SMMC’s road to JCI: What accreditation really means for the hospital and public
CAY HILL--St. Maarten Medical Center has been diligently working toward Joint Commission International (JCI) accreditation, but what does that actually mean for patients, staff, and the new St. Maarten General Hospital. In short, JCI is a globally recognized stamp that hospitals earn by proving, in practice and over time, that they deliver safe, high-quality care. It is not a plaque on the wall, it is a way of running a hospital, from the bedside to the boardroom, every day.
Earlier this week SMMC put that culture on display during a World Patient Safety Day program organized by the Quality and Safety Department. Dionne Williams-David, Sharina David, and Denise Louis introduced 2025’s theme and walked staff through JCI’s International Patient Safety Goals, the basic guardrails that reduce the most common risks in hospitals. Nurses Shana Holaman and Cora Landicho followed with a focused lecture on pediatric and newborn safety. Drs. Andwele Illes of Cay Hill Pharmacy addressed confidentiality in pharmacy services, while Nurse June Pascal and members of the Faults or Near Accidents committee explained how an open culture of safety and incident reporting works in practice. SMMC’s Hygiene and Infection Control Department supported the program, and the day ended with workshops and information sessions that were well attended by employees and hospital management.
In his opening remarks, CEO Dr. Felix Holiday said, “World Patient Safety Day reaffirms this hospital’s commitment to providing safe, patient-centered, high-quality healthcare to all of our patients and I commend the Quality and Safety and HIC Departments, the Pediatrics Department, Cay Hill Pharmacy, and our Faults or Near Accident committee for organizing this special day. Job well done.”
That statement captures the link between a single day of learning and the longer journey to JCI accreditation. The new hospital in Cay Hill is the destination, yet the standards are being embedded now so that the move into SMGH is not a reset but an upgrade.
𝐉𝐂𝐈 𝟏𝟎𝟏: 𝐰𝐡𝐚𝐭 𝐢𝐭 𝐢𝐬 𝐚𝐧𝐝 𝐰𝐡𝐲 𝐢𝐭 𝐦𝐚𝐭𝐭𝐞𝐫𝐬
Joint Commission International is the international arm of The Joint Commission. It accredits hospitals and other health providers outside the United States. The standards are evidence based and organized around two big ideas: keep patients safe in the moments where harm often occurs, and build reliable systems so good care is the default rather than an exception. JCI’s International Patient Safety Goals, often called IPSGs, are the practical starting point. They cover six areas that repeatedly cause preventable harm: correct patient identification, effective communication, safe use of high-alert medications, safe surgery, reduction of infection risk, and prevention of falls. Hospitals are expected to hard-wire these practices so they occur every time, not only when a particular staff member is on duty.
Beyond the IPSGs, the full standards reach into every corner of a hospital. They set expectations for how patients enter the system and move through it, how medications are ordered and dispensed, how the facility is maintained, how staff are trained and credentialed, how leadership oversees quality, and how learning from incidents feeds continuous improvement.
𝐇𝐨𝐰 𝐚 𝐡𝐨𝐬𝐩𝐢𝐭𝐚𝐥 𝐞𝐚𝐫𝐧𝐬 𝐚𝐜𝐜𝐫𝐞𝐝𝐢𝐭𝐚𝐭𝐢𝐨𝐧
JCI accreditation is earned through preparation, operation, and demonstration.
Preparation: Hospitals align policies, protocols, and training with the standards. They make sure core services are running in a consistent way and that data are being collected. In most organizations this is a one-to-three-year lift, because clinical practices, documentation, and measurement systems have to be built and tested.
Operation: JCI expects to see real care happening and real results. That means months of patient care with data on key indicators, for example medication errors, hand hygiene adherence, surgical safety checklist use, falls, pressure injuries, response times, and complaint resolution. It also means the committees that keep a hospital safe are meeting, documenting decisions, and following through on corrective actions.
Demonstration: Trained surveyors visit the hospital for several days and use the tracer method. They pick real patients and follow their care from point to point. They review charts and observe practice at the bedside, in the pharmacy, in the operating room, and in support departments. They also interview staff and leaders. The goal is simple: does what the hospital does each day match what it says on paper.
If the hospital meets the standards, it earns accreditation for three years. This is not the end of the story. It is the start of a cycle that requires constant attention.
