The healthcare institution is required to show the commitment of the following:
• Adopting the HCAC Accreditation Standards.
• Conducting self-assessment to determine the extent to which healthcare institutions are applying these standards.
• Developing an action plan for achieving the standards that are not being applied (the time required and the person responsible for achieving it).
• The implementation of the Action Plan and to overcome all the obstacles and difficulties by working within the same team to achieve the standards.
• Ascertain the readiness of healthcare institution for accreditation and obtaining it in accordance with the conditions and the standards of the accreditation.
• Apply for accreditation from the Health Care Accreditation Council (HCAC).

Yes, participation in the accreditation process is voluntary and available to all healthcare institutions, not only in Jordan but also in the region.

After undergoing the on-site survey, organizations may be granted one of the following accreditation decisions:
1. Accreditation with distinction for two years
2. Accreditation for two years
3. Reassessment of some standards after three or six months (with the list of standards)
4. Accreditation is not awarded

At the end of the facility survey, surveyors will send their report of findings to HCAC's Director of Surveys and Standards Development who will review the report for consistency and accuracy. Thereafter, each survey report is sent to the HCAC board for their concurrence on the recommendations and accreditation decision

It takes about 40 days after the end of the survey

It takes two to four months upon receipt of a completed application for survey

The survey fee itself depends upon the size and range of services offered by the healthcare institution and is not determined until an application is received and reviewed.
Price List for Local Market

You can contact us through Email: contactus@hcac.com.jo or you can call HCAC at Tel: 9626 5814100 Fax: 962 6 5853070 and request us to fax or email one to you.
There is no fee for the application form.

Yes; HCAC will be involved in the consultation process during the construction as well as capacity building. However for granting accreditation; the healthcare institution should be functioning for at least six months.

Yes; HCAC is an internationally recognized organization, which has strived from its onset to ensure all its work is performed at international best practice levels, by having all of its services accredited by the International Society for Quality in Health Care (ISQua). The ISQua is responsible for assessing the standards of organizations that set the benchmarks in healthcare safety and quality and is the only organization to “accredit the accreditors.”

The accreditation award is valid for two years; however there is a midpoint assessment one year after the accreditation.

No. It is a non-profit private shareholding company

No; accreditation is a voluntary process

A sentinel event is an unexpected occurrence involving death, or serious injury. Serious injury specifically includes loss of limb or function. A sentinel event may occur due to wrong site, wrong patient, and wrong procedure surgery. Such events are called “sentinel” because they signal a need for immediate investigation and response.

Complaints are registered and accepted by telephone, fax, posted mail or electronic communication. When the complaint/incident is received via telephone, the caller is requested to and instructed how to submit the complaint/incident in writing and provide an e-mail address. When the report is received via fax or posted mail, the date that the report was received in central office is stamped on the face of the document.

The healthcare institution can appeal on the accreditation decision within 20 calendar days of receiving the accreditation decision. The healthcare institution has another 20 days to submit to the HCAC, in writing, acceptable data and information to support its appeal.

No; HCAC only announces the accredited healthcare institutions.

No, you need to order a copy of the standards from HCAC by posting a request via the website through.

Each healthcare institution is encouraged, but not required, to report to the Council any sentinel event. Alternatively, the Council may become aware of a sentinel event by some other means such as communication from a patient, a family member, an employee of the healthcare institution, a surveyor, or through the media. The accredited healthcare institution is expected to do the following:

• • Prepare a thorough and credible action plan within 45 calendar days of the event or of becoming aware of the event.
• • Submit to the Council its root cause analysis and action plan, or otherwise provide the Council with an evaluation of its response to the sentinel event.

Mock survey is a mimic of the actual accreditation survey, once the healthcare institution deems that it has implemented the HCAC Accreditation Standards within its processes and systems. The Mock survey would be done by HCAC Certified Surveyors against the HCAC Accreditation Standards and a report is issued at the end of the Mock survey highlighting the key exemplary areas and also the areas where the healthcare institution did not meet standards which are the basis for accreditation.

The objective behind the Mock survey is to provide the healthcare institution with a rehearsal opportunity on their readiness for the accreditation and provide them with guidance on whether the healthcare institution can or cannot be accredited at that certain time.

