43-375 / Accreditation program for hospitals

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
National Center for Quality Assessment in Healthcare (NCQA)


Professional learning program on quality and safety
Program on quality and safety
Human factors
GOP Description
Implementation level
Clinical settings
hospital care level
To improve quality and safety of hospital care in Poland.
Patients, hospital management, healthacare professionals.
– offering educational training for hospitals which entered the process
– conducting accreditation survey
– providing the accreditation report indicating the area for improvement;
Timeframe implementation
It took us about 3 years to introduce and implement the national level accreditation program.
For a hospital it takes at least one year to adjust hospital performance to the accreditation standards requirements.
Implementation tools available
– accreditation standards
-accreditation procedure
– training and retraining of surveyors
educational activities for hospitals and staff
Implementation cost
It would be difficult to estimate implementation costs as accreditation department is just one of the few other ones at NCQA and we have a single budget for overall functioning.
Method used to measure the results
– level of compliance to accreditation standards
– implementation of surgical safety checklist
– appropriate antibiotic prophylaxis
– monitoring of HCAIs
– introduction of R&L; systems for ADEs
– patient surveys
Analysis of the results
-feedback is provided to hospitals during the consecutive accreditation surveys;
– discussion with quality teams and hospital leaders during hospital visits
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
resistance to change of healthcare professionals (especially doctors)
lack of the requirement to analyse own clinical practice
Describe the strategies used to overcome the barriers (If needed)
education and training for hospitals
Other information
Other information about the GOP that you would like to add (Link or attached document)
There is no specified text here