Question

What is meant by accrediation and how is it earned? Provide any instances when an accredited health care organization lost it's accreditation.

Answer 1

Accreditation has been defined as “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve”.

Accreditation entities, regulatory bodies, and professional associations serve important roles in the setting standards, regulating healthcare, enforcing compliance, and evaluating healthcare organizations. One of the ways these agencies evaluate health care organisations is by collecting and analyzing data. These agencies include the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA), the American Medical Accreditation Program (AMAP), the American Accreditation HealthCare Commission/Utilization Review Accreditation Commission (AAHC/URAC), and the Accreditation Association for Ambulatory HealthCare (AAAHC). In addition, the Foundation for Accountability (FACCT) and the Agency for Healthcare Research and Quality (AHRQ) play important roles in ensuring the quality of healthcare. Each of the accrediting bodies develops their own accreditation process and programs and sets their own accreditation standards.

Accreditation can be earned by submitting an application to the agency followed by which on site survey is carried out by the agency. For instance, Joint commission requires that for hospitals new to the accreditation process or undergoing an initial survey, surveyors must be able to review records equal to 10% of the average daily census but not fewer than 30 inpatient records, or for small hospitals not fewer than 20 inpatient records. Based on the survey findings and the compliance of the health care organisation to the standards of quality as required by the agency, the accreditation is awarded.

Accredited health care organisations can lose their accreditation for failure to comply to the standards. For instance, in 2008, an Anaheim hospital that treats a large share of poor patients in the region had lost national accreditation for inadequate staffing and poor medical care.

In 2013, the Joint Commission issued a denial of accreditation for Rawson-Neal Psychiatric Hospital in Las Vegas, citing multiple violations of quality care standards, many related to patient safety.

In 2016, Virginia Mason Medical Center in Seattle was denied accreditation by the Joint Commission after a surprise review revealed noncompliance with 29 standards. The accreditation announcement follows news of a possible hepatitis B exposure at the hospital affecting nearly 650 patients.