Finding Hospital Accreditation: What You Need To Know

Hospital accreditation is a valuable asset for any hospital as it helps to ensure patient safety and quality of care. Accreditation is a strategic business tool that helps hospitals meet and exceed expectations. It is a process that varies from country to country and is sometimes mandated by law. In the United States, hospitals can seek accreditation from organizations such as The Joint Commission, which evaluates and reviews hospitals, granting them accreditation and helping them achieve their quality and safety goals. Prospective patients can check online resources such as Healthgrades, which provides profiles and reviews of hospitals and healthcare providers, to make informed decisions about their healthcare. These resources provide insights into hospital quality, patient experience, and recommendations. While hospital ratings and reviews can guide patients, it is important to remember that medical errors can occur anywhere, even in highly-ranked hospitals.

The Joint Commission's accreditation standards and Gold Seal of Approval

The Joint Commission is an organization that aims to improve healthcare by evaluating and inspiring safe, effective, and high-value care. They accredit and certify over 22,000 healthcare organizations and programs in the United States, including hospitals, nursing care, ambulatory care centers, and behavioral health centers. The Joint Commission's accreditation process helps hospitals achieve their quality and safety goals and promotes zero harm. To achieve accreditation, organizations must meet rigorous standards and undergo a meticulous evaluation process.

The Gold Seal of Approval® is a prestigious recognition awarded by The Joint Commission to organizations that demonstrate an unwavering commitment to their rigorous standards. This seal is a powerful symbol of an organization's dedication to providing safe, quality patient care and signifies that they are reliable, high-quality healthcare providers. The seal can only be used by accredited and certified organizations and serves as a way for patients to identify healthcare providers that meet these high standards.

The evaluation process conducted by specially trained professionals from The Joint Commission includes on-site or virtual reviews that assess critical areas such as patient safety, human resources, leadership, technology, education, patient rights, information security, compliance, and management. Organizations that achieve accreditation are provided with tools, solutions, and services to help them sustain their accreditation status and continue their zero-harm journey.

To promote their achievement, organizations that have earned the Gold Seal of Approval® can display the seal in various formats, such as JPEG, EPS, and vector files, on their printed publications and websites. When using the seal, organizations must follow specific guidelines, including maintaining the proportional relationship of its elements and only adding the phrase "Accredited/Certified by The Joint Commission" below the seal.

Accreditation eligibility and pricing

Accreditation is a voluntary process that helps hospitals improve patient care and work towards achieving zero harm. To be accredited, hospitals must meet certain eligibility requirements and comply with specific standards.

In the United States, hospitals must be certified as complying with the Conditions of Participation (CoP) to participate in and receive payment from Medicare or Medicaid programs. This certification is based on a survey conducted by a state agency on behalf of the Centers for Medicare & Medicaid Services (CMS). Alternatively, hospitals can seek "'deemed status" by meeting the standards set by a national Accrediting Organization (AO), which is then "'deemed'" by the CMS as meeting the CoPs.

The Joint Commission is one such accrediting organization that offers hospital accreditation. Hospitals can learn about the eligibility requirements and accreditation options through their resources. They also provide information on the survey process, timelines, checklists, and other tools to help hospitals prepare for their accreditation journey.

Accreditation fees vary depending on the accrediting organization and the specific program. Some organizations, like ABET, charge a base fee for accreditation and additional costs for travel to off-campus locations. Cancellation fees may also apply if a program review is cancelled. NAEYC, on the other hand, bases its fees on the number of enrolled children in a program, with an annual accreditation fee due at the end of each year. NASPAA has a similar annual accreditation fee structure, with additional fees for multi-campus programs, distance campuses outside the home country, and executive education tracks.

It is important to note that accreditation is not a one-time achievement but a continuous process. Hospitals must maintain their accreditation status and prepare for periodic surveys to ensure they continue to meet the required standards.

Survey preparation and resources

The first step in preparing for a hospital accreditation survey is to understand the standards set by the CMS and the AO. These standards cover various aspects of healthcare delivery, including patient care, medication management, infection control, and the physical environment. Familiarize yourself with the accreditation standards relevant to your facility, including those set by The Joint Commission, DNV Healthcare, or other AOs. Organizations like The Joint Commission and DNV Healthcare provide comprehensive accreditation manuals that outline all the standards and elements of performance, which can be essential resources for preparation.

Facilities professionals should involve key leaders and department heads in the preparation process to ensure a coordinated effort. Leadership engagement is crucial, and leaders should actively participate in the process, providing necessary resources and support to staff while fostering a culture of quality and safety. Regularly review your facility's performance against the AO's standards and implement changes as needed, encouraging a culture of continuous improvement.

To prepare for the on-site survey, access resources such as education offerings, complimentary materials, and a survey activity guide provided by the Joint Commission. The survey activity guide includes survey activity details, providing a thorough and individualized description of the on-site survey events, and a sample survey agenda, which outlines what to expect, who to have available, and what you'll need during the on-site visit.

Before the survey, conduct self-assessments and internal mock surveys to identify areas for improvement. Regular internal audits help identify non-compliance issues and opportunities for enhancement. Stay informed about frequently cited standards during surveys and findings from previous accreditation surveys to address potential issues proactively.

