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Accreditation is a formal process by which a recognized body—either governmental or nongovernmental—assesses and recognizes that a health care organization meets pre-established performance standards. Accreditation standards are usually regarded as optimal yet achievable and are designed to encourage continuous improvement efforts within accredited organizations.

The standards used to assess performance for accreditation are commonly developed by expert committees working with the accrediting body and revised periodically to reflect advances in technology, treatment regimes or policy changes. Standards and criteria for accreditation are generally developed through consensus among stakeholders, such as medical associations, Ministries of Health, and nongovernmental organizations. Accreditation programs are generally funded through survey fees, member fees, publications, educational programs, grants, consulting fees, and government support.

Evaluation for accreditation is performed by a group of surveyors that carry out a variety of assessment techniques, such as a review of documents and records, interviews, observation, inspections of the facility, and evaluation of achievements. Based on the results of this thorough evaluation, the survey team recommends whether or not the facility should be accredited or should implement further improvements and be re-evaluated in the future. Renewal of accreditation status is usually required every two to three years.

Accreditation has attracted great interest in recent years as a comprehensive approach for improving and maintaining health care quality. The key difference between accreditation and other forms of quality regulation is that by focusing on optimal or desirable, rather than minimum standards of care, accreditation has a strong performance improvement orientation, stimulating health care organizations to pursue increasingly higher levels of quality beyond the minimum needed for licensing. Another difference is that accreditation has traditionally been a voluntary process in which organizations choose to participate, rather than one required by government regulations; more recently, however, some countries have made participation of health care organizations in accreditation programs compulsory. Other countries, such as the United States, have tied accreditation systems to financing mechanisms, thereby creating a strong incentive to achieve and maintain accredited status. Another incentive to participate in accreditation programs is public demand for accredited services as a result of the dissemination of accreditation results. Sharing accreditation results helps a health care facility gain recognition for its accomplishments and be recognized by the community as a quality institution.

While health care accreditation programs originated in the United States and Canada in the 1950s, their spread to other developed and developing countries has occurred mainly in the past 15 years. South Africa was the first developing country to create an accreditation program (1995), followed by Indonesia (1995), Argentina (1996), Brazil (1998), Thailand (1999), Zambia (1999), and the Philippines (2000). Jordan established its Health Care Accreditation Council in 2007.

The introduction of accreditation programs into developing country public sector health systems has resulted in recognition of the need to adapt traditional accreditation methodologies to the realities of the severe resource constraints and weak underlying performance of many health systems. Providing sufficient resources to effectively implement an accreditation program is also critical.

Facilitated Accreditation

An adaptation of health care accreditation that has been used in many countries is facilitated accreditation, whereby the accrediting organization or another health care body assumes responsibility for helping the health care facility that is seeking accreditation to undertake the quality improvement activities needed to achieve satisfactory levels of compliance with accreditation standards. Under such a scheme, a facility that fails to achieve the threshold for accreditation or meets only some criteria may be granted provisional accreditation status during which time it receives help to improve its performance.  Another strategy for facilitated accreditation is that the accrediting body works with the facility for an extended period prior to the initial accreditation survey to provide in-service training and assistance in quality improvement.

The Council for Health Service Accreditation of Southern Africa (COHSASA) is a pioneer in the use of the facilitated accreditation approach in developing countries. COHSASA uses an approach based on facility empowerment and continuous quality improvement (CQI). COHSASA facilitators initially assist each participating facility to understand the accreditation standards and to perform a self-assessment (baseline survey) against the standards. Detailed written reports on the level of compliance to the standards and reasons for non-conformance are generated and sent to the hospital for use in its quality improvement program. Next, the facilitators assist the hospital in implementing a CQI program to enable the facilities to improve on standards identified as sub-optimal in the baseline survey. This preparatory phase usually takes hospitals from 18 months to two years to complete.

Focused Accreditation

Another recent adaptation of the traditional accreditation model has been to focus on specific services or areas of care, in a process often referred to as focused accreditation. Focused accreditation is a process by which a recognized body performs a selective (or focused) review of one or more functions of a health care organization and assesses its ability to meet a set of standards and criteria specifically related to the selected function or service area.

In focused accreditation programs, health care organizations which meet certain pre-established standards receive recognition from the assessing body and may be awarded a symbol (e.g., gold star, special plaque) to exemplify their achievement. The symbolic quality award and ensuing public recognition make focused accreditation a powerful vehicle to improve individual provider and organizational performance. The process also fosters increased public expectations of quality service.

Internationally, the most prominent example of focused accreditation is the UNICEF-World Health Organization Baby Friendly Hospital Initiative, a focused accreditation program to recognize hospitals and birthing centers for establishing optimal environments for the promotion of successful breastfeeding. Hospitals or birthing centers seek accreditation by submitting an application, which includes a letter of intent, a fee, and self-appraisal in regard to adherence to the “10 steps to successful breastfeeding” established by UNICEF and WHO. When a participating hospital has implemented all 10 steps, an on-site assessment is conducted by a UNICEF-WHO-appointed “baby friendly” survey team, along with a review by the Baby Friendly External Review Board. Those hospitals found by the survey team and the Review Board to have successfully implemented all steps are deemed “baby friendly” and may display the logo of the Initiative.

Focused accreditation is a relatively new concept and one that is likely to evolve over time. As differing from traditional accreditation, focused accreditation has more commonly been applied in primary health care facilities and is usually carried out by a body established specifically to perform the focused assessment. The performance standards used in focused accreditation may be pre-existing, but often they are developed expressly for the purpose of focused accreditation. The accrediting local body for focused accreditation is more likely to be part of or directly associated with the Ministry of Health.

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