INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025

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Compliance with JCI Protocols: A Focus on Employee Safety

Dr. A. Girija

, Husna Ali AL Quattan

Associate Professor, Apollo Institute of Hospital Administration, Hyderabad, Telangana, India

MDHM, Hyderabad, Telangana, India

DOI:

https://doi.org/10.51244/IJRSI.2025.120800058

Received: 08 Aug 2025; Accepted: 14 Aug 2025; Published: 04 September 2025

ABSTRACT

The article explores employee safety compliance with Joint Commission International (JCI) protocols at a

corporate hospital in Hyderabad. JCI provides comprehensive standards aimed at ensuring the safety and

security of healthcare workers. Employee safety remains a top priority for healthcare institutions, covering

areas such as workplace hazards, safety training, emergency preparedness, adherence to health regulations,

accident reporting, and wellness initiatives.

The study employed both primary and secondary data collection methods. Observations were made on

employee safety practices to evaluate whether the healthcare organization complies with JCI protocols.

Adherence to these standards is expected to enhance employee performance and strengthen their commitment

to the organization.

A total of 200 employees participated in the study, including 50 doctors, 50 administrators, 80 nurses, and 20

technicians. Data was collected using closed-ended questionnaires, where employees selected the safety

measures made available to them.

Each employee received a questionnaire to assess their safety-related experiences, which was then used to

evaluate compliance with JCI guidelines. The collected data was analyzed to verify adherence to these

standards. A Chi-square test was performed to examine the relationship between gender and the perceived

responsibility of workload.

The analysis involved various tools and techniques including MS Excel, Chi-square testing, hypothesis testing,

Google Forms, graphical representations (such as bar graphs), and percentage-based evaluations.

Key Words: Employee Safety, JCI (Joint Commission International), Employee care, Quality, Safety

Compliance.

INTRODUCTION

To meet JCI standards, hospital staff must be thoroughly trained in handling hazardous materials, infection

prevention, and emergency response procedures. Regular safety audits, effective communication systems, and

active participation from safety committees are crucial. These efforts should involve all staff members

including doctors, nurses, technicians, and administrators to foster a safe, well-prepared, and compliant

healthcare environment.

This study focuses on evaluating employee safety within the scope of Joint Commission International (JCI)

protocols. Its primary goals are to enhance the quality of care for employees, improve coordination among

healthcare teams, and strengthen safety practices across the organization. The study also aims to reduce

workplace stress, build resilience among hospital staff, and address the essential needs of healthcare workers in

alignment with JCI standards.

INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

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Moreover, it emphasizes the need for operational efficiency by adopting effective safety management

strategies and reinforcing safety protocols. Ultimately, the study seeks to foster a safer, more supportive work

environment for all healthcare professionals.

REVIEW OF LITERATURE

Compliance with JCI protocols is essential for maintaining high standards of patient and staff safety. It

involves adherence to IPSGs, which are critical for accreditation and continuous quality improvement in

healthcare organizations (Siewert et al., 2018). A robust compliance program helps mitigate risks, protect

workers' rights, and promote sustainable business development. Training and resource management are crucial

for preparing preventive compliance reports and managing occupational risks effectively (Paula Andrea

Ramirez Barbosa, 2023). Studies have shown a decline in compliance and awareness of JCI safety goals

post-accreditation, indicating the need for ongoing efforts beyond the accreditation process. Challenges include

maintaining continuous readiness and embedding compliance into the daily routine and culture of the

organization (Chehab et al. 2016.).

Implementing continuous quality improvement measures and regular monitoring of safety practices can

enhance compliance. This includes setting quality indicators and conducting regular audits (Kobayashi et al.,

2021). Michael H et al., (2018) conducted an observational study at a primary stroke center and identified

security gaps that posed risks to patient and staff safety. The study highlights the importance of regular

security audits and staff education to prevent workplace violence.

