Accreditation Criteria

Definitions

Accreditation

'Accreditation is a self-assessment and external review process used by healthcare organisations to accurately assess their level of performance in relation to established standards and to implement ways to continually improve.' (Rooney & Van Ostenberg 1999)

Compliance requirements

Full accreditation

All services should score at least 80/100. There should not be any non-compliant standards or criteria that could result in serious harm or injury to patients or staff; contravention of critical laws and regulations or serious administration, organisational and/or managerial problems.

Pre-accreditation Graded Recognition Status

Pre-accreditation requirements

Intermediate with a Focus Survey This award is given to facilities that, it is estimated, are able to address remaining deficiencies in the form of NC or PC criteria in three to six months.

External Survey score >85
All four area indicator scores (Management, Clinical and Clinical Support, Domestic and Technical and Professions Allied to Medicine - PAMS) >80
Not more than 3 Service Elements <75 >60
The final arbitration of whether a facility gets a Focus Survey depends on the majority decision of the Technical Committee members and careful consideration of remaining non-compliant critical criteria.
Facilities awarded this status may request a Focus Survey within the stipulated time period.

Intermediate (no Focus Survey)
This award is given to facilities when it is estimated that they will be able to achieve accreditation status within nine to 12 months. The award lasts for two years.

External Survey score >80
Three area indicator scores (Management, Clinical and Clinical Support, Domestic and Technical and PAMS) >80 and the remaining area indicator score >70
Not more than three Service Elements <75 but >65
Not more than two Service Elements <65 but >60

Entry
This award is given to facilities when it is estimated that they will be able to achieve accreditation status within 12 to 18 months. The award lasts two years.
 
External Survey score >75
Two area indicator scores (Management, Clinical and Clinical Support, Domestic and Technical and PAMS) >80 and the remaining area indicator score >65
Not more than five Service Elements <75 but >65
Not more than three Service Elements <65 but >55

Lapse
The time between the expiry of the accreditation certificate and the date of re-entry (see below).

Re-entry date
The date of re-entry is defined as the date on which the new contract is signed and a deposit paid.

Validation visit
A maintenance visit (paid for by the facility) to ensure that standards are being maintained in the following high-risk areas: 

  • Quality improvement programmes
  • Documentation audit
  • Health record audit
  • Health and safety programmes
  • Staff appraisal plan
  • Strategic management plan
  • Negative incidents
  • Patient complaints
  • Cardiopulmonary resuscitation

CRITERIA FOR ACCREDITATION

1. On first entry into the Council’s facilitated accreditation programme, a facility that substantially complies with the accreditation requirements will be awarded a two-year accreditation.

2. Should the facility re-enter the Council’s accreditation programme as part of a continuous self-evaluation using CoQIS, and remain in the continuous self-evaluation programme using CoQIS, it will be awarded a three-year accreditation.

3. A facility that re-enters the programme within one year after the expiry of its accreditation certificate will be awarded a three-year accreditation on condition that:

  • there is evidence that the facility’s quality improvement programmes have not only been sustained but improved since the previous accreditation award;
  • the facility agrees to undergo an interim survey by the Council within 15 to 18 months of accreditation to ensure that standards are being maintained or to enter the Council’s continuous self-evaluation programme using CoQIS. 
3.1 Should the facility substantially comply with the standards, but not meet the above requirements, a two-year accreditation will be awarded, with the option of undergoing a validation visit by the Council within 15 to 18 months after accreditation in order to identify any deficiencies:
  • monitor on-going compliance with standards;
  • extend the accreditation award by another year to three years if appropriate.  
3.2. Should any deficiencies indeed be identified, the facility would then have the opportunity to rectify these and to apply for another validation visit, which might result in the extension of the award for another year to three years.
 
4. A facility that re-enters the programme four times and sustains unbroken accrdreditation awards will be awarded a four-year accreditation on condition that:
  • It achieved an initial two year accreditation award with no Focus Survey;
  • The initial award is followed by two successive, three-year accreditation awards with no Focus Surveys;
  • there is substantive evidence that the facility’s quality improvement programmes have not only been sustained but improved since the previous accreditation award;
  • The facility agrees to undergo an interim survey by the Council within 24 months of accreditation to ensure that standards are being maintained or to enter the Council’s continuous self-evaluation programme using CoQIS.