Accreditation Options: A Hospital CEO's Strategic Choice

The vast majority of hospitals seek voluntary accreditation, most through The Joint Commission and now, several hundred through the Healthcare Facilities Accreditation Program and Det Norske Veritas Healthcare using the National Integrated Accreditation for Healthcare Organizations standards. New to the accreditation scene is the Center for Improvement in Healthcare option, which tracks accreditation through standards and a survey process closely aligned with CMS' Conditions of Participation.  

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 a key element of their hospitals' strategies. This series of articles will explore some of the accreditation options available to hospitals  — including TJC, HFAP, DNVHC and CIHQ — paying particular 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 be explored.

When evaluating the desirability of accreditation by an individual regulatory body, CEOs should begin by asking several questions:

  • What are the options? What makes them beneficial?
  • What are the costs associated with accreditation by each regulatory body?
  • 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?

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.

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. CMS tracks "disparity rates" post validation survey and has found variance from 47 percent (TJC) to 27 percent (HFAP) for the different accreditation sources. A successful accreditation survey does not directly equate with CMS validation survey success. 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 elect to skip the costs (direct and indirect) of accreditation preparation.

So, choosing to pursue accreditation can be a very positive step for hospitals, but CEOs should consider carefully the relative benefits and costs of individual accreditation programs and the option of direct survey by the state department of health or appropriate CMS-contracted agency. The next installment of this series will start this discussion, exploring the merits of accreditation by the Healthcare Facilities Accreditation Program.

Kate Fenner has more than 30 years of experience in senior healthcare leadership roles in university, regional, state and national organizations. 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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