A Systematic Evaluation of an Accreditation Readiness Program at an Academic Medical Center

Purpose: The purpose of this scholarly project was to complete a systematic evaluation of an accreditation readiness program at a tertiary care center.

Methods: A systematic review of the literature was performed to determine current accreditation readiness practices implemented at like institutions. Once completed, a program evaluation was conducted, utilizing the CDC 6-step Framework. After performing a stakeholder assessment, compliance data gathered during the institution’s accreditation readiness program, Fridays Before Five (FBF), was compared with results from the hospital’s 2021 Joint Commission Final Accreditation Report.

Results: The program evaluation determined that FBF was effective in preparing the institution for a Joint Commission survey when rounds were completed as intended. Compliance issues were identified, regarding assessment completion and rectifying deficiencies recognized during rounds. Recommendations were made for improved leadership oversight to ensure that evaluations were done and issues resolved in a timelier manner. Additional recommendations included increased surveillance by content experts on more complex issues that were not addressed as part of the FBF program. Stakeholders agreed that sending survey results electronically and improving the availability of contact lists and educational handouts during rounds would enhance the program’s outcomes. Finally, conducting ongoing program evaluations annually was determined to be critical in ensuring stakeholder engagement.

Practice Implications: In this work, the author identified the value of a regulatory readiness programs, and put forth specific strategies that can be implemented at other similar institutions to improve accreditation survey outcomes.