What Is Accreditation in Healthcare? How It Works in the US and Canada

To answer what is accreditation in healthcare in one line: an outside body checks a hospital, clinic, or care program against set standards for safety and quality, then grants accreditation for a fixed term. Surveyors visit, watch care, talk to staff, and read your policies and records.

In the US, accreditation can stand in for a state survey and let you bill Medicare. In Canada, Accreditation Canada runs a four-year cycle for hospitals and health authorities.

This guide explains how accreditation differs from licensure, which bodies accredit which settings, how the survey process works, and how to prepare with the READY Method.

Key Takeaways

 

• Accreditation is an independent review of an organization against published quality and safety standards.
• Licensure is mandatory. Accreditation is voluntary, but it often unlocks Medicare billing, payer contracts, and funding.
• CMS approves nine general accrediting organizations, including The Joint Commission, DNV, and ACHC.
• In Canada, Accreditation Canada applies Health Standards Organization standards on a four-year cycle.
• Surveyors judge you on written evidence. Policies that match practice carry the survey.

Healthcare Accreditation, Defined

 

Accreditation looks at an organization or program. It does not look at one person. Surveyors check how you are run, how you give care, how you keep patients safe, how you train staff, and how you control infection.

They also read the records that prove each one. ACHC calls accreditation an official review that lets you show you meet the rules and standards.

Doctors, nurses, and therapists go through credentialing instead. A hospital holds accreditation, and it also checks the credentials of its clinical staff. The two work together, but they answer different questions.

Accreditation vs Licensure vs Certification

 

Factor	Licensure	Certification	Accreditation
Issued by	State or provincial government	CMS, through a state survey agency (US)	An independent accrediting organization
Required?	Yes, to operate	Yes, to bill Medicare by the state route	Voluntary
Purpose	Permission to operate	Proof of meeting Medicare conditions	Proof of meeting the accreditor’s standards
Example	A state hospital license	A state survey for a home health agency	Joint Commission or CARF accreditation

CMS describes two routes into Medicare. You can pass a state survey, or you can choose accreditation from a body CMS has approved. The second route is your choice, and CMS calls the result deemed status.

Why Healthcare Organizations Seek Accreditation

 

• Medicare participation: Deemed status lets an accredited facility meet Medicare conditions without a separate state survey.
• Payer recognition: Many third-party payers recognize accreditation, which ACHC lists as a core benefit.
• Quality and safety: Survey findings show where your processes fall short and how to fix them.
• Contracts and funding: Government contracts, referral networks, and grant programs often ask for proof of accreditation.

The last point catches many providers off guard. A mental health agency bidding on a county contract, or a group home applying for funding, can lose points without it. Some lose the right to apply at all. If you plan to bid, The Write Direction’s RFP team can check the accreditation terms before you commit.

Healthcare Accreditation in the United States

 

Deemed Status and CMS-Approved Accrediting Organizations

 

The CMS Accrediting Organizations page says CMS approves an accreditor only after it reviews the accreditor’s standards and survey process.

Those standards must meet or beat Medicare’s own rules. Under 42 CFR 488.5, an approved accreditor must also run unannounced resurveys at least once in 36 months.

CMS lists nine general accrediting organizations: ACHC, Quad A, AAAHC, CIHQ, CHAP, DNV Healthcare, The Joint Commission, NDAC, and The Compliance Team. Deemed programs include hospitals, surgery centers, home health, hospice, rural health clinics, dialysis centers, outpatient physical therapy, and labs. Our guide to CMS Conditions of Participation explains how those conditions shape a survey.

Hospitals choosing between the two largest accreditors can compare them in our breakdown of DNV vs Joint Commission. If you see “JCAHO” in older documents, that is The Joint Commission’s former name; our post on Joint Commission vs JCAHO covers the history.

Accreditors Outside CMS Deeming

 

Some accreditors work in settings that Medicare deeming does not cover. CARF is an independent nonprofit founded in 1966.

It accredits mental health and addiction services, aging services, child and youth services, and rehab programs, among others. Health plans often turn to NCQA or URAC.

Healthcare Accreditation in Canada

 

Canada splits the work in two. The Health Standards Organization (HSO) writes the standards. Its partner, Accreditation Canada, runs the surveys. The Health PEI 2026/2027 accreditation toolkit shows how its Qmentum Global program works:

• Four-year cycle: An accreditation decision stays valid for four years.
• Split survey: Outside surveyors visit twice in the cycle, follow patients through care, and may arrive on short notice.
• Required Organizational Practices (ROPs): Health PEI must meet 25 ROPs, such as hand hygiene and falls prevention.
• Four decision levels: Accredited with Exemplary Standing, Accredited with Commendation, Accredited, and Not Accredited.

