by Jodi L. Eisenberg
MHA, CPHQ, CPMSM, CSHA, Senior Director, Accreditation Education Programs


Jugglers always amaze and impress me. Someone who can juggle mismatched items is even more impressive—balls, fruit, bowling pins, for example. In order to keep everything in the air, their focus must be keen.

As a hospital accreditation professional, I see jugglers every day. They are the clinicians who attend to the needs of patients while simultaneously adhering to clinical protocols and remaining mindful of hospital policy. They are amazing, but if they lose focus and something drops, the consequences can be catastrophic.

Wouldn’t it be great to have a structure in place that reduces the increased anxiety level of clinicians during accreditation survey windows to help them narrow their focus to patient care … for every patient, every day?

Here are the top recommendations from Vizient’s accreditation team for creating a structure that reduces staff anxiety and assures compliance with regulations and accreditation standards:

  1. Start with education. Explain the requirements, process, timelines and benefits of accreditation to all levels of the organization. Also, use data to demonstrate the link between regulatory compliance, accreditation and the quality of care patients receive.
  2. Engage leadership. Executive-level leadership, as well as front-line managerial staff must actively support compliance standards and the accreditation process.
  3. Establish an ongoing monitoring system for data collection. Data should be collected monthly with quarterly data analysis by knowledgeable and credible evaluators (either internal staff or external consultants) who can make recommendations for process improvement.
  4. Focus on the core. Prioritize process improvements in areas that are directly related to the core accreditation measures:
       - Patient care
       - Access to care and continuity of care
       - Patient and family rights and education
       - Assessment of patients
       - Management of medication
  5. Be careful not to ‘over-interpret.’  When uncertain how to operationalize a standard or regulation, consider what is best for the patient. This approach will keep patient safety and quality at the forefront of the discussion.
  6. Utilize sources of truth to stay current. Establish a routine for monitoring accreditation standards and utilize credible resources such as Centers for Medicare & Medicaid Services and your voluntary accreditation organizations like The Joint CommissionHealthcare Facilities Education ProgramDNV and the Center for Improvement in Healthcare Quality for information.
  7. Conduct mock surveys. Plan a mock survey at least six to eight months in advance of the target date of the actual accreditation survey. Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organization with a fresh and objective eye. Plan final revisions and corrections based on the findings of the mock survey.

Hospital accreditation programs are important because they establish the operational controls and oversight necessary to meet quality assurance expectations and measures for treating patients. Staff anxiety around these programs can greatly diminish the visible commitment of administrative, physician and nurse leaders. Using the tips above will further help clinicians see accreditation standards as a framework for process improvements instead of just another challenge to juggle as they strive to deliver quality patient care.

About the author. In her role as senior director of accreditation education programs, Jodi leads efforts to help member hospitals develop their continuous patient readiness process, improve their accreditation knowledge, solutions and strategies; and ultimately ensure a focus on quality and patient safety. She has served as faculty for a variety of educational programs and has authored several articles and books related to accreditation and continuous readiness.

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Published: March 16, 2016