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The Role of System Accreditation Post-Pandemic


By Rommie Johnson, Associate Director, Ambulatory Health Care

As the nation steadily continues to emerge from the global pandemic, health care leaders across the country are exploring ways in which they can proactively and continuously reduce unnecessary risk across their sites through standardization.

Joint Commission system accreditation is an increasingly popular standardization option. System accreditation is a Joint Commission survey model that awards a single accreditation decision to an ambulatory “system,” usually composed of a headquarter site and multiple sites. The main site is visited to assess system-wide policies and functions and then a sample of sites are visited to assess the execution of the policies as well the delivery of care. Any ambulatory care system site that provides surgery, general sedation or moderate sedation must be surveyed.

This survey model lends itself well to ambulatory care, where multiple settings within the system can include:

  • convenient care clinics
  • correctional health care centers
  • diagnostic imaging centers
  • freestanding emergency care clinics
  • kidney care/dialysis centers
  • large medical groups
  • medical group practices
  • pain clinics
  • primary care centers 
  • sleep centers
  • telehealth systems

Through system accreditation, organizations utilize a framework of standards and processes to:

  • streamline management
  • reduce inefficiencies
  • ensure regulatory compliance
  • accommodate site expansion
  • prioritize resources

Additionally, system accreditation helps ambulatory health care organizations address these prominent areas of challenge:

  • standardization and integration
  • clinical concerns 
  • industry competition and staff retention
  • regulatory environment
  • financial risks and inefficiencies
  • data collection and performance measurement

Five Steps to Systemwide Success
When asked about key strategies that help streamline the accreditation process, accredited systems offered the following five tips: 

1. Establish an effective governance structure to provide oversight and support

  •  A central governance structure with effective communication ensures that clinics do not have fragmented policies. Processes such as how to disinfect equipment or how to address a patient that may show symptoms of a communicable disease should be standardized across sites. 

2. Identify standards “Chapter Champions”

Once an organization has made the decision to pursue accreditation, it is key to take a deliberate effort to review the standards and perform a gap analysis. There are approximately 16 chapters  in the Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) spanning topics such as:

  •  medication management
  • infection prevention and control
  • emergency management
  • performance improvement

To ensure success, identify Chapter Champions who will have oversight of an assigned chapter and can coordinate with appropriate executive leadership and departments. Additionally, utilize the Chapter Champions as a channel to relay information related to current accreditation topics as well as to help the organization participate in mock surveys. This establishes accountability, provides leadership responsibilities to staff, and most importantly, reinforces staff involvement.

3. Provide monthly progress reports, including chapter status 
 Another factor that contributes to success for large multi-site organizations is the implementation of monthly progress reports and chapter status. This report does not have to be elaborate. In fact, one organization simply coded its monthly findings with red, yellow or green identifiers as a simple way to communicate current status to the leadership team. The utilization of these reports also provides a chance to bring up key issues or risk areas identified. 

4. Education on patient safety issues and related Joint Commission standards upon hire 

To sustain the great work you have built, other successful system accreditation organizations have instituted policies that mandate education and orientation into the Joint Commission accreditation process. Staff are not expected to be experts on all chapters or processes overnight, but this prepares them to be accreditation-ready with the expectation of standardization.

5. Make everyone feel involved because they are involved
Perhaps one of the most important strategies to help your organization successfully navigate the accreditation process is to ensure that every individual within your organization is involved in some capacity. It’s easier to succeed at reducing unnecessary risks through variation if there is buy-in and understanding from the entire team. Staff are a key part of puzzle that makes your organization successful in the care being provided.

For more information on accreditation, please visit You also can contact the Ambulatory Health Care Team at 630-792-5286 or

Rommie Johnson is Associate Director, Business Development at The Joint Commission. Prior to this role, he held numerous positions at Accreditation Association for Ambulatory Health Care.