Industry Voices—Is your accreditor the right fit?

Healthcare organizations must make sure they choose the right accreditor to alleviate the burden of compliance and keep the focus on patient care.
Lawrence U. Haspel

The healthcare industry is highly regulated and evolving rapidly, presenting organizations with a seemingly endless list of moving targets to hit with regard to requirements and reporting. Many facilities opt to engage accrediting organizations to ensure they meet or exceed regulatory standards. 

But if accreditation is used solely to check the box of meeting state or federal requirements, the facility is missing an opportunity. The right accreditor provides resources and guidance to make facilities better in the short and long term. Therefore, which one you choose matters. You want to select an accreditor that suits the needs and culture of your organization to garner optimal outcomes.

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Here are a few key questions to consider when weighing your accreditation options.

Does the accreditor make its requirements clear and simple?

To align with federal regulations and industry guidelines, an accrediting body’s set of standards is often dense and can seem overwhelming. While the list is long, each individual standard is designed to help organizations meet benchmarks for quality and safety.

In order to make the most of an accreditation partnership, you must understand how the standards link directly to improvements in quality of care and patient safety, thus making sense to those who must implement them. You must know not only what is required to meet each standard, but also the intention and connection across standards to ensure full buy-in that supports ongoing improvements and long-term success.

All accrediting organizations with deeming authority from the Centers for Medicare & Medicaid Services will incorporate the CMS Conditions of Participation within their standards. Whether your facility finds added value in additional standards versus a lean approach that works as a framework for your own organizational and clinical expertise is worth considering when making your selection.

Those directly involved in achieving and maintaining accreditation must be comfortable with the accreditor, know how to access support at any point in the process, and feel confident in asking questions so as to properly lead teams and implement necessary change. This means the right accreditor will provide clear procedures, consistent evaluations, avoid additional burdens and offer zero surprises come survey time for organizations that have properly prepared.

Is the survey process balanced and collaborative?

The accreditation process is often applied in lieu of a state survey on behalf of CMS. It should be a positive, welcomed and educational experience.

Working with an accreditor, leaders of healthcare organizations must feel empowered with valuable information and insight to solve problems and implement strategies that boost outcomes and performance. From a leadership perspective, accreditation must help the organization achieve its maximum potential. To achieve this, the accreditation standards must address the requirements of regulators, but the approach to accreditation must acknowledge the unique needs of each facility.

The goal is to identify opportunities for learning, ongoing improvement of patient care, and maintenance of a safe, functional environment for patients, providers and others. All of these opportunities will vary based on the population served and the location of the facility. The right accreditor will be able to strike a balance between consistent standards and a personable, consultative approach that aligns with the facility’s culture, services, physical layout, and patient and staff needs.

Is the accreditor accessible for all inquiries?

The best way for healthcare organizations to stay compliant with ever-changing industry requirements is through knowledge. An accreditor’s role is to provide education and continuous support to guarantee an organization’s questions are answered throughout all stages of the accreditation process—before, during and after each survey.

And customer service means more than offering an automated call-in number with generic responses. The right accreditor provides educational resources: webinars, live education seminars or practice-sharing teleconferences, as well as individual access to knowledgeable experts.

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In addition, a healthcare organization’s accreditation status can be a differentiator within a competitive industry. The ideal accreditor will be available to provide ongoing, comprehensive guidance and services to meet a range of needs, such as certifications for specialties that distinguish facilities from their competitors.

For example, for hospitals that are able to provide treatment for stroke patients, the stroke center certification designation means the local EMS can transport the patient to the hospital knowing the patient will receive the specialized care necessary for quick assessment and treatment. A certification survey focuses on the hospital’s ability to provide the specialized service, and attaining certification lets the community know that the hospital is dedicated to meeting the community’s need.

Key takeaways

Leaders of healthcare organizations must feel they have an approachable partner in the accreditation process, one that meshes with the organization's culture and provides ongoing support for short- and long-term needs. The right accreditor will facilitate a cooperative and informative survey experience that offers a customized approach to improving quality of care and patient safety.

The healthcare industry can be complicated and wrought with challenges, but accreditation doesn’t have to be. Get to know an accreditor and make sure it is the right fit to alleviate the burden of compliance and keep the focus on patient care.

Lawrence U. Haspel, D.O., FACC, is an invasive/interventional cardiologist who currently serves as chairman of the Healthcare Facilities Accreditation Program (HFAP) Bureau of Health Facilities Accreditation. Dr. Haspel is a past chair of the Illinois Hospital Association, former board member of the Franciscan Alliance, and past president of ACOI (Internal Medicine Specialty Society).