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Supervised by: Dr- Fatmah Baddar
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Health Care Service Accreditation
Accreditation
Accreditation is the process of
assessing health institutions against a
commonly accepted set of standards.
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Why Accreditation?
The purpose of accreditation is to ensure and improve quality of health services. The main issue with accreditation is to ensure those providers, both institutions such as hospitals and health centers, and care givers, such as physicians and nurses, provide good quality care.
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Why Accreditation?
So accreditation is an
educational and evaluative
process Through Which, health
providers learn in an objective
manner how they can improve
quality.
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Accreditation Certificate
The accreditation certificate is a
symbol that an organization is
committed to providing high-quality
health care
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Benefits of Accreditation
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• Encourages professionals to continuously seek to improve
quality despite resource limitations
• Provides sustained management of field reviewers, supervision and
ongoing education of surveyors, etc.)
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Benefits of Accreditation
• Ensures a fair, valid, and credible
evaluation process
• Establishes an accreditation
database of information to
determine compliance, pinpoint
problem areas, or highlight
opportunities for improvement
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Accrediting Organizations
There are different accrediting organizations The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO)
has been accrediting hospitals for more than
40 years. Accreditation by the JCAHO is
recognized nationwide as a "seal of approval"
which indicates that a hospital meets certain
performance standards
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Achieving accreditation means that an
organization substantially complies with JCAHO
standards and continuously makes efforts to
improve the care and services it provides.
About JCAHO Accreditation
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An overview of JCAHO Accreditation steps
1. Submit an application for initial
accreditation or re-accreditation.
2. Determine a site visit date.
3. Submit a self-study report.
4. Form an Evaluation Team and
determine logistics of site visit.
5. Conduct an Accreditation Site Visit.
6. Conduct an accreditation surveys
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About JCAHO Accreditation
During an accreditation survey, specially trained
JCAHO surveyors evaluate the level of an
organization’s compliance to JCAHO standards
and identify the organization’s strengths and
weaknesses.
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About JCAHO AccreditationAccreditation surveys result in performance reports, which can be utilized by consumers and health care organizations to ascertain the performance of a given health care organization . The report lists:
• The accreditation status • The date of the survey • An evaluation of key areas reviewed during the accreditation survey •The results of any follow-up activity • Areas needing improvement
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About JCAHO AccreditationAccreditation Duration:-
The time period (three-year) during
which a health care organization,
found to be in compliance with
Joint Commission standards, is
awarded accreditation. To maintain
accreditation for a three-year or
two-year period, satisfactory
resolution of any identified issues is
required
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Benefits of Joint Commission accreditation and certification
• Strengthens community confidence in the quality and safety of care, treatment and services
•Provides a competitive edge in the marketplace
•Improves risk management and risk reduction
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Benefits of Joint Commission accreditation and certification
• Provides education on good practices to
improve business operations
•Provides professional advice and counsel,
enhancing staff education
• Enhances staff recruitment and
development
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Maintaining Accreditation
• Accredited organizations are required to
maintain their operations in compliance
with current Accreditation Association
standards.
• In order to avoid a lapse in accreditation
status, organizations must undergo full,
regular surveys at least once every three
years.
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Maintaining Accreditation
• The Accreditation Association notifies
health organizations a minimum of six
months prior to the expiration of their
current term of accreditation.
• Re-accreditation surveys must occur
within two months of the expiration date.
Therefore it is required that all
documentation be submitted to the
Accreditation Association at least five
months prior to expiration dates.
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Maintaining Accreditation• Accredited organizations must notify the
Accreditation Association in writing within
30 days of any significant organizational,
operational, or financial changes. An
organization's duty to provide this
information continues during the entire
accreditation process. Failure to notify
the Accreditation Association may result
in an immediate revocation of
accreditation, or reduction in the term of
accreditation.