Accreditation Made Easy: Step-by-Step Guide for Healthcare Institutions

1. Comprehend the concept of accreditation and its significance for healthcare institutions.

2. Examine the advantages of accreditation for staff, patients, and the institution as a whole.

3. Learn how to prepare their facility for the accreditation process.

Healthcare accreditation is a methodical assessment ensuring hospitals and clinics meet quality and safety standards. Accrediting organizations, using best practices, review policies, and conduct on-site inspections to verify performance.^[1]

Different countries have their own national accreditation bodies, such as the Saudi Central Board for Accreditation of Healthcare Institutions, the General Authority for Healthcare Accreditation & Regulation in Egypt, and the Health Care Accreditation Council in Jordan.

Additionally, various international accreditation bodies, like the Joint Commission Accreditation, Accreditation Canada, and the Australian Council on Healthcare Standards, initially began with national programs but later expanded them globally to improve healthcare systems and marketing efforts. It is important to note that all accreditation bodies operate as nonprofit organizations.

Accreditation is crucial for providing excellent healthcare. It shows how healthcare institutions are dedicated to patient safety, continuous improvement, and meeting strict accreditation standards.^[2]

Accreditation serves as a hallmark of a healthcare institution’s steadfast dedication to providing exemplary patient care. This involves a meticulous evaluation process overseen by impartial entities operating at either national or international levels. Several nations establish their own national accreditation bodies, which operate independently of healthcare providers. Some countries feature multiple accreditation bodies, while others lack such regulatory frameworks altogether.^[3]

This step-by-step guide helps healthcare professionals and administrators to confidently navigate the accreditation process. It highlights the key elements for achieving and maintaining accreditation, such as building a strong team, identifying improvement areas, and involving staff. It also emphasizes the significance of meticulous documentation and mock surveys for preparedness.

This guide provides a roadmap for accreditation in healthcare institutions, whether for the entire facility or specific departments and specialized programs. By following these comprehensive steps, healthcare institutions will not only achieve accreditation but will also establish a culture of excellence in patient care that extends far beyond survey visits.

Senior healthcare leaders prioritize delivering high-quality care through comprehensive quality assurance strategies. These strategies involve systematic evaluations of healthcare services’ effectiveness and safety. Internal audits, conducted by qualified organizational staff, measure performance against established standards, thereby identifying potential areas for improvement and optimizing operational efficiency. Conversely, external evaluations, such as accreditation, involve assessments by trained external reviewers who benchmark the organization’s compliance with predefined standards, highlighting improvement areas and ensuring accountability.^[4]

Accreditation plays a crucial role in quality assurance within healthcare, signifying an organization’s commitment to stringent standards in patient care, safety, and organizational effectiveness. External peer reviewers provide an objective evaluation of practices against established benchmarks. However, quality assurance extends beyond accreditation, encompassing a range of internal and external measures such as staff training, risk management, and continuous process improvement. This holistic approach ensures that healthcare institutions consistently strive for excellence across all operational aspects, enhancing patient outcomes and overall institutional effectiveness.^[4]

Benefits of accreditation:

• Enhancing patient safety and quality of care: Accreditation guarantees that institutions adhere to stringent standards, reducing risks and supporting safe patient care practices.^[1,5]

• Improving public image and trust: Accreditation aids the public in recognizing a healthcare institution’s commitment to excellence, boosting public confidence in its services.^[1]

• Potential reimbursement advantages: Some payers and health insurance companies offer higher reimbursement rates to accredited institutions. Moreover, some insurance companies only allow reimbursement if the facility retains its accreditation.^[1]

This guide is divided into eight steps, each crucial for success. Figure 1 shows the integrated accreditation framework.

Choosing the appropriate accrediting body is a critical first step in preparing your healthcare institution for accreditation. When selecting an accrediting body, it is essential to consider various factors that align with the strategic direction and services provided by your institution:^[5]

• National law and regulation: Are there any specific accrediting bodies mandated by national laws for your institution? If not, ensure the selected accrediting body is authorized to operate within your country and is nationally recognized.

• Governance recommendations: Does your institution’s governing body have any preferences or directives, particularly in the context of international accreditations?^[5]

• Financial implications: How much are the fees for initial accreditation, reaccreditation, and preparation processes? Is there any potential financial impact on reimbursement rates?

• Scope of accreditation: Does the accrediting body offer accreditation programs that cover your institution’s scope and range of services (e.g., hospitals, ambulatory care, specific specialties)?

• Alignment with your mission and values: Does the focus of the accrediting body align with your institution’s mission, values, and philosophy?

