BHA FPX 4006 Assessment 4 Healthcare Regulation and Compliance


Compliance in healthcare is a top priority and is required by governmental agencies for licensure. Accreditation, while not required, has many benefits for healthcare organizations though, arguably compliance with compliance regulations is primary. The process for accrediting can be long and scrutinizing yet it allows organizations to identify, understand, and act in areas where a need for improvement has been identified. The purpose of this paper is to understand accreditation, its requirements, and benefits.

Accreditation in Healthcare

As previously stated, accreditation is not a mandatory requirement for a healthcare organization, rather is allows the organization to show its commitment to its patients and the quality of care it provides. Accreditation is acquired from a third-party organization and can show the healthcare system their commitment to their patients and the quality of care provided. The process allows a healthcare organization to demonstrate its ability to meet, not only minimum regulatory requirements but also the higher standards set forth by the accrediting body (Greenfield et al., 2012). Accreditation standards are widely considered as a necessary component to promote safe, reliable, and high-quality services. There are over seventy healthcare accrediting agencies worldwide that have defined certain standards of excellence for healthcare institutions (Greenfield et al., 2012).

Though there are often commonalities, each accrediting body has its process for giving its “stamp of approval” to an organization seeking accreditation. Requirements for accreditation for each agency offering it are known prior to the final evaluation decision. A common process would be for a healthcare organization that is seeking accreditation to understand the requirements and perform internal audits to identify shortcomings and improve on those areas prior to the accrediting body coming through. Receiving accreditation, which signifies that the industry experts from the accrediting agency have thoroughly inspected practices and procedures and determined that they align with their expectations, certifies to the healthcare community that this organization has met rigorous nationally accepted standards. The process can be time-consuming but can also strengthen the reputation of the healthcare organization by providing confirmation of their commitment to delivering the highest level of care (Greenfield, et al., 2012).

After receiving initial accreditation, the standards must be maintained. For an organization to remain accredited it will need to be audited at a set time, usually every three years, to determine the organization’s practices remain in in alignment with the accrediting body (Greenfield et al., 2012). Some benefits noted from organizations that have achieved accreditation are an improved quality of care, decreased liabilities, a culture of excellence, and a badge that shows their commitment to the heist standards (Jha, 2018).

Accreditation Requirements

The first step is achieving accreditation is to determine which accrediting agency they’d like to be accredited by. An important consideration is to be sure the standards of the healthcare organization are shared by the accrediting body (Jha, 2018). Healthcare accreditation is a multidisciplinary, systematic inspection of an organization’s practices and policies as well as the physical structure itself. Items of potential inspection include facilities, education, record keeping, and qualification of staff. Typically, a letter from the healthcare organization’s board of directors to the accrediting agency requesting accreditation begins the process.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) more simply referred to as the “Joint Commission”, is the most widely used accrediting body in the United States. To seek accreditation from the Joint Commission for a hospital, for example, the following requirements must be met: 1. They maintain the standards of the Hospital Accreditation. 2. Is in the United States or its territories or is operated by government of the United States if it is located outside of the country. 3. The hospital assesses and maintains the quality of services. 4. The hospital must detail which services they provide. And finally, 5. The stated services are those that the Joint Commission accredits (JCAHO, n.d.).

There are fees to gain accreditation as well as annual fees to maintain the accreditation. The Joint Commission, as noted is the most widely used in the United States and is also the most expensive (Jha, 2018). Though there are costs directly for fees to maintain accreditation, the benefits for a healthcare organization to be nationally accredited with a stamp of approval signifying their commitment to high-quality care are worth it.

Accreditation and Regulatory Compliance

Accreditation and regulatory compliance requirements are different but the end goal of providing quality care and patient safety is shared. Regulation requires certain minimum rules be followed where accreditation signifies that an organization has met specific standards that are above the regulatory rules. Regulations are determined by governments at the federal, state, and local levels and accreditation requirements are determined by independent accrediting organizations.

The process of accreditation is to help healthcare organizations ensure their practices and policies comply with regulatory agency requirements (Warburton, 2009). Regulations are mandatory and there is no choice but to follow them or there will be penalties such as fines, legal issues, and potentially a loss of their license. Accreditation is optional and is voluntarily sought by a health care organization. In addition, there is no cost for regulatory compliance if rules are maintained but there is a cost to the accrediting body for their accreditation.

