Hailey Tran
Hospital accreditation is a process of self-assessment and external peer assessment that health care organizations use to evaluate their performance and implement improvements. Accreditation is not just about setting standards but also has analytical, counseling, and self-improvement dimensions. Various organizations worldwide, such as the Joint Commission, CHKS Ltd, and Center for Improvement in Healthcare Quality (CIHQ), offer accreditation programs for hospitals. These programs aim to promote quality, ensure patient safety, and help hospitals measure, assess, and enhance their performance. The specific standards and requirements may vary across different accreditation schemes and countries, and hospitals typically pay fees to maintain their accreditation status.
| Characteristics | Values |
|---|---|
| Accreditation body | The Joint Commission, CHKS Ltd, Center for Improvement in Healthcare Quality (CIHQ), American Osteopathic Association (AOA), Lembaga Akreditasi Rumah Sakit (LARS), ACSA International |
| Accreditation process | Self-assessment, external peer assessment, mock surveys, gap identification, compliance checks, on-site surveys, validation surveys |
| Accreditation standards | Quality, patient safety, emerging issues from scientific literature, input from committees and stakeholders, reasonable and achievable expectations |
| Accreditation costs | Up to $37,000 annual fees, $18,000 inspection costs every three years, on-site survey fees |
| Accreditation cycle | Three-year cycle for member healthcare organizations, two-year cycle for laboratories |
| Accreditation transparency | Accreditation decision, date, and standards for improvement are published, annual updates on standards and patient safety goals |
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What You'll Learn
The Joint Commission
Accreditation by the Joint Commission follows a three-year cycle for member healthcare organizations, with laboratories surveyed every two years. Hospitals must maintain compliance with the standards for at least four months before the initial survey and throughout the entire accreditation period. The Commission's survey process includes the unique tracer methodology, which involves following patients' care experiences within the hospital.
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Medicare Conditions of Participation
In 1965, the Medicare legislation was passed, stipulating in Section 1861 of the Social Security Act that hospitals participating in the Medicare program must meet specific requirements. The following year, the Conditions of Participation were established, outlining the minimum health and safety standards that hospitals participating in Medicare must adhere to. These conditions were significantly revised in 1986.
The Conditions of Participation, or CoPs, are health and safety standards developed by the CMS (Centers for Medicare & Medicaid Services) that healthcare organizations must meet to initiate and maintain their participation in the Medicare and Medicaid programs. The CMS also ensures that the standards set by accrediting organizations it recognizes meet or surpass the Medicare standards outlined in the CoPs.
Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO or the Joint Commission) or the American Osteopathic Association (AOA) are automatically deemed to fulfill the health and safety requirements for participation, except for certain conditions, such as the utilization review requirement and special conditions for psychiatric hospitals and long-term care providers.
The Health Care Financing Administration (HCFA), a branch within the Department of Health and Human Services (DHHS) responsible for the Medicare program, and the Joint Commission both play regulatory roles in enforcing these standards. The Bureau of Health Standards and Quality (HSQB), a unit within HCFA, administers and enforces the Conditions of Participation, overseeing thousands of certified and accredited hospitals, and enforcing separate sets of conditions for other Medicare providers, including skilled nursing facilities, home health agencies, and laboratories.
The current federal standards for hospitals participating in Medicare are outlined in the Code of Federal Regulations, encompassing 24 Conditions of Participation with 75 specific standards. Hospitals that meet these conditions are automatically permitted to participate in Medicaid as well.
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Accreditation schemes
One prominent accreditation scheme is offered by the Joint Commission, previously known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The Joint Commission has been accrediting hospitals since its founding in 1951 and is recognised for its rigorous standards and survey processes. Hospitals undergoing accreditation by the Joint Commission are subject to on-site surveys, which include the unique tracer methodology that follows patients' care throughout their hospital experience. This survey process is designed to assess compliance with the established standards, and hospitals are expected to maintain compliance during the entire period of accreditation.
