Accreditation

The Basics

Accreditation organizations review a health care organization’s ability to meet regulations and practice standards to provide the highest quality of care. There are numerous accrediting organizations, each with its unique set of standards. Organizations include The Joint Commission, Accreditation Association for Ambulatory Health Care (AAAHC), International Association of Counseling Services (IACS), Accreditation Commission for Health Care (ACHC), Utilization Review Accreditation Commission (URAC), National Committee for Quality Assurance (NCQA), and others. Accreditation may be required for participation in certain insurances including Medicare and Medicaid.

Accreditation is a review process through which a health care organization continuingly seeks to improve the safety and quality of its patient care services. According to AAAHC, this is usually accomplished through “on-going self-evaluation, peer review, and continuing education” with further evaluation through a survey by an accrediting organization. This survey is usually conducted every three years.

Accrediting organizations may also offer certification for specific programs within an accredited or non-accredited health center. Depending on the organization, certification may be based on patient outcomes or accreditation criteria. For example, a lab offering a specific level of services needs to be certified or accredited by an organization such as the American Association for Laboratory Accreditation. Click here to learn about certification through AAAHC. Click here to learn about certification through The Joint Commission.

Which Accreditation Is Best for Your Center?

College health centers seeking accreditation usually turn to AAAHC and The Joint Commission. Each accreditation organization is unique with its own set of standards and criteria for eligibility. The accreditation/certification organization’s mission, standards, eligibility requirements, the type of accreditation/certification programs, and costs must align with the health center’s service lines, mission/vision, resources, and its ability to meet a given set of standards. Also, if the health center is integrated with the campus’s counseling center, consideration must be given to whether the accrediting body includes accreditation of behavioral/mental health services. Leadership must thoroughly evaluate both accrediting bodies for the best fit prior to committing to either.

If the health center, organizationally, falls under the auspices of a school of medicine or hospital, which is already accredited, there may be an organizational requirement to align with the parent organization. Depending on the degree of the health center’s autonomy, it may or may not be able to seek independent accreditation.

To facilitate the process, the following elements should be reviewed and understood in detail:

Eligibility requirements:

  • AAAHC accreditation survey eligibility criteria can be found here.
  • AAAHC certification eligibility criteria can be found here.
  • The Joint Commission accreditation eligibility criteria for ambulatory care can be found here.
  • The Joint Commission certification eligibility criteria can be found here.

Types of accreditation applicable to college health include:

  • Ambulatory health care (AAAHC and The Joint Commission) for primary care organizations
  • Urgent care center (The Joint Commission) for those centers offering urgent care only
  • Medical home (AAAHC [certification and accreditation] and The Joint Commission [certification]) is for those centers that provide safe and high quality, accessible, comprehensive, patient-centered and coordinated care (AHRQ).

Lab certification and accreditation programs are available independent of whether the health center is accredited. Certification and/or accreditation is available from such organizations as American Association for Laboratory Accreditation (AALA) and COLA, as well as the Centers for Medicare & Medicaid Services (CMS) for Clinical Laboratory Improvement Amendments (CLIA) certification.

Survey requirements will vary by organization and may be determined by the length of time in which services have been provided. AAAHC offers different types of surveys including Early Option Survey (for those offering service for less than 6 months) and Initial Accreditation Survey for greater than 6 months of service; each have a separate application with specific requirements. The Joint Commission offers different types of surveys and their requirements can be found here.

Associated Fees/Expenses

Some organizations charge a flat fee based on the size of the organization and the type and scope of services it offers. This is the format for AAAHC, and fees are payable in advance of the survey.

Other organizations charge variable fees based on the type, size, and volume of services offered as well as the number of sites being accredited. This is the format for The Joint Commission, with the full amount being payable over the three-year accreditation period. A non-refundable, non-transferable deposit is required at time of application for accreditation.

There may be additional fees/expenses associated with accreditation. These may include consulting fees for training, or survey preparation and expenditures for supplies and materials to meet standards or correct deficiencies found during the survey.

