[ROJ-TPOR] Hospital Accreditation – Processes of Accreditation Project

[ROJ-TPOR] Hospital Accreditation – Processes of Accreditation Project

by Reynaldo O Joson on Wednesday, June 22, 2011 at 12:01pm

What are the recommended processes in going for hospital accreditation?


Starting point:

Top management decides to have a Hospital Accreditation Project to promote the business development program of the hospital so as to make it viable and sustainable.


Top management creates a Steering Team / Committee for Hospital Accreditation Project with clear functions and authority.


Membership of Steering Team / Committee

Senior Management Representative if not the Hospital Director

Chair (with competency in hospital accreditation and leadership)

Cross-sectoral or multisectoral membership with representatives from key functional areas in the hospital, such as the following: (Note: the senior management team members may constitute the Steering Team / Committee.)

Medical service sector

Nursing service sector

Ancillary medical service sector

Administrative or support service sector

Human resource development sector

Business development sector

Finance sector



Steering Team formulates a master plan for Hospital Accreditation Project.


Steering Team seeks commitment for support and collaboration from top, senior, middle, and lower management on Hospital Accreditation Project.


Contents of master plan for Hospital Accreditation Project

  • Goals and objectives of accreditation project (include short- and long-term goals and objectives)
  • Selection, prioritization, and integration of the accreditation standards
  • Selection of the accrediting bodies
  • Expected outputs (short- and long-term)
  • Expected impact (short- and long-term)
  • Timelines (short- and long-term)
  • Strategies and action plans to achieve expected outputs and impacts (short- and long-term)
  • Budget (short- and long-term)
  • Monitoring and oversight plan
  • Evaluation plan (short- and long-term)
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