What are the most effective ways for hospitals to maintain accreditation?

1 Understand the requirements

The first step for any hospital seeking accreditation is to understand the specific requirements and expectations of the accrediting body. Different organizations may have different standards, processes, and timelines for accreditation. For example, The Joint Commission (TJC), one of the most recognized accrediting bodies in the US, evaluates hospitals on six domains: leadership, environment of care, infection prevention and control, medication management, provision of care, and performance improvement. Hospitals should familiarize themselves with the relevant standards and guidelines, and conduct a self-assessment to identify any gaps or areas of improvement.

2 Implement best practices

The next step for hospitals is to implement best practices that align with the accreditation standards and support quality improvement. Best practices may include policies, procedures, protocols, checklists, training, and education that ensure consistent and safe delivery of care. For instance, hospitals can adopt best practices for hand hygiene, surgical safety, medication reconciliation, patient identification, and infection prevention and control. Best practices should also be evidence-based, meaning they are supported by research and data.

4 Monitor and measure performance

To ensure that accreditation standards are met and maintained, hospitals need to monitor and measure their performance on a regular basis. This involves collecting and analyzing data on various indicators of quality and safety, such as patient outcomes, satisfaction, complaints, adverse events, infections, and readmissions. Hospitals should also use benchmarks and targets to compare their performance with other hospitals or national averages. Monitoring and measuring performance can help to identify strengths and weaknesses, track progress, and guide improvement actions.

5 Prepare for surveys

The final step for hospitals is to prepare for surveys, which are periodic evaluations conducted by the accrediting body to verify compliance with the standards. Surveys can be announced or unannounced, depending on the accrediting body and the type of accreditation. Hospitals should prepare for surveys by reviewing the standards and guidelines, conducting mock surveys, updating documentation and records, and training staff on how to interact with surveyors. Hospitals should also be ready to demonstrate their performance, improvement efforts, and best practices during the surveys.

Hospitals that follow these steps can increase their chances of achieving and sustaining accreditation, which can have positive impacts on their quality of care, patient satisfaction, and competitive advantage. Accreditation is not a one-time event, but a continuous process of improvement that requires ongoing commitment and collaboration from all levels of the hospital.