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Report: JCI Internal Surveyor Certification Training

Empowering Quality Excellence at BCMCH

Date: April 20–23, 2026

Venue: Amphitheatre & MEU Room

Facilitator: Mr. Thomas Mathew

From April 20th to April 23rd, 2026, our institution conducted an intensive 4-day training program focused on the Joint Commission International (JCI) Accreditation Standards for Hospitals. This program was designed to develop a dedicated cohort of Certified Internal Surveyors to maintain the highest global standards of patient safety and clinical excellence at BCMCH.

Training Overview & Surveyor Tracks

The training offered two distinct certification pathways to ensure comprehensive coverage of JCI standards across all hospital domains:

1. JCI Master Surveyors

   1. 1. Requirement: Mandatory full attendance (8:00 AM – 4:30 PM) for all four days.

      2. Responsibility: Candidates are empowered to lead JCI accreditation activities and cross-departmental audits across the institution.

      3. Certification: Awarded the "Master Surveyor Certificate."

2. JCI Chapter Surveyors

   1. 1. Requirement: Full attendance during specific assigned JCI Chapters and timings.

      2. Responsibility: Specialized focus on specific standards relevant to their department or domain.

      3. Certification: Awarded the "Chapter Surveyor Certificate."

• Day 1: Monday, 20th April 2026

Venue: Amphitheatre

The inaugural day of the training commenced at 8:00 AM in the Amphitheatre, marking a significant milestone in our institutional journey toward global quality benchmarks.

Opening Ceremony: The program began with a solemn prayer led by Dr. John Valliattu, setting a focused and dedicated tone for the sessions ahead.

Welcome Address: Dr. Riju Mathew officially welcomed the guest trainer, Mr. Thomas Mathew from Partners Consultants International.

1. Session 1: Accreditation Participation Requirements (APR)

Time: 08:00 AM – 09:00 AM

Mr. Thomas Mathew opened with a comprehensive briefing on the APR Chapter. This chapter is critical as it defines the "rules of engagement" for JCI—detailing the mandatory obligations a hospital must fulfill to maintain its accredited status.

Leadership Roles for the APR Chapter:

• Primary Responsibility: Dr. Riju Mathew

• Secondary Responsibility: Mr. Sunny Kuruvilla

• Quality Representative: Ms. Dhanaya Krishnan PG

2. Session 2: Access to Care and Continuity of Care (ACC)

Time: 09:00 AM – 11:00 AM

Following the foundational APR session, Mr. Thomas Mathew transitioned into the Access to Care and Continuity of Care (ACC) chapter. This session focused on the patient journey—from the moment they enter the hospital to their discharge and follow-up care.

Key topics included the screening process, emergency admissions, and ensuring that patient transfers between departments are seamless and safe.

Leadership Roles for the ACC Chapter:

• Primary Responsibility: Dr. Shammy D. L.

• Secondary Responsibility: Dr. Abel K. Samuel

• Quality Representative: Ms. Jincy Chandran

3. Session 3: Facility Management and Safety (FMS)

Time: 11:00 AM – 01:00 PM

The late morning session shifted focus from clinical flow to the physical environment. Mr. Thomas Mathew led an intensive discussion on Facility Management and Safety (FMS). This chapter is a cornerstone of JCI, ensuring that the hospital building, equipment, and utilities pose no risk to patients, staff, or visitors.

Key areas discussed included:

• Safety and Security: Protecting individuals from harm and loss.

• Hazardous Materials: Management of chemicals, waste, and gases.

• Fire Safety: Prevention, detection, and evacuation protocols.

• Utilities Management: Ensuring 24/7 reliability of water and electrical systems

Leadership Roles for the FMS Chapter:

• Primary Responsibility: Mr. Rajesh Chacko

• Secondary Responsibility: Er. Ajith Kuruvila

• Quality Representative: Ms. Biyona Billy

4. Session 4: Anesthesia and Surgical Care (ASC)

Time: 02:00 PM – 04:00 PM

The afternoon session centered on Anesthesia and Surgical Care (ASC), a critical chapter that governs some of the most high-stakes procedures in the hospital. Mr. Thomas Mathew emphasized the importance of standardized protocols for sedation, pre-surgical assessments, and the "Time-Out" procedure to ensure patient safety in the operating theater.

