Hospital Accreditation: It’s a Process, Not an Exam

The widespread practice of “polishing up” before accreditation surveys and using accreditation mainly as a marketing strategy devalue the accreditation process and ultimately undermine the trust of patients and their families.

Hospital accreditation is “a formal process by which a recognized body, usually a non-governmental organization (NGO), assesses and recognizes that a healthcare organization meets applicable pre-determined and published standards. Accreditation standards are regarded as optimal and achievable, and are designed to encourage continuous improvement efforts within accredited organizations. An accreditation decision about a specific health care organization is made following a periodic on-site evaluation by a team of peer reviewers, typically conducted every two to three years.”1

Continuous Improvement

Unlike licensure, which requires compliance with minimal standards, the focus of accreditation is continuous improvement and achievement of optimal quality standards. Failure to understand this aspect of accreditation may lead to:

  • Misguided approaches to achieving – and maintaining – accredited status; and
  • Misconceptions among the lay public, in part due to “marketese” put forward by hospitals and other interested parties.

A Continual Process

Although accrediting bodies conduct periodic on-site surveys, the accreditation process is a continual one, in which accredited hospitals are expected to adhere to the pre-defined standards and to make incremental improvements. Therefore, a hospital which has not yet been accredited may be justifiably proud of achieving accredited status. On the other hand, a previously accredited hospital may prepare for the next on-site survey, but it cannot “embark on another accreditation” by the same accrediting body. More than poor use of the English language, the latter reflects the erroneous and somewhat worrying approach that some hospitals take toward accreditation: to them, accreditation is akin to an exam, to be sat at the end of each accreditation cycle, with little done between the “exams.” These hospitals tend to use accreditation more as a marketing tool than for its original purpose, i.e. to improve the quality and safety of healthcare.

Unannounced Surveys

To overcome “exam mentality” and to improve care for the next patient (instead of the next survey), The Joint Commission (USA) started conducting regular resurveys on an unannounced basis in its domestic (US-based) accreditation programs in 2006.2 Like surprise exams, these unannounced surveys help to keep healthcare organizations in continual compliance, i.e. on their toes. Not surprisingly, Joint Commission International (JCI), a subsidiary of The Joint Commission, has considered introducing unannounced surveys to the international hospital accreditation program. Despite opposition from some quarters (also hardly surprising), it appears that unannounced resurveys for the international program is not a matter of if but a matter of time. Like it or not, the traditional window dressing by hospitals just prior to scheduled surveys will likely be a thing of the past.

Return on Investment

Accreditation is a quality improvement tool, not an end to itself. Therefore, unless the use of this tool brings favorable clinical and/or operational results, its utility for marketing purposes is limited (but probably not its use for marketing exercises by hospitals). The true value of accreditation lies in its potential to improve the quality and safety of care provided to the patient. For instance, Changi General Hospital, a 797-bed public hospital in Singapore that achieved JCI accreditation in 2005, experienced a decrease in its needlestick injury and hospital-acquired infection rates and lowered their medico-legal and insurance costs as a result of the accreditation journey.3 With results such as these, the hospital and its patients can then see a real return on their investments in the accreditation process – financial costs (which can be substantial), and staff time and effort. Having achieved excellent clinical outcomes, hospitals would also have a far easier time attracting new patients.


Accreditation is a recognized methodology for improving the quality and safety of healthcare delivery. Whilst efforts should be made to instill confidence of patients in their healthcare providers (through accreditation or otherwise), the widespread practice of “polishing up” before surveys and the use of accreditation mainly as a marketing strategy devalue the accreditation process and ultimately undermine the trust of patients and their families.

Contact Teh & Associates today and learn how we can help your organization achieve accreditation in half the time others take and with less resources.


  1. Rooney A.L., vanOstenberg P.R. Licensure, accreditation, and certification: approaches to health services quality. Center for Human Services (CHS), 1999.

  2. The Joint Commission. Facts about the unannounced survey process. 1 May 2010. [PDF – 24 KB]

  3. Changi General Hospital, Singapore, Joint Commission International Practicum, June 2006, Singapore.

  4. Organizations Do Not Need to Prepare for Their Next Survey; They Need to Prepare for Their Next Patient. The Fact on Fiction, The Joint Commission Perspectives February 2005, Volume 25, Issue 2. [PDF – 195 KB]