Anni Vuohijoki et al., (2023) study aims to monitor the effects of implementing the Joint Commission

International (JCI) quality assurance system at Orton Orthopedic Hospital on employee well-being and patient

safety. In the study Hilda Maze et al., (2023) found that nurses, especially younger ones, showed high

engagement and self-efficacy, which positively correlated with the use of quality-enhancing tools and

openness to change. Roselle Marie D et al., (2023) in their study examined how Total Quality Management

(TQM) and safety influence customer satisfaction in private hospitals, revealing strong stakeholder agreement

on these aspects. Their recommendations include better stakeholder profiling, enhanced infection control, and

improved hospital processes for more effective service delivery.

OBJECTIVE OF THE STUDY

1. To evaluate the implementations of the standards and rules set by the Joint Commission International for the

Healthcare Providers.

2. To identify the factors associated with employee care and safety, including quality of healthcare provided.

3. To improvise employee care and providing the best facilities.

4. To look after basic needs and demands of the Healthcare Providers and the staff within JCI Protocols.

METHODS

This study focuses on evaluating the application of Joint Commission International (JCI) protocols for

employee safety and examining the potential benefits of their implementation in a hospital setting. The goal is

to enhance staff satisfaction and ensure consistent, high-quality performance. The study covers various aspects,

including employee safety compliance, emergency preparedness, proper equipment handling, facility

management, workplace hazard prevention, infection control, and the reduction of Hospital Acquired

Infections (HAIs), along with other relevant clinical indicators.

The study employed a convenient sampling method to collect data over a two-month period. A total sample of

200 employees comprising 50 doctors, 50 administrators, 80 nurses, and 20 technicians was selected,

representing 20% of the hospital's total staff. Data collection involved both primary and secondary sources.

Primary data was obtained through observations, interviews, and the distribution of structured questionnaires

INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

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to employees. Secondary data was gathered from JCI guidelines, quality standards, hospital reports, and other

relevant documents.

RESULTS & DISCUSSION

The study gathered and analyzed information on a range of employee safety parameters. These included the

conduct of regular safety assessments, clarity in clinical and administrative roles, communication methods for

safety protocols, physical safety in the workplace, workload distribution, and job security. It also examined

organizational policies, opportunities for learning and development, awareness of safety procedures, infection

control measures, accessibility of emergency exits, safety training sessions, and the use of hazard warning

signals.

Fig 1- Conducting periodic employee safety surveys

Inference:

Figure 1 presents the findings of the employee safety survey conducted in line with JCI guidelines at the study

hospital. The majority of employees confirmed that periodic safety surveys are carried out. This reflects the

hospital’s proactive approach to safeguarding the well-being of its workforce, including doctors,

administrators, nurses, and technicians.

Fig 2 - Clinical and administrative responsibilities covered by the survey

INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

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Inference:

Figure 2 displays a bar graph indicating that the hospital’s employee safety surveys effectively address both

clinical and administrative responsibilities. A significant number of staff members 39 doctors, 42

administrators, 68 nurses, and 16 technicians reported that the surveys cover both areas of their work,

highlighting the hospital’s comprehensive approach to employee safety.

Fig 3 - Methods to communicate employee safety

Inference:

Figure 3 highlights the different methods used by the hospital to communicate employee safety measures to

staff. A large portion of respondents identified inspection rounds as the primary mode of communication,

while others pointed to the role of the safety committee. Specifically, 33 doctors, 38 administrators, 55 nurses,

and 11 technicians reported that inspection rounds are the main method through which employee safety

information is conveyed within the organization.

Fig 4 - Encouragement to inform the unresolved facility regulatory issues

INFERENCE:

The bar graph (figure 4) illustrates employee perceptions regarding the hospital’s encouragement to report

unresolved facility-related issues. A majority of 37 doctors, 38 administrators, 58 nurses, and 16 technicians

stated that their concerns are acknowledged and addressed. However, 11 doctors, 12 administrators, 17 nurses,

and 3 technicians indicated that they do not feel supported or encouraged in resolving these facility issues.

INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

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Fig 5 - Employee safety survey probe

Inference:

The above data from figure 5 portrays the findings from the employee safety survey conducted at the hospital.

The results show that many employees feel satisfied with the supportive work environment, including 23

doctors, 21 administrators, 33 nurses, and 9 technicians. The organization promotes a culture of continuous

learning by encouraging staff to learn from mistakes and stay vigilant in their roles. While some employees

reported feeling comfortable with their superiors, others appreciated that their suggestions are acknowledged

and valued by the management.

