Accreditation has been a voluntary process through which the organization is able to measure the quality of its services and performance against nationally or internationally recognized standards. Using our Accreditation Handbook of Standards, the organization performs a self-evaluation. This is followed by a thorough review by on-site surveyors, who themselves have extensive experience in the ambulatory and/or in-patient health care environments. In many countries of the world, however, what previously had been voluntary is now becoming mandatory – either by government regulation or by third party payer requirements (government run or private insurance programs).(1)
What is accreditation?
The World Health Organization calls accreditation a link between self evaluation and external quality evaluation.(1) WHO adds that it is “the most commonly used external mechanism for standards-based quality improvement in health care.” (2)
But accreditation is much more than merely putting in place a quality assurance program. Comprehensive accreditation includes a review of the entire governance and administration of a health care organization to ensure it is structured to deliver high quality care.
Within the organization seeking accreditation, there must be a system in place to assure qualified health care providers and support personnel: that they adequately meet the needs of the patients; and that they have been granted privileges to work within the organization. This system must not only ensure such personnel is painstakingly selected, their education and experience thoroughly verified , but also that their performance is regularly evaluated by superiors and/or peers.
Bearing in mind that health care organizations exist to provide care to patients, an organization seeking accreditation must have policies and procedures in place to assure patients’ rights and include patients’ responsibilities. “Above all do no harm (Primum non Nocere),” the motto attributed to Hippocrates, the father of modern medicine, should be its constant watchword. Comprehensive accreditation must ensure, by on-site observation, that programs are in place to prevent or manage risk, (errors, deviations or variances from expected care or outcomes), to assure patient safety, infection prevention and control; and to constantly monitor care and outcomes.
That the health care organization operates in accordance with recognized standards is a key component of any accreditation program. Standards should be developed by an accrediting organization that is nationally recognized in at least one country and whose standards are transferable to other countries. Ideally, the standards are revised and updated regularly to stay on top of changing practices and technology. They must also be consistent with local laws and regulations governing health care delivery organizations.
Who provides accreditation?
When WHO surveyed the global marketplace in 2003, there were 47 different countries that had either studied or enacted some form of accreditation or quality management program; or specified licensure recognized by their governments.(3) In some countries, including the United States of America, governmental organizations grant “deeming authority” to recognized accrediting organizations to perform mandatory inspections of health care organizations in lieu of government inspections or surveys. Internationally, the largest multi-national organization of accreditation is Joint Commission International; in Latin America however, Acreditas Global (formerly AAAHC International, a division of the Accreditation Association) is very active – as is Accreditation Canada. All these entities are non-governmental agencies. While standards are generally transferable from country to country, cultural differences and economic disparities may require some modifications. When a local standard or government regulation is more stringent than the published standard, the surveyor expects the higher level to be attained.
Why become accredited?
Acreditas Global firmly subscribes to the credo as it is expressed in an online paper from URAQ (Utilization Review Accreditation Commission), a United States accrediting organization:
“Accreditation is a dynamic process that identifies best practices and promotes high quality performance measures. Organizations that earn accreditation from a nationally recognized accrediting entity validate their commitment to quality and accountability. These companies voluntarily undergo a rigorous and periodic review that evaluates their operations and services against contemporary standards developed by experts and stakeholders in the health care arena.” (4)
Does this guarantee that quality care is being delivered?
Regrettably, no. But being surveyed by experienced and well trained surveyors, independent of the surveyed organization, (5) who will evaluate the organization for compliance with rigorous, recognized accreditation standards, should ensure that the infrastructure, medical, nursing and support staff are in place; that there are policies and procedures to guide care and systems to monitor care and outcomes.
There must also be an active quality assurance program which includes performance improvement studies and incorporates benchmarking. If inspection of the physical facility (building(s), emergency power sources, fire and evacuation drills, etc.) have been carried out by other agencies, governmental or private, the accreditation should verify that they are valid and current. If an inspection has not been performed it will be incorporated into the on-site survey of clinical care areas. In that survey, patient care will be observed in multiple areas: procedure and operating rooms, laboratories, radiology suites, physical therapy, dialysis units, intensive care units, new born nursery, emergency room and support sections – even i food service and waste management. These will all be visited and evaluated on-site.
The accreditation survey is essentially a snapshot in time of what is continually taking place; the organization, should not merely try to satisfy a one-time exposure. Preparation is a continual process whereby the organization is looking to ensure that their operations meet accreditation requirements on an ongoing basis, and remaining in compliance with standards of care that are changing regularly.
The organization should look at this as “management development” (6) and use the preparation, along with the on-site interaction with the surveyors, to improve practices based on the standards or higher guidelines. Accreditation is time sensitive and often requires interim submission of materials or additional on-site visits to assure the organization is current.
Accreditation surveys do incur a cost to the organization, which varies based on the size and complexity of the organization and the number of accreditation surveyors needed on-site. The point to remember however, patients assume that when they enter a health care organization, safe,, high quality care is a priority. the most convincing way of demonstrating this is by undergoing accreditation (7) and educating your patients about it. With the development of many integrated health care systems, accreditation results in standardization within the organization and contributes to a culture of safety.
Careful oversight by the governing body of the organization being accredited in establishing and regularly reviewing policies leads to delivery of reliable and consistent care. Also essential in the credentialing of medical staff and management is that it includes verification of education, special training and experience. But this is not a static activity. Periodic assessing of performance through peer review and/or performance appraisals must be done regularly. Ongoing education of staff in risk prevention and safety management is mandatory. Quality improvement must include analysis of deviations from expected care and outcomes. Ensuring all this may require review and revision of policies and procedures to strengthen the system and make it safer for all. (8)
Government regulatory agencies may acknowledge independent accreditation “as a tool of public accountability.” (9) Confirmation that your organization has demonstrated to an independent survey team that you have all infrastructure, systems and personnel in place to meet recognized standards and deliver safe and high quality care is the bottom line. Do it for yourself and your staff – and your patients will benefit.
(1)Quality and Accreditation in Health Care Services – A Global Review, Evidence and Information for Policy, World Health Organization, Geneva, 2003, page 105
(2) ibid, page 105
(3) ibid, pages 107 – 110
(4) URAQ (Utilization Review Accrediting Commission) policy paper on The Value of Accreditation at www.uraq.org
(5) European Journal of Public Health, volume 7, No.10, 1997,
(6) ibid, page 5
(7) ibid, page 6
(8) Palmieri, et al in Strategic Human Resource Management in Health Care Advances in Health care Management, Volume 9,
(9) European Journal of Public Health, volume 7, no. 10, 1997