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Attaining and Maintaining Ambulatory Health Care Accreditation


Two male healthcare workers and two female healthcare workers sitting together with notebooks in front of them.

By Warria Esmond, MD, Chief Medical Officer, Settlement Health

For many ambulatory care organizations, seeking and maintaining accreditation are a chief priority – especially as accreditation significantly influences the day-to-day care provided to patients through the implementation of standardized processes to improve efficiency and reduce variation. 

Joint Commission accreditation allows organizations to demonstrate they go above and beyond in patient safety and quality of care. More than that, it affords organizations the opportunity for dialogue and collaboration, both with The Joint Commission and within their own organization.

Between my current position at Settlement Health and previously at a large hospital system on Long Island, I have become well versed in the survey process with The Joint Commission. Securing accreditation takes more than just one person, but I’ve had the unique privilege of helping lead Settlement Health on its road to accreditation. 

Working with staff from a broad range of departments, we became familiar with Joint Commission standards and took a closer look at how our organization was functioning. In all, we spent about two years getting everyone up to speed on the standards and preparing for the initial three-day survey, which took place in March 2008.

Benefits of Accreditation 
The survey itself went smoothly and was incredibly informative. Our surveyors had acute knowledge of the ambulatory sector; one of them was even the Chief Medical Officer of a health center. Overall, the survey: 

  • promoted collaboration across leadership and staff
  • highlighted areas where we were excelling as well as a few areas that needed improvement
  • offered strategies to staff to improve the performance of day-to-day operations
  • provided tools to implement improvements, even in areas where there were no findings

In the end, we found out we had passed with flying colors. Today, we continue to proudly share our accreditation achievement on our website and with the patients we treat. Our staff have really taken an interest in promoting what it means to have Joint Commission accreditation and take pride in all that goes into maintaining our accreditation.

We constantly review the standards and carry out mock surveys on a regular basis to ensure we’re always providing the best possible care for our patients. Every two weeks, we meet to make sure everyone understands what’s expected of our organization and train staff on standards that are pertinent to them, especially on initiatives relating to National Patient Safety Goals (NPSGs). 

Although Joint Commission reaccreditation surveys occur every three years, we always keep up to date on any changes to the standards and are confident in our ability to ace our evaluation at any time.

Warria Esmond, MD, is Chief Medical Officer at Settlement Health, a community health clinic located in East Harlem New York, that offers a full range of primary care family medicine services. Dr. Esmond also is Chief Clinical Officer at AllianceChicago, a health center control network funded by the Health Resources and Services Administration (HRSA), to support health centers’ use of electronic health records.