Determine Who Leads the Process

The individual or individuals who lead the accreditation process must have a comprehensive understanding of the organization, performance improvement, data collection and assessment, as well as the authority to compel the staff to meet established deadlines. Options to consider include the health center’s leadership team or the establishment of an ad hoc committee. If an ad hoc committee is formed, members should include individual(s) responsible for the center’s quality management program(s) and supervisory staff, as well as other staff members needed to ensure representation of all departments which will be surveyed. Individuals with prior experience in the process should also be considered.

Get Advice from Colleagues

Networking with colleagues who work in similar health centers and who have been through the accreditation process is a great way to learn how the accreditation process works. Success and failure stories can give insight into the nuances of the survey process. There is variability among individual surveyors and their particular focus. For example, a surveyor may have expertise in a specific area and while covering all required standards, they may be more focused on their area of expertise. Also, bear in mind that standards may change from year to year, requiring a scheduled review and a constant state of readiness.

When networking with other college health centers, you may want to consider the following:

  • Size and scope of services 
  • RN- vs MD- vs PA- vs other professional-managed
  • Query reasons for choice of accreditation organization. Was it
    • Best practices?
    • Insurance reasons?
    • Others such as aligning with the hospital or school of medicine to which it reports?
  • Length of preparation process—how long from start to finish
    • Initial accreditation
    • Re-accreditation
  • Satisfaction with survey process
    • What could the health center have done to better prepare?
    • What could the accrediting body have done better?
    • Was the surveyor objective?
    • Was the surveyor knowledgeable and helpful?

Determine Timeline for Completion

Networking with colleagues may be the best way to get an estimate of the time required for preparation. Timeline considerations include:

Training

Those individuals leading the process should participate in training(s) offered by the accrediting organizations. If everyone is not able to participate, at a minimum, consider having the individual responsible for quality management to participate.

Training among the accreditation organizations vary in format and content of live, in-person presentations or online sessions. Training may include an overview of the accreditation process such as AAAHC’s live “Achieving Accreditation” as well as sessions on individual areas of interest. For more information, refer to the AAAHC and The Joint Commission websites.

AAAHC’s live seminar for those seeking accreditation is offered a limited number of times; there are recorded webinars, but they cover limited topics. The Joint Commission offers online courses on specific topics.

Completion of Application

This process will more than likely involve the inclusion of supporting documents. Applications are usually submitted electronically. The Joint Commission states that organizations have up to 1 year to complete the survey following application submission.

Completion of Self-Assessment

A self-assessment should be conducted to determine the organization’s readiness to meet applicable standards. Review the standards and determine which are applicable to your health center. Next, review policies and any applicable standard operating procedures (SOPs) to ensure they meet required elements of the standards; write or edit as needed. Most critically, you must ensure that staff is adhering to the actual policies and SOPs.

If needed, hire a consultant with experience in the accreditation process of AAAHC or The Joint Commission. A consultant will assist with interpreting and applying the appropriate standards for the health center as well as offer guidance in meeting compliance. AAAHC offers guidance for choosing a consultant, and ACHA’s College Health and Wellness Consulting Program has experienced college health professionals available to assist with accreditation preparedness. ACHA consultants are more knowledgeable about college health centers than a private consultant whose experience may be limited to hospital or physician practices.

Determine your compliant and non-compliant areas. The amount of time this will take depends on your readiness and whether a consultant is involved. The consultant may need additional time to gain enough knowledge about the health center, but this time may be well spent to conduct a more thorough assessment. After assessment, time will be needed to correct any deficiencies.

Meeting Accreditation Standards

Accreditation standards must be addressed systematically such that progress is being demonstrated towards meeting a specific standard. Ensure that your policies, procedures, and processes support requirements of the standards; if there are gaps in the policies, establish/correct them, train any staff involved, and maintain documentation of change(s) and training.

Always showcase your health center’s strengths with supporting documentation. For example, if your patient satisfaction scores are high, you may wish to highlight this by using graphs to display results rather than a descriptive entry.