Regulatory compliance rules are laws instituted by the government and accreditation standards are set by industry experts to ensure that, in addition to regulation laws are being followed, there is a pronounced focus on patient care and safety. If regulatory compliance is not maintained the penalties can result in fines and loss of licensure for individuals and organizations and can even result in some practices being closed. If accreditation standards are not met an organization may lose their “seal of approval” from that accrediting body but, if the minimum standards set in the regulations created by the government, they will not face the penalties discussed previously.

There are multiple government agencies that regulate the healthcare industry and there are multiple accrediting agencies as well. The Occupational Safety and Health Administration (OSHA) is a governmental agency that is a part of the Department of Labor, and it enforces laws related to the responsibility and obligation to provide a safe workplace for its employees. The Department of Health and Human Services (DHHS) enforces many healthcare laws such as the Clinical Laboratory Improvement Amendment (CLIA) and the DHHS’s Office for Civil Rights (OCR) enforces privacy and security measures such as the Health Insurance Portability and Accountability Act (HIPAA). In specific reference to HIPAA violations may result in significant fines and penalties as well as a loss of licensure in certain cases.

Standards for accreditation are set by the accrediting body itself. Compliance with these standards is voluntary and are not mandated by any faction of federal, state, or local governments. In addition to the Joint Commission, introduced previously in this paper, other accrediting bodies exist such as the National Committee for Quality Assurance (NCQA) and the Healthcare Facilities Accreditation Program (HFAP). Both accrediting bodies will be discussed later in this paper.

Joint Commission Standards

The Joint Commission is an independent accrediting body founded in 1951 and is non-profit and focuses on improving patient care. Standards for patient care set by the Joint Commission are recognized by the Centers for Medicare and Medicaid Services (CMS) and are the bar for healthcare organizations to aspire to. They have developed programs to assist healthcare organizations improve practices. Recognized as the oldest healthcare accrediting body the Joint Commission strive to have standards that are reasonable, achievable, and observable. The Joint Commission states their mission to continuously improve the safety and quality care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in healthcare organizations (JCAHO, n.d.). Standards set by the Joint Commission are developed with consideration of feedback from many sources including health care professionals, patients, experts in their field, and CMS (JCAHO, n.d.).

Hospital standards are aimed toward patient and organizational operations. They use evidence-based standards based on evaluating an organization’s improvement before and after these standards were implemented (JCAHO, n.d.). Patient operational standards focus on a patient’s rights and responsibilities, medication management, services, and treatment. Organizational standards focus on health care professionals, emergency management, services, treatment, and improving performance (JCAHO, n.d.). Joint Commission standards pertain to patient visits as well as specific aspects of care received throughout the visit. These standards are reviewed and modified as needed to remain current as health care evolves.

The Joint Commission uses “Tracer Methodology”, which uses data from all components of a patient’s experience, to ensure the highest quality of patient care is practiced. Looking in detail at all aspects of care allows information on how well the organization works together in providing care and can identify areas needing improvement. If multiple areas needing improvement are noted, priority focus areas can be determined; once determined, certain data measurement points are submitted to the Joint Commission to ensure improvement processes are in place and successful to deliver the highest quality and safe patient care possible (JCAHO, n.d.).

The Joint Commission’s “standards manual” is given in both electronic and hard copies. It contains over 250 standards. New standards may be added to the accreditation requirements if they relate to quality of care or patient safety, are accurately measured, and have been shown to have a positive impact on health outcomes. The Joint Commission uses data acquired from scientific journals, advising groups, and professional organizations to prepare potential “draft” standards that are then distributed to organizations across the country to be reviewed and discussed. Once reviewed and revised as needed, the Joint Commission executive leadership would approve the new standard (JCAHO, n.d.).

Accreditation Best Practices

Achieving accreditation is admirable and beneficial for all the reasons previously noted in this paper but it is important to remember that accreditation and a commitment to quality patient care is not a one time, check it off the list task. Maintaining accreditation is an ongoing commitment that must be nurtured. Some best practices to continuously care for these standards are performing internal “mock” surveys and develop a baseline assessment and use tracer methodology to determine and track success and utilizing the tools created by the Joint Commission (JCAHO, n.d.).

