Hospital Accreditation

Updated: June' 2014 

Action Plan                Strategic Paper                 Present Status


A quality conscious and accountable health care system within which all stakeholders have a say and that enables rational, effective, safe and cost-effective provision of care.

Introduction & Background

Health systems currently operate within an environment of rapid social, economic and technological change. Such changes are expected to continue for the foreseeable future as a result of restructured economic and social policies, globalization of markets and enhanced worldwide communication. New insurance mechanisms, restructuring and health reform initiatives, privatization within the health sector, redistribution of human and other resources, reduced public funding, new technology, and many other factors may raise concern for the quality of healthcare. As a result of these health sector reforms, national health systems are coming under increasing scrutiny with a view to cost containment and quality improvement.

Hospital accreditation has been defined as “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve” Critically, accreditation is not just about standard-setting: there are analytical, counseling and self-improvement dimensions to the process. Accreditation is a formal process by which a recognized body usually an independent body assesses and recognizes that a health care organization meets applicable predetermined and published standards. . A health care establishment is said to be “accredited” when the disposition and organization of its resources and activities make up a process which results in medical care of satisfactory quality. Accreditation implies confidence in a hospital by the population. In almost all cases this can be achieved without major investments in infrastructure.


Broadly speaking, there exist two types of hospital accreditation

1)     Hospital and healthcare accreditation which takes place within national borders

2)     International Health care organization

Accreditation can be the single most important approach for improving the quality of healthcare structures. In an accreditation system, institutional resources are evaluated periodically to ensure quality of services. Standards may be minimal, defining the bottom level or base, or more detailed and demanding. Accreditation standards are usually regarded as optimal and achievable, and are designed to encourage continuous improvement efforts within accredited organizations.

In all developed and developing countries, accreditation helps the hospital enhance patient care through continuous quality improvement process. It also strengthens community confidence by highlighting hospital’s commitment to provide safe and quality care to the community. An accreditation decision about a specific healthcare organization is made following a periodic on-site evaluation by a team of peer reviewers, typically conducted every two to three years. Accreditation is often a voluntary process in which organizations choose to participate, rather than one required by law and regulation.

Hospitals are an integral part of health systems; by harmonizing standards in hospitals in line with other institutions and levels of care, continuity of care is improved and the healthcare network strengthened. Hospital accreditation is gaining prominence due to globalization efforts and especially trading in health services. Hospital accreditation is a system of ongoing consensus, rationalization and hospital organization. National ownership is crucial, both to lay the foundation and to maintain, from the beginning, a high degree of integrity and accountability of the national accreditation system.



This accreditation organization is committed to and exists to provide leadership in enhancing health care quality and to promote accountability and rationality in health care.

This mission will be achieved through

a) Accreditation

b) Partnership and Collaboration - promoting networking, partnership and collaboration between disciplines and organizations at regional, national and international level

c) Research and Dissemination - promoting research which is of a quality and scale to achieve a national reputation in all fields and an international reputation in quality areas encouraging and facilitating the development of multi disciplinary research groups which are of sufficient size and quality.

d) Training

e) Quality culture - Promoting innovative and flexible policies in the employment and development of staff


The main purpose of our policy is to help planners to promote, implement, monitor and evaluate robust practice in order to ensure that occupies a central place in the development of the healthcare system In doing so it recognizes the roles to be played by a multiplicity of stakeholders from the govt. , non-governmental and private and economic sectors. Quality should be an integral part of the overall national health policy. It is believed that accreditation if sensibly designed can have a significant impact on improving quality and safety in health care; improving health outcomes; ensuring more equitable health service provision; enhancing management practices; and improving decision making. Such a system must be founded on equity, it must respect diversity, it must honour learning and strive for excellence, it must be owned and cared for by the communities and stakeholders it serves, and it must use all the resources available to it in the most effective manner possible. The national organization should promote the practice of holistic medicine and the integration of the various systems of medicine in the most beneficial manner.

Above all, the policy seeks to develop an enabling environment in which high quality of health care can flourish throughout the country. This is to be done through providing guidance to providers, rather than through control and prescriptive measures.


