By Roy Garmin Chew / Special to Healthcare Facilities Today

The true value of accreditation is not realized when preparing for a survey. Working with the right accrediting organization, the framework of standards and process can offer significant opportunity to build an organizational culture that supports performance and innovation far beyond the survey event. Here are three ongoing benefits of accreditation healthcare organizations should learn to use to their advantage:

Education

While accreditors commonly conduct an onsite survey, some accreditors work to ensure the experience is more than just evaluative, offering an educational benefit as well. These surveyors will dedicate time to teaching healthcare staff why the requirement is in place and why it is important to patient care. Healthcare staff will learn different ways to move good practice to best practice, as well as possible solutions to address any deficiencies that arise during a survey.

In addition, some accreditation organizations design educational tools and events to help facilities prepare for and maintain accreditation, and carry on these practices in between surveys. For example, when new standard requirements are introduced, some accreditors will develop focused webinars and highlight new topics in face-to-face events led by industry experts. These valuable resources break down requirements, answer questions about why and how, and guide development of policies and procedures to ingrain best practices into everyday activities.

Collaboration

At its core, accreditation is an assessment of an entire organization – from its governance structure and how it manages outside contractors to how it establishes clinical protocols and maintains its buildings. Preparing for and maintaining accreditation is a team effort, calling on all departments to work together with clear, consistent communication to meet standards requirements.

Facility engineering teams, for example, are a key component to any accreditation survey prep, but are generally not involved in day-to-day clinical activities. Adopting strategies that involve multiple departments, such as regular clinical/engineering rounding, will ensure seamless collaboration when the next accreditation survey team arrives, while continuously reinforcing cross-functional communications. Establishing a culture of teamwork focused on patient safety and continuous improvement embeds the best practices of accreditation into daily policies and procedures, continually improving the quality of care and overall efficiency.

This collaboration is further extended when surveyors arrive with a mindset of driving excellence within a unique organization. Surveyors then become key members of the team, providing fresh eyes on what is being accomplished and where improvements are needed within a non-confrontational, collaborative review.

Ongoing quality improvement

Accreditation surveys stick to a tight, predictable schedule, taking place every two years for laboratories and every three years for most other facility types. This frequency and regularity ensure healthcare organizations are aware of the latest updates in requirements and are providing continuous training to their teams. Quality improvement programs that are broadly conceived, touch every department in the organization, data-driven to establish evidence-based criteria for change and fully communicated throughout the facility ensure teams are testing and strengthening the culture of safety. 

For teams that use the accreditation cycle this way, continuous improvement becomes second nature, while the time and resources needed to assess and adjust to maintain compliance are reduced. The more frequently organizations are thinking about accreditation, the easier it is to integrate the standards into everyday activities and decision-making. Continuous, small course corrections are easier than major overhauls when a survey is approaching.

Organizations that work through their state agencies may wait years between surveys, depending on the resources of the individual state. In the ever-changing healthcare landscape, significant regulatory updates can occur frequently, often calling on organizations to demonstrate their compliance in new, challenging ways. Ongoing access to accreditation resources, experts and education, helps organizations adjust to regulatory changes more smoothly and efficiently.

By achieving and using accreditation fully, organizations can gain the trust and confidence of individual physicians and allied professionals, while confirming their quality of care and organizational integrity to payers and affiliates within the continuum of care. When working with an accreditor, a healthcare organization should leverage the access to educational resources, a collaborative evaluation and ongoing support to nurture a positive culture of safety and efficiency. In doing so, an organization will learn the true, enduring value of accreditation that carries on well beyond the survey.

Roy Garmin Chew, PhD, is the president of the Kettering Health Network, a not-for-profit network of eight hospitals. Since 2011, Kettering Health Network has aligned all its facilities under HFAP accreditation.