Recommended next step: Review priority findings

AccrediSense Demo Hospital · JCI 8th Edition · Survey window Q1 2027

How ready are we today?

Your documentation is strong, but your biggest vulnerability is the gap between documented process and everyday staff practice. At 81% overall readiness with 5 findings still open, Facilities & Safety and Surgery show the largest differences between what your policies say and what staff describe.

+14%since baseline · improving

81%Overall AccrediScore

Click to open the full breakdown — 1,248 evidence items, 74 staff assessments, 32 tracers.

Readiness dimensions

Every dimension is clickable — open the analysis behind it.

Methodology →

Show me where we're vulnerable

AccrediSense compares documented process against what staff actually describe and what evidence proves.

Takes under two minutes and ends with an approved remediation plan.

What needs your attention?

Generated from your live findings, department trends and document activity.

  • Critical

    Two-identifier check not consistently verbalised before specimen collection

    Silent verification removes the patient from the safety check and is a common trigger for surveyor deep-dive into identification practice hospital-wide.

    • Emergency · Patient Identification
    • 1 staff in scope
    • 2 evidence items linked
    Investigate finding
  • High priority

    Staff unable to demonstrate medication reconciliation at transfer

    Unreconciled medication at transfer is a leading contributor to preventable adverse drug events, and surveyors routinely trace this at the point of care rather than in policy.

    • Pharmacy · Medication Safety
    • 1 staff in scope
    • 3 evidence items linked
    Investigate finding
  • High priority

    Facilities & Safety readiness is 69% (-1%)

    This is your lowest performing department. A surveyor is likely to spend time here.

    • 11 open findings
    • Lead: Tom Becker
    Open Facilities & Safety readiness
  • Action required

    A recently updated policy affects multiple requirements

    "Patient Identification Policy" was re-issued. Staff practice may not yet reflect the new process.

    • 6 requirements potentially affected
    • 214 staff in audience
    Review impact
  • Improvement

    Pharmacy readiness improved 8%

    Targeted remediation and training are working here — consider replicating the approach.

    • Now at 78%
    View progress

Accreditation journey

68%
Mar
71%
Apr
73%
May
76%
Jun
79%
Jul
82%
Aug

What changed: readiness rose because high-priority findings closed and staff completed targeted training. Target for survey window: 95%.

See the full reassessment log →

Activity feed

  • Critical readiness issue identified in ICU — identification practice inconsistency.12 min ago
  • 14 staff members require competency reassessment in ICU.2 hours ago
  • Policy update to Medication Reconciliation Procedure affects 7 requirements.Yesterday
  • Pharmacy readiness improved 8% this month.2 days ago

Department readiness

Click a department to open its readiness analysis.

Critical findings

1

Require leadership attention

High-risk findings

3

Traceable at the point of care

Departments below 80%

3

Likely surveyor focus

Staff requiring training

214

Linked to open findings

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