By José Domingos
From Health Insurance Portability and Accountability Act (HIPAA) laws to the Affordable Care Act, the healthcare industry is highly regulated. In an ever-evolving healthcare landscape, significant regulatory updates occur rapidly and frequently. The COVID-19 pandemic has served to highlight this trend, often requiring organizations to shift focus abruptly while simultaneously demonstrating compliance in a new, challenging environment.
Now, more than ever, healthcare provider organizations can benefit from leveraging the broad value of accreditation. Many people associate accreditation solely with compliance and the survey experience, but with the right partner, accreditation is the source of a business relationship that can help drive performance improvement, operating efficiencies and risk management—all aspects of a successful business growth strategy—while maintaining ongoing regulatory compliance.
Ongoing Quality Improvement
For any healthcare organization, from a group practice to a corporate entity or hospital system, maintaining performance improvement should be the primary goal in seeking accreditation. Performance improvement is central to sustaining all other objectives—fulfilling legal requirements, attaining higher reimbursement and strengthening competitive advantage.
There is considerable evidence to show that accreditation programs improve outcomes across a wide spectrum of clinical conditions.[i] Actively engaging the entire organization—from administrators and practitioners to facility engineers and human resources—in a culture of improvement embeds the practice of accreditation into daily policies and procedures to improve the quality of care and strengthen the organization.
Quality improvement is a pervasive theme across accreditation standards, regardless of setting. The broad issues addressed may be rooted in patient safety and clinical care, but they are also building blocks of a high-performance organization. Elements include:
- Developing a broadly conceived program to touch every area of an organization through data collection activities. Whether employee-based or contracted service, there is very little operationally that cannot be covered by a comprehensive, effective quality improvement program.
- Attaching specific, measurable goals to each service area to establish data-driven, evidence-based protocols. Data for data’s sake is not useful. Context makes the data actionable.
- Fully communicating results to ensure engagement and establish accountability spanning from front-line staff through the governing body. At the staff level, quality data are collected and compared with past performance. At the management level, patterns are identified and recommendations are made to maintain a positive trajectory or adjust to correct off-target trends. The executive level holds ultimate responsibility for the quality of services delivered, and as the quality reporting is communicated upward, there is continuing evaluation of whether performance is serving to advance the organization’s mission and strategic goals.
In short, the more frequently organizations are thinking about accreditation, the easier it is to integrate the standards into daily, front-line activities and managerial decision-making. For executive leaders who embrace a performance improvement process as the nexus of their operating plan, an accreditation focus brings added value to business operations. Continuous, small course corrections are easier and more sustainable than instituting major overhauls when a survey is approaching. This principle applies equally to standards compliance and management of the business.
With healthcare organizations operating on slim margins, operational efficiency is critical to success. Administrators and other leaders hold responsibility for compliance with complex federal and state laws while simultaneously seeking to manage and reduce costs.
For an organization considering expansion, ensuring consistency in quality of care across all services and locations is essential. Whether a home health agency wants to expand into home infusion therapy or a physician group seeks a hospital partner for a joint venture in outpatient surgery, an accreditation resource offering comprehensive service solutions can support sustainable business growth. Taking an integrated approach promotes consistency of practice, optimizing efficiencies across service lines and locations.
Similarly, sharing best practices across service lines and/or facilities is a major benefit for an organization, regardless of size. For a system, a single accreditor facilitates internal benchmarking opportunities. For a smaller setting looking to expand service lines, it streamlines the launch process.
Using an already accredited facility as a template of quality care allows providers to adapt their model of success in other areas. With these best practices established, healthcare organizations also can demonstrate to investors the value of a new operation.
The documented benefits of accreditation are many and include enabling the establishment of better organizational structures and processes, promotion of quality and safety cultures and improvements in patient care.[ii] In a survey of health departments that had been accredited for one year, more than 90% reported experiencing benefits such as stimulation of quality improvement and performance improvement opportunities, increased accountability and transparency, and improved management processes.[iii]
Accreditation standards offer a framework to help your organization develop improved structures and operational excellence. Healthcare leaders should use the accreditation process to inform strategic management and operational decisions.
Differentiating from Competitors
Accreditation status can differentiate a healthcare organization within the community and offers significant competitive advantages. Achieving accreditation assures patients and potential partners that your organization provides the highest quality of care, giving them the confidence to choose your facility over one that is not accredited.
The ideal accreditor provides ongoing, comprehensive guidance and services to meet a range of needs, such as recognition for specialties that distinguish facilities from their competitors. For example, a stroke center designation for a hospital means the local EMS can transport the patient to that facility knowing the patient will receive the specialized care necessary for quick assessment and treatment. This type of recognition focuses on the organization’s ability to provide a specialized service and stresses to the public that the organization is dedicated to meeting the community’s need.
While accreditation standards are designed to meet federal and state requirements, healthcare providers should consider an implementation strategy that is customized and tailored to their organization to ensure adequate differentiation and relevant risk management. Ongoing access to accreditation resources, experts and education helps organizations identify high-risk areas and adjust to regulatory changes more smoothly and efficiently.
By using best practices and data collected to meet accreditation requirements, a process is already in place to adjust for risk or update methods and procedures to improve quality of care. This proactive approach to risk management should limit errors and lead to safer processes. As testament, many liability insurers recognize the benefits of accreditation and reduce premiums for accredited organizations.
Accreditation can be a vital tool to optimize and expand your healthcare business. Through ongoing support from an accreditation provider, an organization can realize the value of accreditation beyond the survey. Its optimal impact is achieved when an organization uses quality improvement and risk management to extend accreditation as a capacity-building tool.
[ii] Nicklin W, Fortune T, van Ostenberg P, O’Connor M, McCauley N. Leveraging the full value and impact of accreditation. IJQHC 2017;29:310-2.
[iii] Kronstadt J, Meit M, Siegfried A, Nicolaus T, Bender K, Corso L. Evaluating the Impact of National Public Health Department Accreditation―United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:803–806.
About the author: José Domingos is President and CEO of Accreditation Commission for Health Care (ACHC), a nonprofit healthcare accrediting organization with 35 years of experience promoting safe, quality patient care. ACHC develops solutions trusted by healthcare providers nationwide and is committed to offering exceptional, personalized service and a customized, collaborative accreditation experience tailored to individual needs. To reach José, email or call (855)937-2242. For more information about ACHC, visit www.achc.org.