Ensuring Quality: Overcoming Hurdles to Hospital Accreditation


In the health care industry, the Joint Commission’s accreditation programs are the gold standard for quality, and many states rely on the JC’s health care facility surveys to uphold their public oversight activities. When a multi-campus health care system with 300 acute care and 20 mental health beds failed its re-accreditation application, it was placed on conditional status. This not only had financial implications; it changed the system’s reputation for top-notch care. Alacer was asked to intervene and help it pass its next re-accreditation survey with flying colors.


Alacer only had six months between re-accreditation surveys to reverse the system’s standing. Initial observations showed the medical center focused on quality reporting rather than continuous quality improvement (CQI). Working with hospital staff, the Alacer team rolled out a Lean Six Sigma approach, coupled with a clinical behavior program (Studor Group’s AIDET), to address problematic internal processes. Some of the integrated program work completed within the short time span included development of training materials, documentation and floor care audits, self-tracers and observed drill-tracers – all areas identified as needing improvement by the JC.


The health care system passed its same-year JC re-accreditation survey with ease, reducing its citations and RFIs by 283%. While not the primary focus, incidental savings of $4.5 million were achieved through reductions in supplies, labor costs and reclaimed revenue due to improvements in coding and billing.