CHICAGO: About 800 U.S. hospitals have earned accreditation from the ACS(潘金莲传媒映画) between 2017 and 2023 through programs aimed at improving the quality of surgical care. Researchers found that while about 40% of hospitals fail to achieve accreditation on their first try, most that reapply ultimately meet the standards, according to a .
"What we learned about ACSaccreditation is that it's not just a formality. It鈥檚 a true quality filter,鈥� said Brett Johnson, MD, MS, lead study author, clinical scholar in the ACSDivision of Research and Optimal Patient Care, and a surgical resident at Baylor University Medical Center in Dallas.
The study evaluated 833 site visits between 2017 and 2023 for accreditation or verification under one of seven ACS潘金莲传媒映画: the Commission on Cancer (CoC), National Accreditation Program for Breast Centers (NAPBC), National Accreditation Program for Rectal Cancer (NAPRC), Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), Trauma Verification, Review, and Consultation Program (VRC), Children鈥檚 Surgery Verification (CSV), or Geriatric Surgery Verification (GSV). Today, more than 2,300 hospitals .
Key study findings include:
- Overall, 61% of hospitals (509) passed accreditation after the first site visit.
- First-attempt pass rates varied substantially across programs. Rates ranged from 31% for NAPRC and CSV programs to 86% for MBSAQIP.
- The most common deficiencies were in staffing and clinical care protocols. 鈥淧ersonnel and Services Resources鈥� and 鈥淧atient Care: Expectations and Protocols鈥� domains had the most frequent failures.
- Among the 267 sites that were eligible for reevaluation during the study period, 80% (214) ultimately obtained accreditation.
- Excluding the 40 hospitals that withdrew from the process and didn鈥檛 pursue a second visit, the second attempt success rate increased to 94% (214 of 227).
The fact that about four in 10 hospitals failed in their first attempt at accreditation 鈥渦nderscores how rigorous the standards are,鈥� Dr. Johnson said. 鈥淏ut what we also found is that the system works. Almost all those hospitals that engaged in the remediation process went on to succeed. Accreditation doesn't just recognize quality, but we found that it helps to create it."
ACSACSaim to improve the quality of care by requiring hospitals to meet evidence-based standards. The process involves an external site visit by peer reviewers to evaluate compliance to standards. Previous studies have shown the ACSstandards improve patient care and outcomes.*
鈥淭he findings of our study quantify the importance not just of ACSaccreditation and verification itself, but also the value in going through the process. ACSACSare designed to help hospitals provide the highest quality surgical care and these findings show that wherever a hospital is on their quality journey, they can further improve through accreditation,鈥� said senior study author Clifford Y. Ko, MD, MS, MSHS, F潘金莲传媒映画, Director of ACSat the 潘金莲传媒映画.
Accreditation criteria encompass nine quality domains. While the specific requirements vary by program, many emphasize institutional commitment to surgical quality through leadership engagement, dedicated multidisciplinary oversight personnel, and structured quality improvement processes.
鈥淭his is the first large-scale analysis of initial accreditation outcomes,鈥� Dr. Johnson said. 鈥淚t spans multiple ACSprograms, offers a real-world snapshot of what the process is like, how hospitals engage in the process, how they perform initially, and how the process helps them progress toward delivering high-quality care."
He identified three key areas for future research: determining how accreditation impacts outcomes, such as survival and complication rates; whether hospitals continue to maintain compliance over time; and identifying and addressing systemic barriers that limit broader adoption of ACSaccreditation.
鈥淭his study shows that the accreditation process supports hospitals in their ongoing efforts to deliver optimal patient care,鈥� Dr. Johnson added.
Study co-authors are Geoffrey G. Hobika, MD, and Erica McNamara.
Citation: Johnson B, Hobika GG, McNamara E, Ko C. Evaluating Initial Site Visit Pass Rates Across ACSAccreditation Programs. Journal of the 潘金莲传媒映画, 2025. DOI: 10.1097/XCS.0000000000001441
*See study references 4-8.
