Licensure, Certification and Accreditation hospitals must meet various requirements in order to legally function as hospitals. Three avenues/requirements are: state licensure, based on minimum state requirements for a hospital; DHHS certification based on requirements for participating in Medicare and Medicaid; and JCAHO accreditation, based on meeting standards set by the Joint Commission. Though JCAHO accreditation is an indication of at least better-than-State standards for performance and quality of care, the accreditation process has some inherent weaknesses.

The Role of Accreditation

In order to understand the role of "Accreditation" in health care, particularly for hospitals, it is best to also review the nature and roles of "Licensure" and "Certification." All three terms apply to many types of health care providers; however, this work focuses on hospitals. As we learned in our course, hospital "Licensure" is overseen by State governments and is usually administered by each State's department of health. Essentially, a license is a privilege to operate as a hospital, based on meeting minimum standards for sufficient facilities, safety, space, equipment and personnel. For example, the New York State Department of Health governs licensure for medical facilities within New York State, oversees hospital performance, may suspend or revoke a hospital's license and imposes fines for violations (New York State Department of Health, 2001). Consequently, the role of licensure is to establish, maintain and monitor minimum State standards for the privilege of operating as a hospital. We also learned that hospital "Certification" is governed by the Department of Health and Human Services and allows hospitals to participate in Medicare and Medicaid programs, provided the hospitals meet "conditions of participation" (Centers for Medicare & Medicaid Services, 2012). Consequently, the role of certification is to establish, maintain and monitor minimum...

Accreditation is governed by the Joint Commission on Accreditation of Hospitals (JCAHO). Founded in 1951, JCAHO began as united effort of the American College of Surgeons, the American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association (Joint Commission, 2012). With a mission statement "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value" (Joint Commission, 2012) and a vision statement of "All people always experience the safest, highest quality, best-value health care across all settings" (Joint Commission, 2012), this nonprofit organization is dedicated to voluntarily accrediting health care organization that meet a higher-than-State standard of performance. Consequently, the role of accreditation is to establish, maintain and monitor exceptionally high standards of performance and care (Levine, 2007). If a hospital has JCAHO accreditation, it is automatically nationally known to have voluntarily met the Joint Commission's high standards (Joint Commission, 2012). In addition, JCAHO has taken on a new role of helping health care providers find "solutions to health care problems" (Gebhart, 2011); consequently, accreditation also means that the hospital is associated with a powerful amalgam of highly skilled health care providers who are consciously finding health care solutions.
Weaknesses Inherent in the Health Care Accreditation Process

Some inherent weaknesses of the accreditation process have been detected. David Greenfield and Jeffrey Braithwaite amassed and examined the results of 66 studies on various accreditation programs,…