  • Quality improvement: using the accreditation process to bring about changes in practice
  • that will improve the quality of care for patients;
  • Informing decision-making: providing data on the quality of health care that various stakeholders, policymakers, managers, clinicians and the public, can use to guide their decisions;

  • Standards are statements of expectation that define the structures, processes, and results that must be firmly established in an organization so that it may provide quality care. For example, standard of structure refers to equipment, physical area, support services, personnel; standard of process includes admission, nursing procedures, medical procedures, operational manuals, norms, routines, flows; and standard of outcomes covers mortality, morbidity, readmissions, complications, infections and client satisfaction (accessibility, information, personnel and facilities.). All these standards require evidence of performance (or qualitative indicators) that are simple, inexpensive and easy to observe by the surveyors. Currently, as well, many hospitals have a great variation in quality among their services, independently of their size.


  • Conduct comprehensive assessments of health care organizations in consonance with the national framework, for the promotion and maintenance of quality and standards.

  • To engage and train conscientious surveyors and to develop training systems generally for accreditation surveyors.

  • To promote accreditation, including its values, purpose and results to health care organizations, medical profession, patients and the community.


Reasons for implementing Hospital Accreditation

 Currently, there are great discrepancies in quality among different services of the same hospital, independent of the number of beds. Much government, semi-private and private health institutions seek a recognized accreditation system in order to cope with the newly emerging competitive environment of health care service delivery. Hospital accreditation processes have recently begun to be implemented in some countries in the region. Institutionalizing improved quality of care through accreditation requires more than a technical approach; more than the application of tools and methods. Failure to change the behavior of people and organizational attitudes is the commonest cause of ineffective quality initiatives. Sustained improvements often require a change in attitude and acquisition of a sense of ownership with regard to the quality of services provided by an organization. Many supporting factors are required to integrate accreditation into the structure and function of an organization. The challenges in setting and measuring against standards are mostly technical; the challenges in making appropriate changes are social and managerial. Sustainable quality needs a supportive environment of leadership, clarity of purpose and organization, in other words, a strong accreditation programme. Accreditation can be the single most important approach for improving the quality of health care structures.


Hospital accreditation is a method of ongoing consensus, rationalization and hospital organization. The first instrument for the explicit and objective technical evaluation of quality will be the accreditation manual. The creation of the National Accreditation Council should be of great importance. It should be a nonpolitical, multi-representational, and should undertake its work energetically, prudently and periodically. This entity will be responsible for the administration and policy-making of the accreditation system at the country level. It will be responsible for the setting of national standards for accreditation, adopting WHO guidelines for accreditation, identifying and training the surveyors, conducting and monitoring the site surveys and making the decisions related to the awarding of accreditation and maintaining it. It is essential to have uniformity; therefore, this body should apply uniform accreditation standards to be followed by state.

In spite of recommendations that the national accreditation Council will be multi-institutional, and include the most prominent and active players in the civic, public and private sectors of the national health sector, the presence of the Ministry of Health & family Welfare is essential because of its authority and its capability of transferring resources within the process of national hospital accreditation. The mandate of such a l entity would be to ensure that national accreditation systems are competent to: monitor and evaluate adherence to national health system policy and responsiveness to current and future challenges; monitor and evaluate quality performance of health organizations /facilities on various levels; cover managerial and clinical aspects; enhance organizations’ learning environment and quality improvement culture; and establish a national framework to take full responsibility for the accreditation initiative.


So, if we would be able to implement the Hospital Accreditation System, the following change would be visible as follows:

• It stimulates the improvement of care delivered to patients

• It strengthens community confidence in its hospital

• It reduces unnecessary costs

• It increases efficiency

• It provides credentials for education, internships, and residencies

• It can protect against lawsuits

• It facilitates acceptance by and funds from third-party payers




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Action Plan: Hospital Accreditation                   







Approval of the draft document of hospital Accreditation





















Development of hospital Accreditation standard





















Capacity development of the assessors





















Development of the assessors check list





















Accreditation Survey ( Piloting hospitals)





















Final Accreditation






















Roll out & Feed back


























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Present Status


 The Hospital Accreditation draft document already prepared and submitted to MOHFW in 2008.

The document contain:

1.      Strategic planning

2.      Objective

3.      Executive summary

4.      Composition of Hospital Accreditation body, TOR & its modality

5.      Areas of Hospital Accreditation & its standard

6.      Accreditation Process

7.      Assessors

8.      Accreditation survey

9.      Rating system

10.  Final Accreditation