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.