Accreditation; The Whole Nine Yards

1) Gain a knowledge about Accreditation

What does the accreditation mean?

To healthcare institution, governing board, leadership, and staff. The resources and effort needed, in addition to stakeholder resistant.

Try to communicate with others who have gone through the accreditation process.

2) Select your accreditation scheme

It depends on your hospital need; some countries mandate a national accreditation or give an advantage of an international one.

Healthcare providers may feel a specific accreditation scheme fulfills their requirements and helps them more to improve their services, easy to be implemented and related to their culture.

3) Interpret the Standards

Learn the standards language to interpret them correctly, pick up a standards manual and read it; understand the requirement of each standard, care about each detail and how to comply with it.

Assign someone or group that can answer questions may be raised by staff in relation to the implementation of standards.

4) Be familiar with the survey process

Understand the survey process, what is the required evidence will be checked for each standard, and how? e,g. through document review, staff interview or observation.

Learn about the scoring process of each standard and the whole score required to be accredited; are all standards have the same weight or some have a priority.

5) Do a Self Assessment

Learn how to score standards, read the survey guide for Agenda, scoring, steps and learn how to take the proper attitude and ask the suitable questions to collect data related to standards. 

Learn about the methodology used in the assessment of each chapter and activity.

  • Focus on the requirements of each standard.
  • Identify existing examples of evidence.
  • Identify areas of partial or no compliance with standards.

Document your self-assessment finding with score. 

6) Formulate an Action Plan

Based on self assessment, formulate an action plan to fulfill the gap between your assessment and the standards requirements.

Specify who is responsible, target date, methodology for follow up and evaluation.

Start with preparation of documents required, as the surveyors firstly will be looking at the overall system of your organization, programs and plans through reviewing your documents.

You might go through documents checklist to make sure you have all.

Incorporate standards into day-to-day work by educating the staff on the standards and how to meet them.

7) Prepare for Surveyors visit

It’s important to facilitate surveyors mission and make everything as easy as possible for them.

Surveyors like  to maintain the proper boundaries of  relationship between them and the organization, so please keep it also the same.

Surveyors usually  arrive early in the morning, be sure the receptionist is prepared to deal with them. Some times they want to look for the patient rights or the patient education in the hospital reception .


8) Frequent walk-rounds, Care about Cleaning

Before the survey visit, It’s essential to increase leadership walk rounds. Focus on intensive cleaning on the visit day, maintain the environment, do inspections and fix any defects immediately. 

For example: Expired medications, outdated food must be disposed of even surfaces with daily use should be tidy and clean. 

9) Planning for a successful survey visit

  • Initiate a survey management team and office for readiness of any contingency.
  • Assign responsibilities for every activity of the survey agenda.
  • Showpieces of evidence of compliance with standards.
  • Train the staff of the survey attitude and the best way to deal with surveyor questions.
  • Inform patients about the visit and possible questions so they will know what to expect.
  • Keep at least a year’s track record of evidence or according to accreditation scheme requirements.
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Dr. Khalid Abulmajd

Healthcare Quality Consultant

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