Key focuses included:

• Standardizing pre-anesthesia and pre-surgical evaluations.

• Documentation and monitoring during the recovery period

Leadership Roles for the ASC Chapter:

• Primary Responsibility: Dr. Stephen K. Punnoose

• Secondary Responsibility: Dr. Ashu Sara Mathai

• Quality Representative: Ms. Salini Antony

Dr. Riju Mathew conducted a Quiz Session at the conclusion of every module. These quizzes served to validate the participants' understanding of the JCI chapters and prepared them for the practicalities of an internal survey.

• Day 2: Tuesday, 21st April 2026 

Location: Amphitheatre

5. Session 5: Medication Management and Use (MMU)

Time: 08:00 AM – 10:00 AM

The second day opened with a critical look at Medication Management and Use (MMU). This chapter is vital for patient safety, as it covers the entire medication system—from selection and procurement to storage, prescription, preparation, and administration.

Mr. Thomas Mathew emphasized the need for strict protocols regarding "High-Alert Medications" and the institutionalization of the "Five Rights" of medication administration. The session also touched upon the role of the clinical pharmacist in multidisciplinary care.

Leadership Roles for the MMU Chapter:

• Primary Responsibility: Dr. Grace Mary John

• Secondary Responsibility: Mr. Biju Thomas

• Quality Representative: Dr. Aleena Jose

6. Session 6: Prevention and Control of Infections (PCI)

Time: 10:00 AM – 12:00 PM

The training transitioned to one of the most rigorous sections of the JCI manual: Prevention and Control of Infections (PCI). Mr. Thomas Mathew emphasized that infection control is not just a departmental responsibility but a hospital-wide culture.

Key areas of focus included:

• Hand Hygiene Compliance: Strengthening the institutional "Who 5 Moments" protocols.

• Surveillance Programs: Monitoring healthcare-associated infections (HAIs).

• Sterilization and Disinfection: Ensuring high standards in CSSD and laundry services.

• Isolation Precautions: Proper management of infectious patients to prevent cross-contamination.

Leadership Roles for the PCI Chapter:

• Primary Responsibility: Dr. Reena Anie Jose

• Secondary Responsibility: Ms. Jayaleskshmi Nair

• Quality Representative: Ms. Sreekutty P. V

7. Session 7: Health Care Technology (HCT) & Management of Information (MOI)

Time: 12:00 PM – 01:30 PM

This session explored the vital link between physical medical equipment and the digital systems that store and communicate patient data. Mr. Thomas Mathew emphasized that JCI standards require both hardware reliability and data confidentiality.

Health Care Technology (HCT)

The training focused on the Equipment Life Cycle, ensuring that every device—from basic monitors to advanced imaging systems—is procured, calibrated, and  maintained to prevent clinical errors. A major highlight was User Competency, stressing that only staff with verified training should operate critical technology.

Leadership Roles for the HCT Chapter:

• Primary Responsibility: Dr. Sumitha Arun

• Secondary Responsibility: Ms. Rosy Marcel

• Quality Representative: Ms. Neeraja R. Nair

Management of Information (MOI)

This segment addressed the hospital’s ability to manage patient records and institutional data. The goal is to ensure that information is accurate, easily accessible to clinicians when needed, and strictly protected against unauthorized access.

Leadership Roles for the MOI Chapter:

• Primary Responsibility: Ms. Jiji George

• Secondary Responsibility: Dr. Sumitha Arun

• Quality Representative: Ms. Sreekutty P. V

8. Session 8: Care of Patient (COP)

Time: 02:30 PM – 04:30 PM

The final session of the day focused on the Care of Patient (COP) chapter. Mr. Thomas Mathew detailed the standards for providing uniform care to all patients, ranging from high-risk services to basic nutritional care.

