A Guideline for Quality Accreditation in Hospitals

Leaders of quality assurance programs must be able to generate interest and commitment without burdening clinical and administrative staff with an activity they neither understand nor believe in.

Hospital accreditation has been defined as “A self-assessment and external peer assessment process used by healthcare organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve.” Hospital quality assurance systems are operational control systems intended to fulfill specific expectations for treating patients.

Importance of accreditation in hospitals

Accredited hospitals offer higher quality of care to their patients. Accreditation also provides a competitive advantage in the healthcare industry and strengthens community confidence in the quality and safety of care, treatment, and services. Overall it improves risk management and risk reduction and helps organize and strengthen patient safety efforts and creates a culture of patient safety. Not only does it enhance recruitment and staff education and development, it also assesses all aspects of management and provides education on good practices to improve business operations. International accreditation such as that from the Joint Commission International (JCI), a nonprofit organization that is part of The Joint Commission on Accreditation of Healthcare Organizations—aka JCAHO or The Joint Commission—and founded in the late 1990s to survey hospitals outside of the United States, creates a mark on the world map and increases business through medical tourism.

The accreditation process

Begin with accreditation process by education: Educate the leaders and the managers and explain the benefits, advantages, process, timeline, etc., of the accreditation

1. Baseline assessment: Use knowledgeable and credible evaluators (either internal or external consultants) who will critically and objectively assess each area and conduct a detailed baseline assessment of the organization’s current adherence to the standards and each measurable element. Score as “Met,” “Partially Met,” or “Not Met” and cite specific findings and recommendations. Also collect and analyze baseline quality data as required by the quality monitoring standards (e.g., medication errors, hospital-associated infection rates, antibiotic usage, surgical complications, etc.) Establish an ongoing monitoring system for data collection (e.g., monthly, with quarterly data analysis) to identify problem areas and track progress in improvement. Action planning: Using the findings of the baseline assessment, develop a detailed project plan starting first with priority areas of the core standards. Responsibilities, deliverables, and time frames should be assigned (e.g., revise informed consent policy, develop a new informed consent statement, educate staff in the next two-month time period).


2. Chapter assignment: Look for good people skills, time-management skills, and consensus-building skills, and assign oversight of each chapter of standards to a respected champion or leader who will identify team members from throughout the hospital and carry out the process. Policies and procedures: In addition to an overall project plan, it is often helpful to compile a list of all required policies and procedures that will need development and revision. Continue to monitor your progress in meeting the standards, such as through a mini-evaluation of each chapter at regular intervals (e.g., quarterly).


3. Final mock survey: Plan for a final “mock survey ” at least four to six months in advance of the target date of the actual accreditation survey. Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organization with a fresh and objective eye. Plan final revisions and corrections based on the findings of the final mock survey.