • Surgical and procedural safety
  • Falls, pressure injuries, and other patient safety risks
  • Incident reporting and safety event classification
  • Root cause analysis and contributing-factor analysis
  • Corrective and preventive action planning
  • Clinical risk registers and risk prioritisation
  • Safety culture, learning systems, and organisational response
  • Practical Application: Analyse a simulated patient safety event, identify root causes, and develop a corrective action plan.
Day 3

JCI Tracer Methodology, Clinical Standards & Documentation

  • Principles and objectives of the tracer methodology
  • Preparing departments and teams for tracer activities
  • Patient journey and system tracer approaches
  • Interview techniques and evidence verification
  • Reviewing clinical records and supporting documentation
  • Assessing continuity and coordination of care
  • Patient rights, communication, informed consent, and education
  • Assessment and reassessment of patients
  • Care planning and clinical documentation
  • Discharge planning and continuity of care
  • Staff competency, credentialing, and clinical privileges
  • Identifying gaps between documented procedures and actual practice
  • Practical Application: Conduct a mock tracer exercise across a patient care pathway and document findings.
Day 4

Quality Indicators, Continuous Improvement & Compliance Monitoring

  • Designing effective healthcare quality indicators
  • Patient safety and clinical performance measures
  • Indicator definitions, data sources, sampling, and validation
  • Data collection, analysis, interpretation, and reporting
  • Benchmarking and performance comparison
  • Quality dashboards and management reporting
  • Identifying trends, recurring failures, and performance variation
  • Continuous improvement methodologies
  • Root cause analysis and improvement prioritisation
  • Corrective action effectiveness monitoring
  • Departmental quality plans and multidisciplinary improvement projects
  • Preparing objective evidence of sustained improvement
  • Practical Application: Develop a quality indicator dashboard and improvement plan for a selected healthcare process.
Day 5

Accreditation Survey Preparation & Sustainable Quality Improvement

  • Final accreditation readiness review
  • Mock survey planning and surveyor-style assessment
  • Tracer preparation and staff readiness
  • Evidence organisation and document accessibility
  • Managing survey interviews and staff communication
  • Responding to findings and non-compliance
  • Corrective action and improvement follow-up
  • Monitoring compliance after accreditation
  • Leadership review of quality and patient safety performance
  • Integrating accreditation into strategic and operational planning
  • Building a sustainable quality improvement culture
  • Maintaining readiness through continuous monitoring and internal assessment
  • Linking accreditation performance with patient outcomes and organisational excellence
  • Final Workshop: Develop a comprehensive JCI accreditation readiness roadmap covering gap assessment, tracer preparation, quality indicators, patient safety, documentation, corrective actions, governance, and continuous improvement.

Upcoming Dates

Selected date

Manama · 14 – 18 Dec 2026 · Classroom

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CityDatesPrice per ParticipantEarly Bird
IstanbulScheduled
2 – 6 Nov 2026€4,700—
GenevaScheduled
2 – 6 Nov 2026€6,300—
JeddahScheduled
8 – 12 Nov 2026€4,200—
KigaliScheduled
16 – 20 Nov 2026€5,100—
Kuala LumpurScheduled
16 – 20 Nov 2026€4,400—
LisbonScheduled
23 – 27 Nov 2026€5,400€4,860until 2 Nov
LondonScheduled
30 Nov – 4 Dec 2026€5,600€5,040until 9 Nov
MadridScheduled
7 – 11 Dec 2026€5,400€4,860until 16 Nov
MadinahScheduled
14 – 18 Dec 2026€4,200€3,780until 23 Nov
ManamaScheduled
14 – 18 Dec 2026€4,700€4,230until 23 Nov
MilanScheduled
21 – 25 Dec 2026€6,000€5,400until 30 Nov
MarbellaScheduled
21 – 25 Dec 2026€5,400€4,860until 30 Nov
MuscatScheduled
28 Dec 2026 – 1 Jan 2027€5,300€4,770until 7 Dec
OnlineScheduled
3 – 7 Jan 2027€1,700€1,530until 14 Dec
MakkahScheduled
4 – 8 Jan 2027€4,200€3,780until 14 Dec
ParisScheduled
11 – 15 Jan 2027€5,700€5,130until 21 Dec
RomeScheduled
18 – 22 Jan 2027€5,800€5,220until 28 Dec
SingaporeScheduled
25 – 29 Jan 2027€6,700€6,030until 4 Jan
SalalahScheduled
25 – 29 Jan 2027€5,300€4,770until 4 Jan
ViennaScheduled
1 – 5 Feb 2027€5,700€5,130until 11 Jan
AmmanScheduled
7 – 11 Feb 2027€3,100€2,790until 18 Jan
AmsterdamScheduled
8 – 12 Feb 2027€5,400€4,860until 18 Jan
BarcelonaScheduled
15 – 19 Feb 2027€5,400€4,860until 25 Jan
AbujaScheduled
15 – 19 Feb 2027€5,100€4,590until 25 Jan
CairoScheduled
22 – 26 Feb 2027€3,300€2,970until 1 Feb
CasablancaScheduled
1 – 5 Mar 2027€4,300€3,870until 8 Feb
DammamScheduled
8 – 12 Mar 2027€4,200€3,780until 15 Feb
AccraScheduled
8 – 12 Mar 2027€5,100€4,590until 15 Feb
DohaScheduled
15 – 19 Mar 2027€4,400€3,960until 22 Feb
DubaiScheduled
21 – 25 Mar 2027€4,400€3,960until 1 Mar

Available in: Istanbul · Dubai · London · Doha · Amsterdam

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