Introduction

Accreditation and quality standards are fundamental to ensuring patient safety, clinical excellence, and operational efficiency in healthcare organizations. With the evolving landscape of healthcare regulations, achieving and maintaining accreditation is not just about compliance but also about fostering a culture of continuous improvement. This 5-day Healthcare Accreditation and Quality Standards Training Course is designed to equip healthcare professionals with the knowledge and skills to navigate accreditation processes, implement quality standards, and drive organizational excellence.

Participants will explore major accreditation bodies such as The Joint Commission (TJC), National Committee for Quality Assurance (NCQA), the International Organization for Standardization (ISO), Commission on Accreditation of Rehabilitation Facilities (CARF), and others, gaining practical insights into achieving and maintaining accreditation while improving patient outcomes.

Objectives

By the end of this training, participants will be able to:

1. Understand Healthcare Accreditation Fundamentals – Learn about the role of accreditation in improving healthcare quality, safety, and efficiency.
2. Navigate Accreditation Standards – Gain in-depth knowledge of key accreditation bodies, their requirements, and best practices.
3. Implement and Sustain Quality Standards – Develop frameworks to integrate accreditation requirements into daily operations.
4. Prepare for Accreditation Surveys and Audits – Learn how to conduct self-assessments, address deficiencies, and succeed in external audits.
5. Enhance Patient Safety and Risk Management – Apply accreditation standards to strengthen patient safety and reduce errors.
6. Leverage Data for Quality Improvement – Use performance metrics and benchmarking to meet accreditation criteria and drive continuous improvement.
7. Develop an Accreditation Readiness Plan – Create a roadmap for achieving and maintaining accreditation in healthcare facilities.

Who Should Attend?

This course is ideal for healthcare professionals responsible for quality management, accreditation, and regulatory compliance, including:

• Hospital and Healthcare Administrators
• Quality and Patient Safety Officers
• Accreditation and Compliance Specialists
• Healthcare Risk Managers
• Physicians, Nurses, and Clinical Leaders
• Healthcare Consultants and Policy Makers
• Health Information Management Professionals
• Any healthcare professional involved in regulatory compliance and quality improvement

Course Outline

Day 1: Introduction to Healthcare Accreditation and Quality Standards

Morning Session

• The Role of Accreditation in Healthcare

  • Why accreditation matters: Enhancing quality, safety, and efficiency
  • Overview of accreditation and certification processes
  • Key differences between national and international accreditation bodies

• Understanding Quality Standards in Healthcare

  • Key dimensions of healthcare quality: Safety, effectiveness, efficiency, patient-centeredness, timeliness, and equity
  • Relationship between quality improvement and accreditation

Afternoon Session

• Major Healthcare Accreditation Bodies and Their Standards

  • Joint Commission (TJC) & Joint Commission International (JCI) – Hospital Accreditation Standards
  • National Committee for Quality Assurance (NCQA) – Healthcare provider and payer quality standards
  • International Organization for Standardization (ISO 9001 & ISO 14001) – Healthcare Quality Management Systems
  • Commission on Accreditation of Rehabilitation Facilities (CARF) – Rehabilitation and long-term care standards
  • Healthcare Facilities Accreditation Program (HFAP) & DNV GL – Alternative hospital accreditation bodies

• Exercise: Comparing Accreditation Standards and Their Applications

Day 2: Meeting Accreditation Requirements and Implementing Standards

Morning Session

• Understanding Core Requirements for Accreditation

  • Governance and leadership standards
  • Patient rights and responsibilities
  • Performance measurement and data-driven quality improvement

• Accreditation Compliance Strategies

  • Integrating accreditation standards into daily hospital operations
  • Developing policies and procedures aligned with accreditation criteria

Afternoon Session

• Preparing for Accreditation Surveys and Audits

  • Conducting self-assessments and mock audits
  • Common pitfalls and how to avoid them
  • Staff readiness: Training and engagement strategies

• Exercise: Conducting a Mock Accreditation Audit

Day 3: Quality Improvement and Patient Safety in Accreditation

Morning Session

• Implementing Continuous Quality Improvement (CQI) Initiatives

  • Lean Six Sigma and PDSA cycle for healthcare quality improvement
  • Using Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA)

• Ensuring Patient Safety through Accreditation Standards

  • Patient safety goals and compliance measures (e.g., WHO and TJC guidelines)
  • Reducing hospital-acquired infections (HAIs) and preventable medical errors

Afternoon Session

• Risk Management and Compliance with Accreditation Standards

  • Identifying and mitigating risks using accreditation frameworks
  • Incident reporting and response strategies

• Exercise: Developing a Patient Safety and Quality Improvement Plan

Day 4: Data-Driven Decision Making and Performance Measurement

Morning Session

• Using Data and Analytics for Accreditation Success

  • Key Performance Indicators (KPIs) for accreditation compliance
  • Healthcare dashboards and scorecards for tracking quality performance

• Benchmarking and Best Practices in Accreditation

  • Learning from top-performing hospitals and healthcare systems
  • International benchmarking and continuous improvement strategies

Afternoon Session

• Patient Experience and Engagement in Accreditation

  • Measuring patient satisfaction and feedback mechanisms
  • Incorporating patient-reported outcomes into quality initiatives

• Exercise: Developing a Data-Driven Quality Improvement Strategy

Day 5: Sustaining Accreditation and Building a Culture of Excellence

Morning Session

• Leadership’s Role in Accreditation and Quality Management

  • Building a culture of safety and continuous improvement
  • Leadership accountability and staff engagement strategies

• Sustaining Accreditation Beyond Initial Certification

  • Maintaining compliance through routine assessments and audits
  • Updating policies and training programs based on evolving standards

Afternoon Session

• Emerging Trends in Healthcare Accreditation

  • The role of digital health and AI in accreditation compliance
  • Future regulatory changes and accreditation landscape updates

• Final Exercise: Creating an Accreditation Readiness Plan

  • Participants develop an action plan for their organizations

Conclusion and Certification

• Course Wrap-Up and Key Takeaways
• Q&A and Discussion
• Certification Ceremony – Participants receive a certificate of completion