Key areas discussed included:

• Uniformity of Care: Ensuring all patients receive the same quality of care, regardless of the department or time of day.

• Care of High-Risk Patients: Standards for the ICU, emergency department, and handling of patients on life support.

• Clinical Alarms: The importance of responding to and managing medical equipment alarms promptly.

• End-of-Life Care: Respecting patient dignity and managing symptoms for terminal cases.

Leadership Roles for the COP Chapter:

• Primary Responsibility: Dr. Abel K Samuel

• Secondary Responsibility: Dr. Philip Mathew and Dr. Anie Thambi

• Quality Representative: Ms. Salini Antony

Day 3: Wednesday, 22nd April 2026

Location: MEU Room, Medical College

9. Session 9: International Patient Safety Goals (IPSG)

Time: 08:00 AM – 10:00 AM

Mr. Thomas Mathew led an in-depth review of the six IPSG goals, emphasizing that these are non-negotiable standards designed to prevent the most common and dangerous errors in healthcare.

Key areas discussed included:

• Identify Patients Correctly: Using at least two identifiers.

• Improve Effective Communication: Implementing "Read-back" and SBAR protocols.

• Improve the Safety of High-Alert Medications: Concentrated electrolytes and LASA drugs.

• Ensure Safe Surgery: Correct site, correct procedure, correct patient (Time-Out).

• Reduce the Risk of Health Care-Associated Infections: Hand hygiene mastery.

• Reduce the Risk of Patient Harm Resulting from Falls: Assessment and reassessment.

Leadership Roles for the IPSG Chapter:

• Primary Responsibility: Ms Ponnamma Thomas

• Secondary Responsibility: Ms. Mini Geevarghese

• Quality Representative: Ms. Neeraja R Nair

10. Session 10: Assessment of Patient (AOP)

Time: 10:00 AM – 12:00 PM

Following the morning break, Mr. Thomas Mathew shifted the focus to the Assessment of Patient (AOP) chapter. This session highlighted that a comprehensive assessment—covering medical, nursing, and nutritional needs—is the foundation for an effective plan of care.

Key Technical Areas Covered:

• Initial Assessments: Ensuring all patients receive a standardized assessment within the timeframe required by hospital policy.

• Reassessment Protocols: Determining the frequency of reassessments based on the patient’s condition and response to treatment.

• Laboratory and Imaging Services: Managing the quality and safety of diagnostic services, including turnaround times and critical value reporting.

• Nutritional and Functional Screening: Identifying patients who require specialized dietary or rehabilitative support.

Leadership Roles for the AOP Chapter:

• Primary Responsibility: Ms. Mini Sarah Thomas

• Secondary Responsibility: Ms. Shiny Santhosh

• Quality Representative: Ms. Salini Antony

11. Session 11: Patient Centred Care (PCC)

Time: 12:00 PM – 01:30 PM

Just before the afternoon lunch break, the group delved into Patient Centred Care (PCC). This session, led by Mr. Thomas Mathew, highlighted that quality healthcare is not just about clinical outcomes, but about respecting the patient’s values, preferences, and expressed needs.

Key areas discussed included:

• Patient & Family Rights: Ensuring informed consent and respecting the right to second opinions.

• Effective Communication: Providing information in a language and format that the patient can understand.

• Shared Decision Making: Involving the patient and their family in the development of the care plan.

• Education: Ensuring the patient is properly educated about their condition and discharge instructions.

Leadership Roles for the PCC Chapter:

• Primary Responsibility: Ms. Winnie Elizabeth

• Secondary Responsibility: Mr. Sunny Kuruvilla

• Quality Representative: Ms. Sreekutty P V

12. Session 12: Staff Qualifications and Education (SQE)

Time: 02:30 PM – 04:30 PM

The final session of Day 3 focused on Staff Qualifications and Education (SQE). Mr. Thomas Mathew emphasized that a hospital’s safety is only as strong as the competence of its workforce. The session covered the rigorous process of verifying that every staff member—from doctors and nurses to administrative personnel—is qualified for their specific role.