Another notable accreditation scheme is the Center for Improvement in Healthcare Quality (CIHQ), based in Round Rock, Texas. The CIHQ was granted deeming authority for hospitals by the CMS in July 2013. This accreditation programme focuses on continuously improving healthcare quality and patient safety. The CIHQ updates its accreditation standards and patient safety goals annually, demonstrating its commitment to staying abreast of the latest advancements and requirements in healthcare.
In addition to these, there are other accreditation schemes such as CHKS Ltd, which is a UK-based specialist provider of healthcare accreditation programmes accredited to ISQua and ISO 17021:2015 standards. ACSA International is another example, accredited by ISQua, and working in agreement with the Brazilian Institute for Excellence in Health (IBES) to export the Andalusian certification model for hospitals to Brazil. These schemes vary in scope, size, intent, and marketing skills, as well as in their focus on assessing medical ethical standards and clinical standards.
It is important to note that accreditation schemes are typically independent of governmental control. While governments play a role in regulating healthcare quality, accreditation schemes provide a complementary self-assessment and peer assessment process for healthcare organisations to continuously improve their performance and maintain high standards of care.
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Continuous improvement
The Joint Commission, a major accrediting body for hospitals in the United States, has a stated mission of "continuously improving healthcare for the public". They offer a free 90-day trial of their hospital standards for organisations considering accreditation, allowing hospitals to assess their readiness for accreditation and identify areas for improvement. Hospitals can conduct mock surveys, walk-throughs, identify gaps in compliance, and document areas requiring improvement to focus their efforts and allocate resources effectively. The Joint Commission updates its accreditation standards and patient safety goals annually, making the information transparent to all stakeholders.
Another example of continuous improvement is the evolution of Medicare's Conditions of Participation. Initially promulgated in 1966 and substantially revised in 1986, these regulations set minimum health and safety standards for hospitals participating in Medicare. Over time, the focus has shifted from ensuring a minimum capacity to provide adequate care to encouraging hospitals to comprehensively and continuously assess and improve their organisational and clinical performance.
Internationally, there are several other accreditation bodies promoting continuous improvement in healthcare quality. These include CHKS Ltd in the UK, Lembaga Akreditasi Rumah Sakit (LARS) in Indonesia, and the Center for Improvement in Healthcare Quality (CIHQ) in the United States. These organisations develop standards, conduct surveys, and provide accreditation to hospitals and healthcare providers to ensure quality and safety.
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Patient safety
The Joint Commission's accreditation standards cover various aspects of the care delivery process, ensuring a comprehensive review of the patient care experience. Hospitals can assess their readiness for accreditation by conducting mock surveys, identifying gaps in compliance, and documenting areas for improvement. The Joint Commission also offers a free 90-day trial of its hospital standards for organisations considering accreditation.
In addition to the Joint Commission, other organisations also play a role in patient safety and accreditation. The American Osteopathic Association (AOA) and the Bureau of Health Standards and Quality (HSQB) are responsible for enforcing Conditions of Participation, which set minimum health and safety standards for hospitals. These regulations ensure that hospitals provide safe and reliable care to their patients.
Overall, patient safety is at the core of hospital accreditation standards. By adhering to these standards, hospitals can continuously improve the quality of care they provide and ensure the safety and well-being of their patients.
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Frequently asked questions
Hospital accreditation is a process of evaluating and approving hospitals to ensure they meet specific standards of quality and safety. Accreditation is crucial to demonstrate a hospital's compliance and commitment to patient safety.
The Joint Commission (TJC) is an independent, non-profit organization that accredits more than 20,000 healthcare organizations and programs in the US. It aims to ensure quality healthcare, prevent harm, and improve patient advocacy.
The Joint Commission has specific standards and quality measures that hold healthcare organizations accountable for patient safety and health-related outcomes. These standards are based on reported adverse events such as medication errors, surgical mistakes, and communication issues. Hospitals must be in compliance with these standards during the entire period of accreditation.
The Joint Commission conducts on-site surveys of hospitals to evaluate their performance and compliance with safety standards. These surveys are unannounced and occur every 2 to 3 years. The commission provides support to hospitals throughout the accreditation process and offers data analytics tools to drive quality improvement.
