Accreditation: A hospital CEO’s strategic choice

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This is part 1 of an 8 part series on Hospital Accreditation Options. It was previously published in Becker’s Hospital Review. Compass Clinical Consultinghas updated the content to reflect changes in the Accreditation Options since the previous publication.

The clear majority of hospitals seek voluntary accreditation, most through The Joint Commission (TJC) and now, several hundred through the Healthcare Facilities Accreditation Program (HFAP) and DNV GL - Healthcare (DNV GL) using the National Integrated Accreditation for Healthcare Organizations (NIAHO®) standards. A newer option in the accreditation scene is the Center for Improvement in Healthcare Quality (CIHQ), which tracks accreditation through standards and a survey process closely aligned with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs).

This decision—to maintain accredited status with one particular source—is rarely questioned, much less examined from a strategic perspective.

But perhaps it is time for hospital leaders to evaluate the decision to pursue accreditation and view it as an essential element of their hospitals’ strategies.

This series of articles explores some of the accreditation options available to hospitals—including TJC, HFAP, DNV GL, and CIHQ—paying close attention to the philosophies of different accrediting bodies, as well as the implications, costs, and benefits associated with them. Additionally, the rarely utilized but also practical approach of using the state department of health inspection as a route to CMS approval will also be explored.

Accreditation Options: Questions to Ask
When evaluating the desirability of accreditation by an individual regulatory body, CEOs should ask several important questions:

• What are the options? What makes them beneficial?
• What are the direct costs associated with accreditation by each regulatory body?
• What are the costs for institutional support, such as additional or altered data capture/analysis, technical personnel, training, or IT system changes?
• What happens if we choose to use an alternative external accrediting source? Is our Medicare/Medicaid status endangered?
• How will our daily operations be impacted by pursuing accreditation by different regulatory bodies? Will we lose a competitive advantage?
• Are there managed care, insurance, or bond underwriter requirements for accreditation or state approval that must be weighed in decision-making?

Deemed status
The most expedient reason for selecting any accreditation process is the regulatory body’s deemed status. When a regulator achieves deemed status, this signifies that CMS has recognized the accrediting process of the organization as addressing the requirements of the CMS CoPs. Consequently, a regulator’s deemed status provides assurance that successfully completing the process of that regulator is equivalent to achieving compliance with the CoPs of CMS.

However, through contracts with each state’s department of health or the equivalent, CMS conducts periodic validation surveys following accreditation by another regulating body to assure that compliance with CoPs has, in fact, been achieved. It should be noted that success on an accreditation survey does not necessarily equate to automatic success on a follow-up validation survey. But achieving accreditation may better prepare hospitals for the CMS survey, should it occur. Alternatively, hospitals can prepare for state or CMS scrutiny by evaluating compliance with the individual CoPs directly and skipping the costs (direct and indirect) of accreditation preparation.

So, choosing to pursue accreditation with an organization with deemed status can be a very positive step for hospitals, but CEOs should carefully consider the relative benefits and costs of individual accreditation programs and the option of a direct survey by the state department of health or the appropriate CMS-contracted agency.

In the next installment of this series, we explore the merits of accreditation by the Healthcare Facilities Accreditation Program.


Kate Fenner, PhD, RN understands hospital leadership. First as a nurse, and later as an education leader and consultant, Kate has immersed herself in the regulatory and operational issues that face today’s healthcare organization for more than 35 years. Throughout her career, she has worked with and presented to hospitals on a variety of regulatory topics including performance improvement, leadership standards, human resources management, root cause analysis, and board involvement in quality. In addition, she has led and participated in dozens of mock surveys to help healthcare organizations meet the standards and expectations of regulatory bodies such as The Joint Commission, CMS, and state departments of health.

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