Healthcare Accreditation Explained: What It Is, Who It’s For, and How Organizations Prepare

Healthcare Accreditation Explained: What It Is, Who It’s For, and How Organizations Prepare

Healthcare accreditation is a major player in the United States for ensuring quality, safety, and consistency across the healthcare system. For any healthcare provider whether a hospital or medical association, accreditation is not only tied to regulatory compliance but also patient trust.

For many companies, accreditation can feel like an overwhelming burden. Constantly evolving standards, paperwork, educational requirements and working with your learners to ensure everyone is compliant.

This guide explains what healthcare accreditation is, who oversees it, what it typically requires, and how organizations prepare, with particular attention to the role of education, credentialing, and continuing professional development.

What Is Healthcare Accreditation?

Healthcare accreditation, like any accreditation, if the official review of the to assess if the healthcare organization is meeting the required standards set by the accreditation body. These can vary widely depending on what type of accreditation the organization is looking for.

Accreditation is generally:

  • Voluntary, but often required for payer participation
  • Standards-based and evidence-driven
  • Conducted on a recurring cycle, not a one-time event

For many providers, accreditation supports:

  • Medicare and Medicaid participation
  • Contracts with commercial payers
  • Public trust and organizational credibility
  • Internal quality and safety improvement efforts

Critically, accreditation is not just a one time process but must reflect the healthcare organizations commitment to maintaining the compliance.

Major Healthcare Accrediting Bodies in the U.S.

Several nationally recognized organizations oversee healthcare accreditation in the United States. Each focus on different care settings, provider types, or operational standards.

Common accrediting bodies include:

Every accreditation body has its own set of rules, procedures, reviews, and renewal timelines. Each healthcare organization can choose which accreditation to apply for.

Accreditation vs. Credentialing in Healthcare: What’s the Difference?

In healthcare, accreditation and credentialing are closely related, but they are not the same.

Knowing the difference is critical for an organization to know what departments to allocate their resources.

Healthcare Accreditation

Accreditation applies to organizations and programs. It evaluates whether healthcare entities meet defined standards related to quality, safety, governance, and operations.

Accreditation answers the question:
“Does this organization or program meet required standards?”

Healthcare Credentialing and Continuing Education

Credentialing applies the individual doctor, nurse or employee. It ensures they are up to date in their licensure including their continuing education.

Credentialing answers the question:
“Is this professional qualified, licensed, and up to date?”

This is where continuing education (CE) and continuing medical education (CME) requirements play a critical role and where education teams are often deeply involved.

Most healthcare organizations must support both accreditation and credentialing simultaneously.

Major Healthcare Credentialing and Continuing Education Bodies

In addition to organizational accreditation, many healthcare providers must align with nationally recognized credentialing and continuing education bodies.

ACCME (Accreditation Council for Continuing Medical Education)

ACCME is the main body that accredits organizations or associations who provide continuing medical education (CME/CE) for physicians and healthcare teams.

ACCME standards emphasize:

  • Educational independence
  • Outcomes-based education
  • Documentation of participation and credit
  • Continuous improvement in educational quality

Groups that offer CME must show reliable systems for tracking, reporting, and maintaining compliance with ACCME requirements.

ANCC (American Nurses Credentialing Center)

ANCC oversees accreditation for continuing nursing education (CNE) providers and credentialing programs.

ANCC-accredited organizations are expected to:

  • Track learner participation and credit
  • Align education with nursing competencies
  • Maintain documentation for audits and renewals

ACPE, AAPA, and Other Profession-Specific Bodies

Depending on the care setting and audience, organizations may also support education aligned with:

  • ACPE (pharmacy education)
  • AAPA (physician assistant education)
  • Specialty boards and professional societies

For multidisciplinary healthcare organizations, managing education across professions adds significant operational complexity.

What Healthcare Accreditation Typically Requires

While every accrediting body has their own requirements, there are still some commonalities.

Documented Policies and Procedures

Organizations must demonstrate that clinical and operational processes are:

  • Clearly defined
  • Consistently applied
  • Regularly reviewed and updated

Staff Training and Competency

Nearly all accreditation standards include requirements related to:

  • Initial onboarding education
  • Ongoing training
  • Role-based competencies
  • Evidence that staff understand and follow policies

Performance Improvement and Quality Monitoring

Accreditation bodies expect organizations to:

  • Monitor performance metrics
  • Identify risks and gaps
  • Implement improvement initiatives
  • Document outcomes over time

Audit-Ready Documentation

Surveyors often request proof and not just states that include:

  • Training records
  • Competency validations
  • Policy acknowledgments
  • Evidence of corrective actions

Initial Accreditation vs. Ongoing Compliance

Although an initial accreditation is time and labor intensive, it does not end there. There is ongoing compliance that must be met.

Organizations must maintain:

  • Continuous compliance
  • Ongoing education and documentation
  • Readiness for recurring or unannounced surveys

This can be especially challenging for large, distributed, or fast-growing healthcare organizations.

Sustainable success depends on repeatable systems, not last-minute preparation.

The Role of Education in Accreditation and Credentialing

Education sits at the intersection of accreditation and credentialing.

Organizations are expected to demonstrate that:

  • Staff receive appropriate, role-specific training
  • Education supports competency and quality standards
  • Training evolves as standards and regulations change
  • Participation and outcomes are documented consistently

As requirements grow more complex, manual tracking methods often become unsustainable.

Where Technology Fits In

To manage education at scale, which includes tracking every learner’s activities and CME/CE completions a healthcare organization typically uses an LMS.

A learning management system (LMS) can help organizations:

  • Deliver role-based education across teams and locations
  • Track completions, competencies, and credit
  • Maintain audit-ready records
  • Support continuous compliance and not just survey preparation

Platforms like OasisLMS are designed to support regulated learning environments, including continuing education, compliance training, integration with ACCME PARS and accreditation-related education workflows.

Accreditation as a Long-Term Strategy

The best healthcare organizations don’t view accreditation as a chore. Instead, they view it as a framework to continuously improve health outcomes. For example, they use it for:

  • A framework for quality improvement
  • A driver of safer patient care
  • A catalyst for stronger education and compliance systems

By aligning the requirements set by the accreditation board, high quality education, and the right technology ecosystem, healthcare organizations can ensure they are always ready to be audited.

Final Thoughts

Healthcare accreditation is complex and can be scary. However, if you have the right team and systems in place it can become more manageable.

By understanding:

  • The role of accrediting and credentialing bodies
  • The central importance of education and competency
  • How accreditation and credentialing intersect
  • Why sustainable systems matter

Healthcare organizations can approach accreditation with greater confidence and long-term success.

 

Sam Hirsch

Vice President, Sales and Marketing

Sam Hirsch is the Vice President of sales and marketing at 360 Factor. He has helped over 250 associations find the right LMS for their organization.

Share on socials:
oasis lms

Deliver learning that drives impact

Whether managing CME for physicians or supporting member growth, Oasis LMS helps deliver high-impact education efficiently and at scale.

Book a demo
Walk through use cases with us
Deliver learning that drives impact with Oasis LMS