Key areas discussed included:

• Credentialing and Privileging: The systematic process of verifying licenses, education, and experience for medical and nursing staff.

• Staff Recruitment & Orientation: Ensuring new hires are properly introduced to the hospital's safety culture.

• Competency Assessment: Ongoing evaluation of staff skills to ensure they meet the demands of their departments.

• Health and Safety of Staff: Protocols for staff vaccinations and managing occupational exposures.

Leadership Roles for the SQE Chapter:

• Primary Responsibility: Ms. Sudha Mathew

• Secondary Responsibility: Dr. John Valliattu

• Quality Representative: Ms. Athulya A S

Day 4: Thursday, 23rd April 2026

Location: MEU Room, Medical College

13. Session 13: Governance, Leadership, and Direction (GLD)

Time: 09:00 AM – 09:30 AM

The morning session was dedicated to the Governance, Leadership, and Direction (GLD) chapter. Mr. Thomas Mathew discussed how the hospital's leaders—from the Board of Governors to Department Heads—must work in unison to provide a safe environment for patient care.

Key Technical Areas Covered:

• Hospital Governance: Defining the roles of those responsible for the hospital’s mission and financial stability.

• Leadership Accountability: How leaders oversee the quality of clinical and contracted services.

• Ethics & Culture: Establishing a "Just Culture" where safety concerns can be reported without fear of retribution.

• Resource Allocation: Ensuring the hospital has sufficient staff, equipment, and supplies to meet patient needs safely.

Leadership Roles for the GLD Chapter:

• Primary Responsibility: Ms. Rosy Marcel 

• Secondary Responsibility: Mr. Sunny Kuruvilla

• Quality Representative: Dr. Riju Mathew

14. Session 14: Medical Professional Education (MPE)

Time: 09:30 AM – 11:00 AM

As a Medical College hospital, the Medical Professional Education (MPE) chapter is a vital part of the JCI survey. Mr. Thomas Mathew explained that when students and trainees are involved in patient care, there must be a clear boundary between educational activities and clinical safety.

Key focuses included:

• Supervision of Trainees: Ensuring every student or resident is supervised by a qualified clinical staff member with documented privileges.

• Patient Consent: Informing patients that they may be cared for by trainees and respecting their right to refuse.

• Academic Integration: Ensuring that the clinical experience provided to students aligns with the safety and quality standards of the hospital.

Leadership Roles for the MPE Chapter:

• Primary Responsibility: Dr. Abel k Samuel

• Secondary Responsibility: Dr. Jacob Jesurun

• Quality Representative: Dr. Aleena jose

15. Session 15: Global Health Impact (GHI)

Time: 11:00 AM – 12:30 PM

The late morning session was dedicated to Global Health Impact (GHI). Mr. Thomas Mathew discussed how healthcare institutions today are measured not just by their internal quality, but by their contribution to broader health outcomes, sustainability, and community well-being.

Key focuses included:

• Community Health Initiatives: Integrating hospital services with public health needs and preventive care.

• Environmental Sustainability: Reducing the hospital’s carbon footprint and managing medical waste with global environmental standards in mind.

• Disaster Preparedness & Resilience: Ensuring the institution can serve the community during large-scale health crises or natural disasters.

Leadership Roles for the GHI Chapter:

• Primary Responsibility: Er. Ajith Kuruvila

• Secondary Responsibility: Mr. Rajesh Chacko

• Quality Representative: Ms. Athulya A S

16. Session 16: Human Subjects Research Programs (HRP)

Time: 01:30 PM – 03:00 PM

Following the lunch break, Mr. Thomas Mathew led the final technical session on Human Subjects Research Programs (HRP). For hospitals involved in clinical trials and medical research, JCI mandates strict oversight to protect the rights, safety, and well-being of all research participants

Key Technical Areas Covered:

• Ethical Oversight: The role of the Institutional Review Board (IRB) or Ethics Committee in approving and monitoring research.