Fig 6 - Physical safety at workplace

Inference:

The bar graph (figure 6) reflects employee responses regarding physical safety in the workplace. A significant

number of employees including 28 doctors, 22 administrators, 37 nurses, and 12 technicians strongly agreed

that they feel physically safe within the hospital premises. Many others also expressed agreement. This

suggests that the hospital maintains a secure and physically safe environment for its staff.

INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

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Fig 7 - Workload reasonability at the organization

Inference:

Figure 7 represents employees' perceptions of workload reasonability within the hospital. A majority of 23

doctors, 22 administrators, 33 nurses, and 7 technicians agreed that their workload is reasonable. Some

employees strongly agreed with this assessment, while a few reported feeling overburdened. Overall, the data

indicates that most staff members consider their workload to be manageable, though there are some concerns

that may require attention.

Fig 8 - Job security at workplace

Inference:

The above bar graph (figure 8) depicts physical job security of the employees at the work place. Majority of

the employees agreed towards their job security at the firm. A significant majority of 43 doctors, 44

administrators, 64 nurses, and 16 technicians indicated that they feel secure in their positions. This suggests a

strong overall sense of stability and confidence in employment among the hospital staff.

INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

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Fig 9 - Satisfaction with organisational policies

Inference:

Figure 9 reflects employee perceptions of various organizational policies, such as leave entitlements, fringe

benefits, and healthcare consultation services provided at the workplace. A majority of employees 16 doctors,

20 administrators, 28 nurses, and 5 technicians reported being satisfied with these policies. This indicates a

positive overall response toward the hospital’s organizational practices and employee support systems.

Fig 10 - Opportunities to learn and grow

Inference:

The graph (figure 10) highlights the professional development opportunities available to employees within the

hospital. Among the staff, 15 doctors, 18 administrators, 20 nurses, and 7 technicians expressed agreement

regarding the hospital's efforts to promote learning and growth. Additionally, a subset from these groups

reported strong agreement, indicating even deeper support for the hospital’s commitment to fostering

organizational development and continuous learning.

INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

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Fig 11 - Effective methods for employee awareness and safety

Inference:

Figure 11 presents the various methods used to promote employee awareness and safety within the hospital.

The majority of employees identified training sessions as the most effective method, with 22 doctors, 22

administrators, 37 nurses, and 10 technicians selecting it. A smaller portion of staff chose mock drills, while

only a few opted for posters, leaflets, and other informational materials. These results emphasize the value of

hands-on training in enhancing safety awareness among hospital staff.

Fig 12 -Methods adopted to reduce risk of infection in the hospital

INFERENCE:

The graph (figure 12) illustrates the effective methods adopted by the hospital to reduce the risk of infection

among employees. The main strategies include cleaning and sterilization, use of disinfectants, and ensuring an

adequate supply of equipment. The majority of employees include 21 doctors, 18 administrators, 32 nurses,

and 5 technicians who identified cleaning and sterilization as the most effective method. Others selected

disinfectants, while some opted for adequate equipment supply or all of the listed methods. These results

underscore the hospital’s emphasis on hygiene and infection control to protect its staff.

INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

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Fig 13 - Proper emergency exits in the hospital

Inference:

Figure 13 highlights employee feedback on the presence of proper emergency exits within the hospital. All

employees unanimously agreed that the hospital has well established emergency fire exits in place, indicating

strong adherence to safety protocols and a proactive approach to emergency preparedness.

Fig 14 - Safety trainings in the hospital

Inference:

Figure 14 depicts the safety training programs attended by employees as part of the hospital’s employee safety

protocols. These trainings include fire safety drills, hazard communication, lockout procedures, and laboratory

safety. A significant majority of employees reported attending all of these training programs, while a smaller

portion participated in only one. This demonstrates the hospital’s commitment to comprehensive safety

training and preparedness for its staff.

INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

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Fig 15 - Laboratory safety and proper equipments supply in radiology department

Inference:

Figure 15 illustrates employee perceptions of laboratory safety and the availability of appropriate equipment in

the radiology department for those exposed to radiation. Nearly all employees confirmed that the radiology

labs are well-equipped and maintain proper safety measures, reflecting the hospital’s commitment to protecting

staff working in high-risk areas.

