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Accreditation readiness checklist

Use this high-level checklist to align your hospital before JCI, SQH, or similar surveys. It complements—not replaces—your standard-specific requirements and local regulations.

Leadership & governance

  • Executive sponsor and accreditation programme owner named
  • Cross-functional team (clinical, nursing, quality, admin, records) with clear roles
  • Steering rhythm: milestones, risks, and decisions documented

Standards & documentation

  • Master index of required policies, procedures, and clinical guidelines
  • Version control, approval dates, and owners for each document
  • Alignment with selected standard (e.g. JCI / SQH) and local regulation

Clinical & operational readiness

  • Tracer-ready patient flows (admission, medication, surgery, infection control)
  • Incident reporting, RCA, and improvement projects active—not only pre-survey
  • High-risk areas audited: medication safety, IPC, patient identification, consent

Mock survey & culture

  • At least one full mock survey with realistic tracer scenarios
  • Staff briefed on how to describe actual practice (not aspirational)
  • Feedback loop: findings tracked to closure before survey window

Need a structured gap analysis or mock survey tailored to your facility? View our accreditation support or call +1 (252) 691 4076.