• Informed Consent in Research: Ensuring participants understand the risks and voluntary nature of clinical trials—distinct from standard clinical consent.

• Data Integrity and Privacy: Protecting the confidentiality of research subjects.

• Conflict of Interest: Managing and disclosing any financial or professional interests that could influence research outcomes.

Leadership Roles for the HRP Chapter:

• Primary Responsibility: Dr. E T Arun

• Secondary Responsibility: Dr. Abel K Samuel

• Quality Representative: Ms. Jincy Chandran

17. Session 17: Quality Improvement and Patient Safety (QPS)

Time: 03:00 PM – 04:30 PM

The final technical session of the program was dedicated to Quality Improvement and Patient Safety (QPS). Mr. Thomas Mathew emphasized that JCI accreditation is not a "one-time event" but a commitment to a continuous cycle of measurement and improvement.

Key Technical Areas Covered:

• Data Collection and Analysis: Identifying key performance indicators (KPIs) to monitor clinical and managerial processes.

• Sentinel Event Management: Standardizing the Root Cause Analysis (RCA) process to learn from adverse events and prevent recurrence.

• Standard of Care: Reducing practice variations through the implementation of clinical pathways and evidence-based guidelines.

• Proactive Risk Assessment: Using tools like FMEA (Failure Mode and Effects Analysis) to identify and mitigate risks before they reach the patient.

Leadership Roles for the QPS Chapter:

• Primary Responsibility: Dr. Nithin Thomas Philip

• Secondary Responsibility: Dr. Riju Mathew

• Quality Representative: Ms. Dhanya Krishnan P G

The JCI First Step Meeting and Sensitization Program was successfully conducted on 25th March 2026 at 3:00 PM in the Amphitheatre, marking the official initiation of the organization’s journey toward Joint Commission International (JCI) accreditation.

This session served as the first phase of planning and sensitization, aimed at orienting domain leaders and representatives on the structure, expectations, and roadmap of the JCI accreditation process. The program witnessed active participation from all domain leaders and representatives, with each domain presenting their respective roles and responsibilities aligned with JCI standards.

🎯 Meeting Overview

The sensitization program focused on providing a comprehensive understanding of the upcoming survey initiative. Key areas covered included:

• Program structure and implementation strategy

• Survey methodology, including tracer-based evaluation

• Scoring metrics and evaluation systems

• Roles, responsibilities, and expected deliverables from each domain

The session emphasized the importance of patient safety, quality improvement, and standardized documentation practices as core principles of JCI accreditation

• The session commenced with a welcome address delivered by Rev. Fr. Sijo Pandapallil (Manager). He also provided an overview of the sensitization program and outlined its objectives.

• Mr. Sunny Kuruvilla (Associate Director) who formally welcomed the gathering and Mr. Thomas Mathew, Director of Partners Consultants International, the consultancy firm guiding the organization through the JCI accreditation process.

Expert Session by Mr. Thomas Mathew
Mr. Thomas Mathew delivered an insightful and highly informative presentation, highlighting:

• His extensive experience in JCI accreditation consultancy

• The structured roadmap for achieving accreditation

• The importance of systematic planning and interdepartmental coordination

He detailed the survey framework, which includes:

• 8 core chapters covering primary accreditation requirements

• 17 total chapters forming the complete survey structure

• 2 additional chapters specifically designed for the Medical College

• A 5-day on-site inspection process

📊 Survey Framework & Deliverables

The session provided clarity on the operational aspects of the survey process:

• It is a 10-month program. During the file audit, they will review a six-month report; one file contains 650 elements, each of which they will examine.

• After the inspection every 6 month 4 hrs zoom session is for evaluation