Accreditation process drives surgical quality improvement, study shows

About 800 U.S. hospitals have earned accreditation from the American College of Surgeons (ACS) 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 study published in the Journal of the American College of Surgeons.

“What we learned about ACS accreditation is that it’s not just a formality. It’s a true quality filter,” said Brett Johnson, MD, MS, lead study author, clinical scholar in the ACS Division of Research and Optimal Patient Care, and a surgical resident at Baylor University Medical Center in Dallas.

The study evaluated 833 site visits between 1027 and 2023 for accreditation or verification under one of seven ACS Quality Programs: 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’s Surgery Verification (CSV), or Geriatric Surgery Verification (GSV). Today, more than 2,300 hospitals participate in the various ACS Quality Programs.

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. “Personnel and Services Resources” and “Patient Care: Expectations and Protocols” 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’t 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 “underscores how rigorous the standards are,” Dr. Johnson said. “But 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.”

ACS Quality Programs aim 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 ACS standards improve patient care and outcomes.*

“The findings of our study quantify the importance not just of ACS accreditation and verification itself, but also the value in going through the process. ACS Quality Programs are 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,” said senior study author Clifford Y. Ko, MD, MS, MSHS, FACS, Director of Quality Programs at the ACS.

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.

“This is the first large-scale analysis of initial accreditation outcomes,” Dr. Johnson said. “It spans multiple ACS programs, 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 ACS accreditation.

“This study shows that the accreditation process supports hospitals in their ongoing efforts to deliver optimal patient care,” Dr. Johnson added.

Study co-authors are Geoffrey G. Hobika, MD, and Erica McNamara.

About 800 U.S. hospitals have earned accreditation from the American College of Surgeons (ACS) 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 study published in the Journal of the American College of Surgeons.

“What we learned about ACS accreditation is that it’s not just a formality. It’s a true quality filter,” said Brett Johnson, MD, MS, lead study author, clinical scholar in the ACS Division of Research and Optimal Patient Care, and a surgical resident at Baylor University Medical Center in Dallas.

The study evaluated 833 site visits between 1027 and 2023 for accreditation or verification under one of seven ACS Quality Programs: 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’s Surgery Verification (CSV), or Geriatric Surgery Verification (GSV). Today, more than 2,300 hospitals participate in the various ACS Quality Programs.

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. “Personnel and Services Resources” and “Patient Care: Expectations and Protocols” 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’t 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 “underscores how rigorous the standards are,” Dr. Johnson said. “But 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.”

ACS Quality Programs aim 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 ACS standards improve patient care and outcomes.*

“The findings of our study quantify the importance not just of ACS accreditation and verification itself, but also the value in going through the process. ACS Quality Programs are 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,” said senior study author Clifford Y. Ko, MD, MS, MSHS, FACS, Director of Quality Programs at the ACS.

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.

“This is the first large-scale analysis of initial accreditation outcomes,” Dr. Johnson said. “It spans multiple ACS programs, 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 ACS accreditation.

“This study shows that the accreditation process supports hospitals in their ongoing efforts to deliver optimal patient care,” Dr. Johnson added.

Study co-authors are Geoffrey G. Hobika, MD, and Erica McNamara.