Programme KPIs & JCI Quality Measures
Accreditation performance tracking and JCI 8th Edition Quality & Patient Safety (QPS) mandatory clinical & managerial indicators.
Hospital enterprise systems continuously feed clinical, managerial, and governance data into all 18 JCI KPIs.
99.8% Uptime
< 4.2s
JCI QPS.03 Mandatory Quality & Patient Safety Monitoring
Under JCI Standard QPS.03.00 through QPS.03.04, hospital leadership is required to continuously aggregate and analyze performance data across Clinical Focus Areas (patient identification, high-alert medications, infection bundles, surgical time-outs, resuscitation) and Managerial Focus Areas (life-support PM uptime, emergency disaster drills, staff credentialing, medical record timeliness, sentinel event RCAs).
Select a baseline to measure hospital readiness improvements and CAP velocity
JCI Recommended & Mandatory Quality Measures
Clinical focus and managerial focus indicators mandated under JCI Quality & Patient Safety standards.
Dual-identifier verification before medication and invasive care
Dual-RN verification adherence and near-miss reporting on high-alert drugs
Surveillance care bundle adherence for CLABSI, CAUTI and Surgical Site Infections
100% WHO surgical safety pause completion prior to skin incision
Arrival and equipment readiness of the Code Blue resuscitation team under 3 minutes
100% periodic maintenance completion for Tier-1 life support assets
Bi-annual hospitalwide emergency evacuation and hazardous material drill rotations
Primary source verification (PSV) completed prior to clinical privilege granting
Discharge summaries and operative notes finalized within mandated 24-hour window
Comprehensive root-cause analysis and CAPA completed within 45 calendar days
Accreditation Readiness & Operational Governance KPIs
Executive hospital performance indicators, evidence completeness, document quality, and corrective action velocity.
AccrediScore against the survey target
Expected evidence items on file
Mean quality score across the library
Corrective actions marked closed
Critical findings still open
Mean days a finding stays open
Staff evaluated against their competency profile
Round observations verified