For Medicare certification, hospitals have the option of being surveyed by an AO or a state agency on behalf of CMS. All surveys for Medicare certification are unannounced, and CMS conducts random validation surveys and complaint investigations of accredited hospitals.

Accreditation survey alternatives

Accreditation is a significant milestone, but it is not the final goal. Hospitals can explore alternatives to the accreditation survey to maintain their accreditation status and deliver consistently high-quality care. Here are some strategies and alternatives to consider:

Understanding Accreditation and Its Alternatives:

Accreditation is a voluntary process that recognises a healthcare organisation's commitment to meeting specific standards and delivering quality care. While accreditation surveys are a common method for evaluating healthcare organisations, alternatives include:

• Certification: In the United States, for example, healthcare organisations must comply with the Conditions of Participation (CoP) to receive payment from Medicare or Medicaid programs. This certification is typically based on a survey conducted by a state agency on behalf of the Centers for Medicare and Medicaid Services (CMS). However, national Accrediting Organisations (AOs) with equivalent standards may be granted "deeming authority," allowing healthcare facilities to obtain "deemed status" without undergoing the Medicare survey process.
• Continuous Improvement: Accreditation is a journey towards zero harm. Maintaining accreditation requires ongoing improvement efforts and a focus on sustainability. Organisations can invest in high-reliability tools, solutions, and services to enhance patient safety processes and stay ahead of the curve for future surveys.

Survey Preparation and Alternatives:

The survey process can be demanding, and organisations should be well-prepared to showcase their accomplishments. Here are some alternatives and strategies to enhance survey preparation:

• Early Planning: Start by deciding which programs or services you want to get accredited. Appoint a committee to coordinate survey preparation, involving all levels of leadership and personnel. This committee should review the standards manual and relevant documentation, ensuring conformance to the required standards.
• Training and Education: Encourage committee members to participate in training sessions, such as CARF 101, to familiarise themselves with the accreditation process. This empowers them to answer questions and address any concerns raised during the survey.
• Organisational Engagement: Keep personnel informed about the general survey schedule and their potential involvement. Ensure easy access to relevant files and documents for the survey team, and provide an updated organisation chart with names and titles.
• Communication and Transparency: Maintain open communication with the accrediting body and survey team. Notify interested individuals about the survey dates and their input methods. This transparency fosters stakeholder engagement and contributes to the reliability of the accreditation process.
• Conflict of Interest Disclosure: Ensure that all surveyors disclose any potential conflicts of interest with the applicant or facility before their assignment. This includes consulting services provided, personal relationships, or future employment contracts.

Maintaining Accreditation and Quality Care:

Beyond the survey, organisations must focus on sustaining their accreditation status and delivering consistent quality care. Here are some alternatives to traditional surveys for maintaining accreditation:

• Verification Surveys: Accrediting bodies may conduct verification surveys to confirm the implementation of changes documented in your Corrective Action Plan (CAP). These surveys ensure ongoing compliance with accreditation standards and provide opportunities for evaluating surveyor performance.
• Random Quality Control Surveys: Accrediting bodies reserve the right to conduct random, unannounced quality control surveys to evaluate consistency across accredited locations. These surveys may be triggered by consumer or professional complaints, ensuring patient satisfaction and addressing any concerns promptly.
• Promote Accomplishments and Continuous Improvement: Share your accreditation achievement through various communication channels. Simultaneously, continue your journey towards zero harm by implementing processes that sustain and enhance your accreditation status.

In conclusion, while accreditation surveys are a crucial aspect of evaluating healthcare organisations, there are various alternatives and strategies that complement the survey process. By understanding certification requirements, investing in continuous improvement, and effectively preparing for and maintaining accreditation, healthcare organisations can deliver high-quality care and achieve their patient safety goals.

Accreditation's impact on patient care and safety

Accreditation is a reputable tool to evaluate and enhance the quality of healthcare. It is not the end goal, but rather a means to achieving zero harm and improving patient safety and care. While its effect on performance and outcomes is still unclear, there is evidence to suggest that it has a positive impact on patient safety and care.

A systematic literature review of 76 studies found that over 55% showed a positive accreditation effect, particularly on process-related performance measures, safety culture, hospital efficiency, and patient length of stay. The review also found that staff job stress was negatively impacted, while staff job satisfaction, patient satisfaction, and experience were unrelated to accreditation. However, it is important to note that the studies with poor methodological quality showed a positive or neutral accreditation effect, and their findings should be scrutinized carefully.

Another systematic review of healthcare professionals' appraisals found that accreditation had a positive impact on the quality of care and patient safety. It also fostered more effective teamwork and enhanced the health system in general. The implementation of accreditation standards increased recognition among healthcare professionals, who understood their responsibility for providing safe and standardised care.

In some cases, accreditation can also impact a hospital's participation in and reimbursement from certain programs. For example, in the United States, healthcare organisations must meet eligibility requirements and be certified as complying with the Conditions of Participation (CoP) to receive payment from Medicare or Medicaid programs. Accreditation can also provide exemptions from certain survey and certification processes.

Frequently asked questions