Fig 16 - Appropriate hazard warning signs in the laboratory

Inference:

The graph (figure 16) highlights employee feedback on the presence of hazard warning signs in the laboratory,

with a focus on ensuring employee safety. All respondents unanimously agreed that appropriate warning

signboards are properly displayed in the radiology department, reflecting the hospital’s commitment to

maintaining a safe and well-regulated work environment.

INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

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Hypothesis Testing

 A Chi-square test is conducted to examine the association between gender and the perceived responsibility

of workload within the organization. The test is conducted at 0.05 level of significance.

 Null Hypothesis includes:

H0: There is no association between gender and workload responsibility at the organization.

 Alternate hypothesis is:

H1: There is association between gender and workload responsibility at the organization.

 Table 1 shows the observed frequency values and table 2 shows expected frequency values.

Workload responsibility

Gender

Yes

Total

Male

100

Female

100

Total

155

200

Table 1 - Observed frequency values

Workload responsibility

Yes

Male

77.5

22.5

Female

77.5

22.5

Table 2 – Expected frequency values

Microsoft Excel is used to find out the Chi-Square value. 0.183437 is the calculated value (P value). At 0.05 level

of significance, as P value is greater than 0.05, H

is accepted. Hence it is concluded that there is no association

between gender and workload responsibility at the organization.

The hospital prioritizes employee safety and satisfaction by conducting regular surveys in alignment with JCI

norms, covering both clinical and administrative responsibilities. These surveys involve inspection rounds,

safety committees, and hospital newsletters, and they incorporate employee feedback to resolve regulatory

issues and improve workplace conditions. Most healthcare workers including doctors, nurses, technicians, and

administrative staff, report feeling physically safe and secure at work. This is further supported by employee-

friendly policies such as flexible leave, fringe benefits, and healthcare consultations, which contribute to a

positive work climate. To enhance safety, the hospital has installed JCI vaults in key areas like reception desks,

nursing stations, and laboratories.

Infection control is maintained through routine cleaning, sterilization, and the use of disinfectants to reduce

hospital-acquired infections. The hospital also provides regular training programs to improve employee

performance and raise awareness about safety protocols. These include fire safety drills, hazard

communication, lockout procedures, and laboratory safety. Departments like Radiology are equipped with

safety kits and manuals, and proper signage is displayed throughout the hospital to ensure smooth workflow.

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Chi-square analyses indicate not a significant association between gender and the perception of workload

responsibility.

CONCLUSION

The study highlights the critical role of employee safety in hospital policy-making, especially in a setting

where individuals from diverse cultural backgrounds collaborate for a common purpose. It emphasizes the

importance of addressing workplace safety concerns and the necessity of creating a secure environment for all

staff members. The research reveals inadequacies in current employee satisfaction tracking and monitoring

systems, pointing to the need for more effective approaches to manage these challenges and ensure smooth

workflow. Key issues such as staff perceptions of care quality, skill development, and overall safety and

satisfaction are identified as major concerns. To address these, several recommendations aligned with Joint

Commission International (JCI) protocols have been proposed.

To improve employee safety and satisfaction, the hospital should consider implementing several important

measures. Introducing a recommendation box would encourage staff to share suggestions and feedback,

promoting a more inclusive and responsive workplace culture. Forming a counselling committee could help

address employee concerns, provide emotional support, and motivate staff by resolving work-related issues.

Additionally, the hospital must take strict action, including penalties or legal steps, against patients or

attendees who misbehave with staff, ensuring a respectful and secure work environment.

It is also recommended that the hospital offer full salary and paid leave to employees affected by hospital-

acquired infections, as a gesture of support and fairness. More frequent safety drills and hazmat

communication sessions should be conducted to keep staff well-prepared for emergencies. Providing basic

safety kits to all employees, including front desk and housekeeping staff, would ensure that everyone has the

tools needed to stay protected. Furthermore, implementing flexible working hours based on employee needs

and safety can greatly improve work-life balance and overall job satisfaction.

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