Decision level	ROPs met	Other criteria met
Accredited with Exemplary Standing	100%	At least 95% of normal and high-priority criteria
Accredited with Commendation	At least 90%	At least 85% of normal and high-priority criteria
Accredited	At least 80%	At least 75% of high-priority and 70% of normal criteria
Not Accredited	Below these thresholds	Below these thresholds

Community and group home providers in Canada also use CARF Canada, part of the CARF group.

Which Accreditor Fits Which Setting

 

Setting	Common accreditors
Hospitals (US)	The Joint Commission, DNV, ACHC
Ambulatory surgery centers	AAAHC, Quad A, ACHC
Home health and hospice	ACHC, CHAP, The Joint Commission
Behavioral health and addiction treatment	CARF, The Joint Commission
Aging services	CARF
Child and youth services	CARF
Health plans and care management	NCQA, URAC
Hospitals and health authorities (Canada)	Accreditation Canada

Check the scope with each accreditor before you apply. Fees and survey cycles differ. Some payers and funders also name one accreditor in their contracts.

How the Accreditation Process Works

 

Most accreditors follow a similar sequence:

1. Apply: You open an account, pick a program, and send in details about your group.
2. Self-check: You read the standards and fix the gaps you can find. ACHC offers workshops and workbooks at this stage.
3. Site visit: Surveyors watch care, talk to staff, and read your documents. Accreditation Canada surveyors follow patients through care to test each step.
4. Findings and fixes: You get a list of gaps and send back a plan to fix them.
5. Decision: The accreditor grants, limits, or denies accreditation.
6. The cycle continues: ACHC reviews operations on a three-year cycle (two years for clinical labs). Accreditation Canada runs a four-year cycle.

The READY Method for Accreditation Preparation

 

Surveyors judge you on what they can see and read. Your written policies have to match your practice, and your records have to prove it.

• R, Requirements: List the standards that apply to your setting and program. Pull the accreditor’s current manual, not last cycle’s.
• E, Evidence: Map each standard to the policy, procedure, form, or record that proves it. A crosswalk table makes gaps visible.
• A, Assess: Run a mock survey or tracer. Ask a staff member to walk through a policy and see whether practice matches the page.
• D, Document: Write or revise the policies that fall short, then train staff on the changes and keep the sign-off records.
• Y, Year-round: Keep a review calendar so policies stay current between surveys. Unannounced resurveys leave no time to catch up.

Our guide to Joint Commission documentation requirements shows what surveyors ask for under Accreditation 360. The Write Direction builds crosswalks and policy manuals for providers preparing for their first survey or their next one.

Frequently Asked Questions

 

What is the purpose of accreditation in healthcare?

 

Understanding what is accreditation in healthcare starts with its purpose. It gives patients, payers, and regulators outside proof that you meet set standards for safety and quality. In the US, it can also give you deemed status for Medicare. And the survey shows you where your own care falls short.

Is healthcare accreditation mandatory?

 

In most cases, no. Licensure is the step you must take to operate. In the US, CMS treats accreditation as one of two routes into Medicare; the other is a state survey. Still, some payers, funders, and contracts require it. For many providers, that makes accreditation a must in practice.

What is the difference between accreditation and licensure?

 

A state or provincial government issues a license, and you need it to operate within the law. An outside body grants accreditation, and you choose to seek it. A license sets the floor. Accreditation checks you against a wider set of quality and safety standards, and it runs on a fixed survey cycle.

How long does healthcare accreditation last?

 

It depends on the accreditor. ACHC works on a three-year cycle, or two years for clinical labs. Accreditation Canada decisions last four years. US federal rules make CMS-approved accreditors resurvey deemed providers at least once in 36 months, without warning. Check your accreditor’s manual for your exact cycle.

Who accredits hospitals in Canada?

 

Accreditation Canada, an affiliate of the Health Standards Organization, accredits Canadian hospitals and health authorities such as Health PEI.

Its Qmentum Global program runs on a four-year cycle with required safety practices and four decision levels. If you are looking into what is accreditation in healthcare in Canada, note that provincial rules differ, so check with your ministry of health.

Getting Your Organization Accreditation-Ready

 

Accreditation is an outside check that you meet set standards. In the US, it can also open the door to Medicare through deemed status.

The right accreditor depends on your setting, your country, and the payers and funders you work with. Whichever you choose, surveyors will read your policies, and those policies need to match what your staff do.

At The Write Direction, we write and update policy manuals, procedure sets, and standards crosswalks for hospitals, behavioral health agencies, and community care providers across the United States and Canada. Explore our healthcare compliance writing services or our policy manual writing service.

Ready to start? Book a consultation or email us at [email protected].