#	Topic	STD.no	Question	Reply
1	Radiophramecutical Preperations	MM.10.6	Is it required to oversee and manage Radiopharmaceutical policies and procedures by the pharmacy department?	It is recommended that all operations be carried out under the authority and supervision of the nuclear physician in charge and/or a qualified radio pharmacist, who is responsible for the setting up of the radio pharmacy and for an appropriate QA program. Therefore the oversight and management is not limited, and not specified to be done by the pharmacy department.
2	Medication Managemnet & quality Improvement Activites	MM.18.1	The standard states that head of the pharmacy leads the quality improvement activities in coordination with (PTC) members, Why with PTC? and does it apply to all projects related to medication, since some are initiated and lead by the nursing for example???	As applicable and according to the project area, medication management requires multidisciplinary team engagement, not only pharmacy staff, this can be agreed upon according to the area for improvement and through process mapping by the initiator or leader department then relevant staff to participate in the quality project or improvement activity can be selected.
3	Advanced Cardiac Life Support Training (ACLS), Pediatric AdvancedLife Support (PALS)	TD.10	Shall the hospital trains all staff working in the critical care areas on ACLS and PALS or is it enough to train all CPR team members and in- charges of critical areas such as (Intensive Care Unit (ICU), Post Anesthesia Care Unit (PACU), Critical Care Unit (CCU), Emergency Department (ED) ??	The hospital shall identify the relevant staff members working in the critical areas who must be trained other than the CPR team, the relevant staff must include all physicians working in the critical areas and regarding the relevant nursing staff working in the critical areas this will be identified taking into consideration the following : • Scope of service provided in the critical areas • Number of beds in the critical areas • Number of staff working in the critical areas (per each shift) • The effectiveness of staffing plans in these areas • The number of CPR occurred in these areas • The succession rate of CPR • The testing of CPR response rate by conducting drills and testing the response
4	Monitoring of Platelets temprature	BB.9	Is it mandated to have a temperature monitoring system within with in the platelets agitator/shaker device, or is it sufficient to monitor temperature by placing a thermometer near the agitator??	The best practice is to have an internal monitoring system within the device. However, its completely acceptable to monitor the temperature of the environment -by ensuring the following: • Continuous monitoring and recording of the temperature (Every 4 hours). • Placing the thermometer near the shaker/agitator, to detect changes in temperature accurately. • Developing a process to deal with temperature readings exceeding the allowable limits.
5	Sharing Research Knowledge and findings	R.6.	Is this requirement applicable to publications and research papers, or for the quality improvement projects ?	This standard is specific to research publication and studies. not just any improvement project. (however, if the improvement project is reflected into a research study and then published, it falls under the requirements applicable to this standard)
6	Monitorig Patient physiological status during anesthesia	AN6	How can levels of conciousness durring anesthaesia be measured?	• Achieving adequate depth of anesthesia during surgical procedures is required. Therefore, assessment and monitoring/ measurement of the depth of anesthesia is fundamental to anesthetic practice • Different types of tools developed to-date to monitor the depth of anesthesia, The hospital needs to determine the level of risk of the operation and the types of anesthetics used in order to decide the appropriate tool needed for the monitoring of consciousness: a) In Simple surgeries with short duration and low risks, Clinical techniques and conventional monitoring can be adopted. b) In major surgeries with long duration, and with the use of TIVA (Total Intravenous Anesthesia), advanced monitoring techniques such as Brain electrical activity monitoring are needed.

#	الموضوع	رقم المعيار	السؤال	الجواب
7	طلب وحدة الدم	BB.11, BB.12	لا يحتوي طلب نقل الدم المعتمد من بنك الدم المركزي على جميع متطلبات البنود التعريفية الخاصة بوحدة الدم والمطلوبة في المعيار	لقد تم التواصل رسمياً مع مديرية بنك الدم المركزي وذلك لإدراج وزن الوحدة على الرقع التعريفية التي يتم وضعها على وحدات الدم الكامل أو مكوناته، وإدراج الوقت / تاريخ الحاجة إلى الدم/ مكونات الدم والسبب لنقل الدم على نموذج طلب الدم الكامل أو مكونات الدم. حيث سيتم إضافة هذه المكونات قبل عملية الطباعة القادمة بعد انهاء الكميات المطبوعة المتوفرة حالياً بمستودعات مديرية بنك الدم المركزي. وبما أن هذا الإجراء قد يستغرق عدة أشعر، وحتى ذلك الحين الرجاء العمل على ما يلي: • وزن الوحدة: التأكد من قبل الشخص الذي سينقل الدم من بنك الدم الى المستشفى من أنه تم كتابة وزن الوحدة على الرقعة التعريفية وخصوصاً تلك التي يتم استخدامها للأطفال أو بعض الفئات ذات الخطورة من البالغين مثل مرضى القلب والكلى (لحين صدور الرقعة التعريفية الجديدة) • سبب نقل الدم: ممكن إضافته مؤقتاً في خانة التشخيص (لحين صدور النموذج الجديد) • وقت / تاريخ الحاجة إلى الدم/ مكونات الدم: ممكن إضافتها كتابة بشكل مؤقت (لحين صدور النموذج الجديد)

They are educational workshops designed to facilitate a successful accreditation process for a healthcare facility. They cover the trainings necessary to support capacity building for implementing the identified policies, procedures, plans, and clinical guidelines compulsory for a healthcare institution to achieve accreditation under the HCAC Accreditation Standards.

HCAC will conduct a general assessment to your healthcare institution or support your healthcare institution’s self-assessment. Based on the results of the assessment, healthcare institution leaders, with HCAC support, can select those educational sessions, which will provide the healthcare institution and the staff with the necessary information and skills development to successfully implement the identified standards and address necessary improvements