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Healthcare Accreditation

Healthcare Accreditation

In the United States, there are numerous accreditation bodies and programs. These organizations are in charge of hospitals, schools, and universities. “Peer review is used in the licensure and accreditation processes of federal and state regulations, insurance companies, and volunteer organizations” (Kavaler & Alexander, 2014, p. 286).

Accreditation for healthcare organizations provides the following benefits: it aids in the identification of organizational strengths and weaknesses, it promotes transparency, it improves management processes, it stimulates quality improvement performance management, it increases accountability to community members, stakeholders, and policymakers, and it makes the organization more competitive in funding opportunities (Benefits & Impacts of Accreditation, 2020).

This author’s choice of organization will remain anonymous. Because this author has a family member who works for this organization, it will not be identified. The Joint Commission on Accreditation of Healthcare Organizations (JHACO) and the Healthcare Facilities Accreditation Program both accredit this organization (HFAP).

The Joint Commission on Accreditation of Healthcare Organizations accredits healthcare organizations using a multifaceted approach that includes an onsite evaluation designed to assess organizational compliance with their standards and verifies successful improvement activities when noncompliance is identified (Home, 2020, para. 3). This accreditation is not required, but it is one option mandated by the Centers for Medicare and Medicaid Services (CMS) that a healthcare organization may pursue to make the path to receiving Medicare reimbursement more seamless.

The Healthcare Facilities Accreditation Program (HFAP) is a non-profit organization whose mission and goal is to assist healthcare organizations in developing and maintaining high patient care standards, as well as complying with constantly evolving government regulations, as well as the churning and changes in the healthcare environment currently deeming authority from the Centers for Medicare and Medicaid Services (CMS) (Meldi et al., 2016).

Accreditation is important to patients because it ensures that the healthcare organization they are using to diagnose, treat, and improve their healthcare status is held to the highest level of oversight and compliance with research-based, evidence-based practice guidelines. The community benefits from having healthcare available to its residents that is capable and competent in improving each resident’s health and well-being. The organization benefits from being in a constant state of the process and care provision improvement, as well as having resources and governing bodies that provide oversight that identifies fallouts and action plans to correct the breach.

The accrediting body defines the organization’s accreditation requirements, which are tailored to the standards of the specific accrediting body. Organizational financial investment is required to maintain accreditation, not only in bringing the organization up to standard if there are breaches but also in administrative and staff buy-in.

The initial accreditation process includes a site visit to determine the facility’s “status quo.” Accrediting body violations are identified, and an opportunity is provided to correct the variables that resulted in the violations. During this time, the organization develops an action plan, which it uses to correct the factors identified in the violation, and then the accrediting body follows up with another site visit to confirm the violations are no longer present (Benefits & Impacts of Accreditation 2020).

Reaccreditation follows the same procedures and takes place at different time intervals: a site visit during which violations or breaches are identified, followed by the time allotted to develop and implement an action plan, and finally, a revisit to confirm compliance.

The Agency for Healthcare Administration (AHCA) and the Florida Department of Health both have licenses for this organization.

The Agency for Healthcare Administration works to ensure that healthcare facilities meet the safety and quality standards established by state and federal regulations (Licensure Requirements, 2020). Organizations that provide inpatient services must submit data to an agency-approved database about their facility’s emergency planning, preparation, and operations (Licensure Requirements, 2020).

The Florida Department of Health “is responsible for the regulation of health care practitioners in order to preserve the public’s health, safety, and welfare” (Licensing and Regulation, 2020, para. 1). It is in charge of hospitals and other healthcare facilities, as well as nail salons and other entities involved in public safety.

If the organization’s license is revoked, it may be forced to close. If a hospital fails to comply with state laws and regulations, an opportunity to bring the organization into compliance exists. This is determined by the gravity of the offense. Individual healthcare providers’ privileges are suspended for noncompliance with licensure requirements, which can result in the loss of their license.


(2020). The Joint Commission. Retrieved October 25, 2020, from https://www.jointcommissiononaccreditationofhealthcareorganizations

Benefits & Impacts of Accreditation. (2020). Centers for Disease Control and Prevention. Retrieved October 25, 2020, from

Home. (2020). The Joint Commission. Retrieved October 25, 2020, from

Jha, A. K. (2018). Accreditation, quality, and making hospital care better. JAMA, 320(23), 2410. Retrieved October 25, 2020, from

Kavaler, F., & Alexander, R. S. (2014). Risk management in healthcare institutions: Limiting liability and enhancing care (3rd ed.). Jones & Bartlett Learning.

Licensing and regulation. (2020). The Florida Department of Health. Retrieved October 25, 2020, from

Licensure Requirements. (2020). Agency for Healthcare Administration. Retrieved October 25, 2020, from

Meldi, D., Rhoades, F., & Gippe, A. (2016). The big three: A side-by-side matrix comparing hospital accrediting agencies [Editorial]. National Association Medical Staff Services, 137–155. Retrieved October 25, 2020, from


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Practice – Healthcare Accreditation

Healthcare systems and patients benefit from accreditation standards. Many accrediting bodies are represented in various practice settings. This activity is designed to expose you to some of the major aspects of accreditation and see how it affects quality and safety.

Healthcare Accreditation

Healthcare Accreditation

Explore The Joint Commission and the Commission on Accreditation of Rehabilitation Facilities (CARF) sites to understand what standards these accreditors require participants to meet. Consider:

  • History and original purpose for creation
  • The purpose for existence now—how has it evolved?
  • Where the requirements for each agency are publicly reported
  • Why public reporting of metrics is important
  • How each body operates

Although we focused on CARF and The Joint Commission in this activity, there are many other accrediting bodies to consider:

  • Accreditation Association for Ambulatory Health Care (AAAHC)
  • Accreditation Commission for Health Care, Inc. (ACHC)
  • American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
  • American Osteopathic Association Healthcare Facilities Accreditation Program (AOA/HFAP)
  • Center for Improvement in Healthcare Quality (CIHQ)
  • Community Health Accreditation Program (CHAP)
  • Det Norske Veritas Healthcare (DNV Healthcare)

Review the prompts above and summarize your notes in 525 words for future reference

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