Hospital Accreditation Standards



A. Introduction

The fourth edition of the HCAC Hospital Accreditation Standards has retained the patient centered-focus as in the previous editions but several changes were made to eliminate duplication, clarify the wording of standards, revise standards based on current evidence, and add new standards that reflect current practice. Also, several standards were reclassified as either core or critical. These decisions were based on data derived from accreditation scoring results and stakeholders feedback meetings. For instance, if the majority of hospitals were meeting a “stretch” standard, then it was reclassified to “core”. The definition of critical includes those standards required by law and regulation, as well as standards that have the potential to result in harm to patients, staff, or visitors if not carried out. This edition contains 15 clusters, 426 standards.

B. Aim

Accreditation helps the hospital enhance patient care through a continuous quality improvement process. In almost all cases this can be achieved without major investments in infrastructure. It also strengthens community confidence by highlighting the hospital’s commitment to provide safe and quality care to the community.The purpose of accreditation is to encourage and support health facilities to undergo comprehensive survey processes and achieve national benchmarks that demonstrate the highest standards of health care quality

C. Framework and guiding principles of HCAC Hospital Standards

The standards are written with a focus on the patients - not on a department or the professional who provides health care services.

Patient-centered care is based on several key principles:

Dignity and respect:
Incorporating the values, beliefs and cultural backgrounds of patients into the planning and delivery of care; resolving complaints and conflicts as soon as possible.

Information sharing:
Encouraging patients to share their perspectives & questions and healthcare professionals providing information regarding illness & treatment options in terms that the patient can understand.

Preparing and supporting patients and families to participate in care at the level they choose.

Providing care across the continuum; designing systems that promote seamless transitions between home, hospital, primary health care, and the community.

D. Eligible Institutions

All hospitals that offer health care services are eligible to apply for accreditation.

E. Organization of the standards Manual

This manual follows the structure of the hospital standards. They are divided into 15 clusters as follows:

Cluster 1: Ethics and Patients’ Rights

Cluster 2: Access and Continuity of Care

Cluster 3: Patient Care

  • Patient Assessment
  • General Care
  • Surgical Care
  • Anesthesia and Sedation Care
  • Emergency Services
  • Dental Care
  • Critical Care
  • Neonatal Care
  • Pediatric Care
  • Obstetric Care
  • Dialysis Services
  • Rehabilitation Services
  • Fertilization Services

Cluster 4: Diagnostic Services

  • Laboratory
  • Blood Bank
  • Radiology Services

Cluster 5: Medication Management

Cluster 6: Infection Prevention and Control

  • Sterilization

Cluster 7: Environmental Safety

Cluster 8: Support Services

  • Housekeeping
  • Food Service and Kitchen
  • Laundry

Cluster 9: Quality Improvement and Patient Safety

Cluster 10: Medical Records

Cluster 11: Information Management

Cluster 12: Human Resources Management

  • Employee Health

Cluster 13: Management and Leadership

Cluster 14: Education and Training

  • Patient and Family Education
  • Employee Training and Education

Cluster 15: Research

For each cluster, there is an intent statement that assists the staff to understand the standards and a list of the key documents that are required for review by the surveyors. In each cluster, every standard is listed followed by the measurable elements, and survey process. The survey process is identical to what the surveyors will look for to determine how to score the standard.

F. Classification of standards

Standards are classified as critical, core, and stretch. The guiding definitions are as follows:

Critical (69 Standards)
Critical standards are those standards that address laws and regulations or, if not met, may cause death or serious harm to patients, visitors, or staff.

Core (317 Standards)
Core standards are the standards addressing systems, processes, policies and procedures that are important for patient care. However, partially met compliance with these standards must not pose a threat of harm or death for patients, visitors or staff.

Stretch (40 Standards)
Stretch standards are standards that are important, but not easy to implement due to time or resource constraints, or a need for culture change.

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