Internal mock surveys are performed by employees of the organization, maybe an individual department manager or a compliance team. These surveys provide valuable information on the state of reality and maintaining an “always ready” operation. Surveyors should be knowledgeable of the survey requirements and be objective in their assessments. Its better to discover a performance gap internally than to have it noted in a Joint Commission audit (JCAHO, n.d.). Having regular meetings with leaders and key personnel is beneficial as well. Discussing a finding in one department can bring focus to an issue that may be an issue in others.

Using tracer methodology allows leadership to evaluate the care that has been provided and look for inconsistencies or gaps. This tactic uses real time data of actual patients and their care. Risks can be identified and root issues, that could be contained to one area or could be systemic, improvement processes can be developed and implemented (JCAHO, n.d.).

Using baseline information is valuable to determine an organization’s current state of readiness. Taking an in depth, objective look at the practice and policies of the organization and how they align with the Joint Commission standards can allow improvement steps to be taken. Having audits performed by those outside one’s own department is a great tool because when a performance gap is seen daily it can go unnoticed because that’s “just the way it’s always been”. Having fresh eyes in an area is a way to avoid such incidences.

Other Accrediting Organizations

While the Joint Commission is most widely used accrediting body in the United States, others are available. The Healthcare Facilities Accreditation Program (HFAP) is nationally recognized by CMS. The mission of the HFAP is to advance high quality patient care and safety through objective application and recognized standards (Fennel, 2017). HFAP was funded in 1945 by the American Osteopathic Association to be an objective reviewer of services provided. It was also named as the authorizing Social Security Act as the accrediting authority for all acute care hospitals under Medicare Conditions of Participation (CoP) (Fennell, 2017).

HFPA also accredits specialty surgery centers, rehabilitation centers, behavioral facilities, and long-term acute hospitals. Their standards are patient treatment and safety, quality improvement, and environmental safety (Fennel, 2017).

The cost of accreditation with the HFAP is determined by the physical size and volume of a facility. Access to their standards manual, which includes specific scoring procedure, is available free of charge online or can be purchased in print (Fennel, 2017).

The National Committee for Quality Assurance (NCQA) was founded in 1990 and is another non-profit accrediting agency. Their accreditation program uses evidence-based standards to determine the quality of health care by working with federal and state officials, employers, doctors, patients, and health plans (NCQA, 2020). Accreditation is available for health organizations as well as health plans that meet their standards.

NCQA uses the Healthcare Effectiveness Data and Information Set, better known as HEDIS, to measure performance in managed care. There are over 90 items measured in HEDIS and organizations seeking accreditation must meet them all (NCQA, 2020).

Conclusion BHA FPX 4006 Assessment 4 Healthcare Regulation and Compliance

Accreditation is not mandatory yet the benefits of achieving accreditation have been well documented. Accreditation standards exceed the minimum standards required by merely achieving regulatory compliance. Given the many benefits and national seal of approval earning accreditation can provide the argument for accreditation seems almost inarguable. Though the process to gain and maintain accreditation can be arduous and time consuming it is worth it. The cost of self-auditing and annual accreditation fees pale in comparison to the potential fines, litigation, and loss of licensure if not compliant with governmental regulations.

Patient trust is also a benefit of the accredited organization. Having this seal of approval is something that patients expect and an organization not having it could urge a patient to seek care elsewhere. Again, there are costs to accreditation but building an organization with a laser focus on quality care and patient safety being in a state of constant readiness and being ethical and truly operating to accreditation standards is why many of us chose a career in healthcare.


Fennel, V. (2017). Understanding healthcare facilities accreditation program (HFAP). Retrieved

From https://www.beckershospital

Greenfield, D., Pawsey, M., Hinchcliff, R., Moldovan, M., & Braithwaite, J. (2012). The

standard of healthcare accreditation standards: A review of empirical research

underpinning their development and impact. PubMed Central (PMC).

JCAHO. (n.d.). The Joint Commission. Retrieved from

Jha, A. (2018). Accreditation, quality, and making hospital care better. JAMA Network.

NCQA. (2020). NCQA. Retrieved from .

Warburton, R. (2009). Accreditation and regulation. Retrieved from

Leave a Comment

Your email address will not be published. Required fields are marked *

Scroll to Top