HCPL Centre for Audit Quality and Accreditation

International accreditation is the area of the HCPL Centre for Audit Quality and Accreditation in which we prepare Polish healthcare providers for quality and safety standards recognised beyond the national assessment system. Its first programme is the collaboration around the Joint Commission International standard: Healthcare Poland Foundation has entered into a Collaborative Agreement with Joint Commission Resources, Inc., acting through its international business division Joint Commission International. Under that Agreement the Foundation is the exclusive JCI authorized and trained provider of the JCI Services in the territory of the Republic of Poland and works jointly with JCI to provide JCI-related consulting services.

The parties

Joint Commission International

JCI is the international business division of Joint Commission Resources, Inc., a not-for-profit organization whose mission is to continuously improve the safety and quality of care in the United States and in the international community through the provision of education, publications, consultation and evaluation services.

Healthcare Poland Foundation

Healthcare Poland Foundation (KRS 0001066269) is a private foundation established under the laws of the Republic of Poland, with the purpose of strengthening international quality and safety standards in healthcare, integrating stakeholders across the hospital sector, and acting as the primary institutional gateway for international accreditation and quality programmes in Poland. The Foundation operates as a supporting member of the Polish Hospital Federation (PFSz), which represents over 250 hospitals directly and approximately 500 hospitals through affiliated structures.

The Centre for Audit Quality and Accreditation

The Agreement expressly acknowledges and supports the establishment, within the Foundation, of the Centre for Audit Quality and Accreditation as the designated institutional platform for JCI-aligned quality, audit and accreditation readiness services in Poland. The Centre:

• serves as the single point of contact for JCI-related institutional readiness and consulting engagement in Poland, in collaboration with JCI;
• maintains qualified consultants trained in JCI standards and methodology;
• develops and delivers the JCI Readiness Program – Poland;
• discusses JCI standards before Polish government authorities, the Ministry of Health, the National Health Fund (NFZ), the National Centre for Quality Assessment in Health Care (CMJ) and other stakeholders — only in collaboration with JCI;
• pursues JCI recognition for qualified Foundation consultants as a medium-term objective.

The Centre is not — and under the Agreement may not hold itself out as — an accreditation body, a certification body, a survey authority, a representative for accreditation decisions, or a delegate of JCI accreditation functions.

Quality in the health system: why this matters now

In Poland, quality has ceased to be a declaratory category. The Act of 16 June 2023 on quality in healthcare and patient safety (Journal of Laws 2023, item 1692) moved it into the domain of statutory obligation and tied it to the conditions of public financing. The Act rests on several pillars: authorisation of entities providing inpatient care, a mandatory internal quality and patient safety management system, voluntary accreditation granted by the minister competent for health, medical registries, and a system for recording and analysing adverse events together with a non-judicial compensation mechanism.

Three practical consequences follow. First, quality has become a matter of management accountability rather than clinical ambition alone: the head of the organization answers for whether the system exists and operates, not for the declaration that it does. Second, the analysis of adverse events has been separated from the search for a culprit; the system works only if staff report, and staff report when reporting serves organizational learning rather than sanction. Third, the requirement of measurability means an organization must be able to demonstrate not only that a procedure exists, but that it is applied, monitored and improved.

This is where an international accreditation standard adds what no internal document can substitute. JCI standards are a body of requirements centred on the clinical process and on patient safety — from patient identification and team communication, through medication safety and infection prevention and control, to governance and leadership oversight. For a Polish hospital they provide a benchmark complementary to national accreditation conducted by CMJ: they neither replace it nor compete with it, but allow an organization to test itself against an internationally comparable measure.

Scope of services open to application

The Agreement authorises the Foundation to deliver the full spectrum of JCI readiness and consulting services in the Territory, including in particular:

Delivery: how the work proceeds

1. Enquiry and initial conversationThe organization describes its starting point and intent. We establish whether the right path is a readiness assessment, an implementation programme, or an executive briefing only at this stage.
2. Scope and contractScope of work, schedule, team and cost. Delivery begins once a written engagement contract is in place.
3. Readiness assessment and gap analysisDocument review, process observation, interviews with staff and leadership. The output is a findings report ranking gaps against the requirements of the standard.
4. Implementation planFindings translated into the organization’s own work plan: tasks, owners, deadlines, measures. The plan belongs to the organization and remains executable without further external support.
5. Implementation and capability buildingSupport for the teams in the areas covered by the plan, training and academies for quality staff, periodic progress review.
6. Mock surveyA simulated survey conducted using JCI methodology, with a report and corrective action plan ahead of any application to JCI.
7. Application to JCIAn organization that decides to seek accreditation applies to JCI. Application acceptance, eligibility determination, survey scheduling, survey team selection, survey conduct, the survey report and the accreditation decision belong exclusively to JCI.

Exclusivity in the Territory

The Foundation is the exclusive partner for the JCI Services in the territory of the Republic of Poland. The exclusivity covers consulting, training, readiness assessments, mock surveys, institutional representation and market development, and extends to all categories of stakeholders — hospitals and hospital systems, government entities, the payer (NFZ) and regulatory bodies. The Foundation holds this exclusivity in its own right, as the Centre for Audit Quality and Accreditation, and selects in its own discretion the organizations it prepares.

Who may apply

Organization	Typical entry point
Public and private hospitals, including inpatient care providers	Executive briefing or readiness assessment
Hospital groups and networks, owners (local government, universities)	Readiness assessment for a reference site, then a group programme
Organizations holding or pursuing national accreditation	CMJ-to-JCI transition package
Providers serving international patients and reference centres	Readiness assessment and implementation programme
Quality and patient safety teams	Training academy for quality managers
Government authorities, the payer, regulators	Institutional dialogue on JCI standards — in collaboration with JCI

An enquiry commits you to nothing and does not require a prior decision to seek accreditation. The first conversation exists to establish whether, and which, pathway makes sense.

Person responsible

Enquiry form

The form is addressed to the Director of the Centre for Audit Quality and Accreditation, copied to the Centre’s office. We reply within two business days.

Organization *

City / country

Name *

Position

E-mail *

Phone

Subject of enquiry * — select — Introductory workshop / executive briefing Readiness assessment and gap analysis Implementation programme Mock survey CMJ-to-JCI transition package Training academy for quality managers Institutional dialogue (authority, payer, regulator) Other — described below Size of the organization (beds, departments, sites) Situation and expectations *

I consent to being contacted by Healthcare Poland Foundation in the matter of this enquiry. The data controller is Healthcare Poland Foundation, KRS 0001066269.

Send enquiry

An enquiry does not constitute a contract. Delivery of services begins once a written engagement contract is in place.

The limits we hold ourselves to