Augusta Health

Will Roden

The Joint Commission (TJC), Det Norske Veritas (DNV), National Committee for Quality Assurance (NCQA), or the Accreditation Commission for Health Care (ACHC) is on-site” are words spoken in whispers at healthcare organizations around the country.

Why?

It is often because organizations, leaders, or staff do not fully understand the mission of these organizations, nor do they appreciate the immense benefits that accreditation by one of these organizations brings to the facility in question. So why does accreditation matter anyway?

To better understand why accreditation matters, you must understand how the accreditation process works and why organizations invest the time, effort, and resources into meeting accreditation standards. The benefit of accreditation varies for each institution based upon that organization’s ethos, but specific benefits include:

• National recognition by insurance companies and third parties, which may be a condition of reimbursement, as well as possible deemed status by Medicare

• Demonstrated commitment to excellence in quality, accountability, and patient safety

• Competitive advantage over other organizations in a robust healthcare market

• Improves risk management and risk reduction in the organization

• Provides standardization and consistency for processes across the organization

• Supports continuous improvement efforts

"The Bottom Line Is That Accreditation Improves Care By Setting Standards, Increasing Operational Efficiencies And Fiscal Outcomes, And Reducing Organizational Risk, Thereby Providing A Sound Foundation For Quality Improvement And Driving Better Patient Outcomes"

As you can see, the benefits of accreditation can have a real-world impact on the organisation’s reputational, fiscal, and operational aspects. So, what is the accreditation process, and how can I explain it to someone who hasn’t participated in a site visit in their career?

To start, accreditation agencies define standards encompassing a wide range of organizational operations, from safety to documentation or facility maintenance to national patient safety goals. Those standards are typically considered best practices and are often gleaned from professional organizations throughout the country and guidance from third parties such as CMS. The accrediting agencies then share those standards with the participating institutions, who review the standards, modify policy and practice to align with those documented best practices, and then present that data to the accrediting agency during a site visit or subsequent follow-up visits if deviations are found.

So, how do you get this information down to your team so that they better understand the importance of accreditation? Leaders throughout the organization must take the time to educate and coach staff on the importance of any given standard as well as the underlying reasoning for compliance. Once a standard has been trained, the leader must empower staff to adhere to and enforce the standard so that the organization remains compliant.

Failure to maintain can lead to deviations, which may ultimately affect accreditation or lead to a vicious cycle of continually ramping up to meet standards, only to have gaps between accreditation cycles due to ineffective maintenance of standards.

The bottom line is that accreditation improves care by setting standards, increasing operational efficiencies and fiscal outcomes, and reducing organizational risk, thereby providing a sound foundation for quality improvement and driving better patient outcomes.