Formulating the accreditation team(s), considering the size and complexity of your institution, you may need several structures to guide the preparation process. These structures may include an accreditation coordinator, an accreditation committee, a chapter leader/advisor (or chapter team), and champions. Develop a charter for each structure to define expectations, establish accountability measures, set objectives, promote transparency, and enhance engagement. Schedule regular meetings.^[6,7]

This individual acts as the central point of contact for all accreditation activities, overseeing communication, documentation, and timelines. The coordinator starts by reviewing the standards manual of the selected accrediting body. This review should cover accreditation prerequisites, eligibility criteria, survey visit application procedures, survey protocols, documentation requirements, and the process leading to certificate issuance.^[7]

This structure, composed of the accreditation coordinator and senior leaders from key institutional functions (e.g., medical, nursing, quality management), plays a crucial role in facilitating the accreditation process. This includes providing direction, sustaining momentum, and fostering leadership integration.^[6]

This individual is assigned to each accreditation chapter, supported by a team of champions. The leader and team members should possess expertise relevant to the content of their respective chapters. For example, in the Medication Management chapter/standards, the team leader can be a senior pharmacist, and team members should include hospital staff involved in the medication management process, including procurement, dispensing, and monitoring of adverse drug reactions.^[8] The team should study the relevant accreditation standards and specific performance criteria their institution must meet to achieve accreditation (e.g., patient-centeredness, medication management, infection control). This not only allows for understanding the required practices but also for identifying the gap between the current and the required practices^[5] (see next step).

A successful accreditation journey starts with understanding your institution’s strengths and weaknesses in relation to the standards. Gap analysis identifies what needs work to meet accreditation standards.

When performing the gap analysis, it is helpful to prepare an audit tool/checklist in which the accreditation coordinator and chapter leaders/champions teams provide a list of requirements based on the chosen accreditation standards. Each chapter leader/champions team should review their assigned part of the checklist. The team should review documents, observe performance, trace patient journeys, and conduct interviews with staff and patients to identify areas where compliance may be lacking or improvements are needed.^[7]

After this analysis, there will be a clear understanding of the necessary steps to achieve accreditation. The team can start by prioritizing the identified gaps based on their significance to accreditation readiness and patient safety, then developing a detailed action plan outlining specific steps to address each identified gap, including:

• Action items: specific tasks to be completed (e.g., creating a policy, implementing a new training program, purchasing a new fire alarm system, collecting data for performance indicators, etc.)

• Timelines: deadlines for achieving each action item.

• Responsible parties: individuals accountable for completing each action item.

Some items should be included in the action plan even if not identified in the gap analysis because of their critical impact on accreditation preparation processes. These include supporting the culture of safety, managing change, maintaining leadership commitment, and fostering staff engagement.

Staff involvement and buy-in are crucial for the successful accreditation of any healthcare institution. However, several barriers may hinder staff participation. These barriers include cultural factors (e.g., cultures that foster fear of admitting mistakes or prioritize physician autonomy over collaboration), training deficiencies (e.g., programs that do not consider adult learning styles or individual needs), and resource limitations (e.g., lack of trust in data or inadequate resources for staff to effectively complete their roles).^[8] To effectively address these barriers, consider the following strategies:

• Comprehensive training programs: Educate staff about the accreditation process, relevant standards, and their specific roles in the process.

• Open communication: Encourage an environment where staff feel comfortable raising concerns and suggestions for improvement and reporting potential noncompliance issues.

• Teamwork and collaboration: Encourage collaboration across departments to facilitate collective efforts toward achieving accreditation goals.

The involvement of institutional leaders is crucial for preparing healthcare institutions for accreditation. They oversee the entire process, ensuring staff awareness of accreditation standards and coordinating readiness activities. They allocate resources, lead internal assessments, and develop action plans to address deficiencies. During accreditation surveys, they facilitate communication with surveyors, provide documentation, and address concerns. Their leadership and commitment are essential for maintaining the high quality and safety standards necessary for accreditation.^[4]

Robust documentation is indispensable for successful accreditation. Maintain meticulously organized and readily accessible documents covering the required track record documentation. Gather strong evidence demonstrating your institution’s compliance with the standards (e.g., policies and procedures, clinical practice guidelines, meeting minutes, quality improvement data, patient experience surveys, performance indicator reports, hospital plans, risk registries, patient safety reports, and medication safety reports).^[4]

Conducting mock surveys that simulate the actual accreditation process proves invaluable for staff preparedness. These simulations allow staff to practice their responses, identify areas for further refinement, and build confidence before the actual survey. It is advisable to conduct a mock survey well before the actual survey (4-6 months) to allow enough time to address any issues identified.^[9]

On the survey day, remain professional and courteous when interacting with surveyors. Provide clear, honest, concise responses to their inquiries and readily share requested documentation. Remember, the survey is an opportunity to showcase your institution’s dedication to quality, continuous improvement, and unwavering commitment to delivering exceptional healthcare.^[10]

Getting your healthcare institution ready for accreditation takes a lot of planning, teamwork, and dedication from everyone involved. This guide helps healthcare professionals and leaders succeed in this process. By following these steps, from choosing the right accrediting body to doing well on the survey day, your institution can show its commitment to providing excellent patient care. This process also helps ensure your institution keeps improving and delivers top-notch healthcare.