𝐊𝐞𝐞𝐩𝐢𝐧𝐠 𝐢𝐭: 𝐜𝐨𝐧𝐭𝐢𝐧𝐮𝐨𝐮𝐬 𝐫𝐞𝐚𝐝𝐢𝐧𝐞𝐬𝐬 𝐛𝐞𝐭𝐰𝐞𝐞𝐧 𝐬𝐮𝐫𝐯𝐞𝐲𝐬
Once accredited, a hospital must stay survey-ready. The IPSGs must be in full use. Quality and safety indicators must be tracked, studied, and improved. Infection prevention has to be visible and measured. Medication systems must remain reliable, from prescribing through dispensing and administration. Facility risks must be found and fixed. Staff education and competency checks must be ongoing. Leadership must review trends, allocate resources, and hold teams accountable. JCI calls these expectations the continuous compliance mindset. The standard is clear: accreditation reflects daily practice, not a temporary push during a visit.
JCI also sets participation requirements that apply at all times. Hospitals must give surveyors accurate information, report major organizational changes, permit on-site evaluations if serious safety concerns arise, and represent their accreditation status truthfully in public materials. These guardrails protect patients and maintain trust in the program.
𝐂𝐚𝐧 𝐚𝐜𝐜𝐫𝐞𝐝𝐢𝐭𝐚𝐭𝐢𝐨𝐧 𝐛𝐞 𝐰𝐢𝐭𝐡𝐝𝐫𝐚𝐰𝐧?
Yes. JCI can deny, suspend, or withdraw accreditation if a hospital fails to meet standards or does not comply with participation requirements. Examples include an immediate threat to patient or staff safety, unresolved serious noncompliance, refusal to permit an evaluation, or misrepresentation of status. There is a formal process for notification and appeal, however the bottom line is clear: the badge is earned and kept by performance.
𝐇𝐨𝐰 𝐒𝐌𝐌𝐂 𝐡𝐚𝐬 𝐛𝐞𝐞𝐧 𝐛𝐮𝐢𝐥𝐝𝐢𝐧𝐠 𝐭𝐡𝐞 𝐟𝐨𝐮𝐧𝐝𝐚𝐭𝐢𝐨𝐧
SMMC’s effort over the past several years mirrors that playbook. The hospital has been aligning with standards in the core areas patients feel most directly: patient rights and communication, medication management, infection control, leadership and governance. The work has included staff training, standardized clinical guidelines, evidence based policies and procedures, and a formal grievance mechanism so concerns are captured and resolved. SMMC has also strengthened its committee structure so that complicated issues are managed in a disciplined way. These include Medical Ethics, Infection Control, Medication, Complaints, and FONA, the group that looks at faults or near accidents so lessons are not lost.
At hospitals pursuing JCI, similar safety days place core structures in the spotlight. Quality and Safety teams present the International Patient Safety Goals, so every unit works from the same playbook for the coming year. Nursing leaders often devote sessions to high risk groups such as newborns and pediatric patients. Pharmacy speakers frame confidentiality and safe medication processes as clinical safety issues, not only compliance. Near miss and incident review committees translate lessons into daily routines, with an emphasis on reporting for improvement rather than blame. Hygiene and Infection Control provide the backbone, since environmental hygiene and hand hygiene underpin every safety program. Workshops and small group drills help staff apply the ideas to their own settings, and strong participation signals buy in across departments.
𝐖𝐡𝐚𝐭 𝐭𝐡𝐢𝐬 𝐦𝐞𝐚𝐧𝐬 𝐟𝐨𝐫 𝐭𝐡𝐞 𝐧𝐞𝐰 𝐒𝐭. 𝐌𝐚𝐚𝐫𝐭𝐞𝐧 𝐆𝐞𝐧𝐞𝐫𝐚𝐥 𝐇𝐨𝐬𝐩𝐢𝐭𝐚𝐥
The transition to SMGH will not only be about new bricks and new equipment. JCI reviews how a hospital’s systems function in the real environment, so SMMC’s current preparation reduces risk during the move. Policies, pathways, and team habits that already match the standards will travel with the staff. That includes IPSG behaviors such as positive patient identification every time, surgical time-outs that are performed correctly, medication double checks for high-alert drugs, and a culture where staff escalate concerns early. As the new facility comes online, the tracer lens that surveyors use can also be used internally by SMMC leaders to test whether new workflows are performing to standard.
For patients and families, JCI standards translate to fewer communication errors, safer procedures, cleaner hands, and faster correction when something goes wrong. They produce clearer discharge instructions, better medication reconciliation, and more consistent pain assessment. They push the organization to listen to complaints and show how it fixed the underlying issue. They require leadership to monitor the system and invest in improvement, not only respond after an event.
SMMC has been steadily building the systems that JCI expects. The World Patient Safety Day program made that visible, from the IPSGs to pediatric safety, from pharmacy confidentiality to incident learning. Accreditation will ultimately be decided by how consistently those practices show up in daily care, and by how reliably they are sustained in the new hospital.