Accreditation: What Boards Need to Know

Voluntary accreditation is considered to be an important symbol of a hospital’s commitment to high-quality, safe care. Some consumers look for accreditation when choosing a hospital. Many health care professionals believe it is an important indicator of the commitment to quality and safety they are looking for when choosing a place to practice. For some types of health care facilities, accreditation provides a competitive advantage in attracting talented staff and patients. For hospitals it is more of an expectation than a distinction, with more than 80 percent of hospitals receiving voluntary accreditation from one of four recognized accrediting organizations: The Joint Commission, Healthcare Facilities Accreditation Program (HFAP), Det Norske Veritas (DNV), and Center for Improvement in Healthcare Quality (CIHQ).

Accreditation is one of the paths hospitals can take to be declared in compliance with the Medicare Conditions of Participation (CoPs). Compliance with the CoPs is a prerequisite for payment from the Medicare and Medicaid programs, which on average constitute nearly 60% of hospital costs.1 Some payers also require accreditation or accept it as fulfillment of their contractual requirements around quality.

For boards and others overseeing health care delivery organizations, voluntary accreditation can provide assurance that the hospital is in compliance with current standards and regulations. It also provides a source of information about areas where additional attention or investment of resources may further enhance the safety and quality of care. As part of their oversight responsibilities for compliance and care quality and safety and to fulfill their role as effective stewards of hospital resources, boards should understand the range of organizations that oversee hospital performance. Regular reports at designated committees and the full board can help trustees ensure their hospitals are meeting applicable legislative and regulatory requirements and standards and are receiving appropriate payment for the services they provide.

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