Structure, function, and impact of hospital accreditation in South Korea: a narrative review

Introduction

Overview of hospital accreditation

Health care services accreditation is a comprehensive framework that can apply various methodologies and generate synergistic values (1). Hospital accreditation is widely recognized as a tool for improving healthcare systems and evaluating the quality of care (1-4). Many countries implement hospital accreditation as an effective strategy to assure and improve the quality of healthcare services (4-13).

The first hospital accreditation was founded and conducted by the American College of Surgeons in 1917, and several types of hospital accreditation programs have developed (14,15). When government-led hospital licensing is a compulsory process requiring compliance with minimum standards to ensure patient safety, hospital accreditation is often performed by non-governmental organizations, requiring voluntary participation by hospitals and adherence to the highest standards (9). Hospital accreditation, in contrast to relative evaluation systems that rank institutions, operates as an absolute evaluation system, assessing whether medical institutions meet predefined accreditation standards. This process involves awarding an accreditation mark (16,17), typically valid for 4 years, to institutions that achieve a designated level of compliance with the established accreditation survey standards (18,19).

According to the literature on hospital accreditation, positive effects include the establishment of organizational structure and processes, improvement in quality and safety culture, enhancement of patient care, and the development of professional expertise (1,15,20). Although systematic reviews of the effectiveness of hospital accreditation have shown positive aspects, existing studies have not provided definitive evidence to support these conclusions. There is also some evidence suggesting negative aspects of accreditation (21). For instance, accreditation has been reported to negatively impact the learning environment of medical students and residents by reducing clinical learning opportunities and increasing non-medical administrative tasks (9,22).

Importance of hospital accreditation

Establishing unified standards according to hospital accreditation assessment criteria ensures consistency in how all staff perform their duties. This standardization could reduce variations in healthcare service delivery methods that existed on an individual, departmental, or institute level. Such standardization extends across all areas including clinical operations, staffing, and facility management, thereby enhancing overall workforce utilization and operational efficiency within the hospital. Particularly, hospital accreditation systems prioritizing patient safety require measures to predict and prevent potential patient safety incidents, thus reducing medical errors and adverse events (1).

Among Organization for Economic Cooperation and Development (OECD) countries, South Korea placed first on the number of hospital beds in 2021, with 14 beds per 1,000 people, which is 2.9 folds the OECD average of 4.3 beds. However, in 2020, the number of public hospital beds in South Korea was 1.2 per 1,000 people, which is lower than the OECD average of 2.8 beds. In 2021, the proportion of public hospital beds among all beds is 9.5%, the lowest among OECD countries, and only about one-seventh of the OECD average of 72% (23,24). Therefore, it is necessary to establish standards for systems and services in privately operated hospitals, which manage their operations autonomously, to ensure equitable access to medical services for all citizens. In this context, the need for hospital accreditation is even greater.

Since the Middle East respiratory syndrome (MERS) outbreak in 2015, South Korea has strengthened hospital accreditation standards, leading to improvements in healthcare institutions’ infectious disease response systems. This has enabled healthcare facilities to cope effectively, even during the coronavirus disease 2019 (COVID-19) pandemic (25). Despite the global interest in how South Korea operates its hospital accreditation system, particularly following its highly regarded response to COVID-19, there has been a lack of comprehensive studies summarizing its structure, function, and impact.

Objectives and scope of the review

This article aims at reviewing how hospital accreditation started in South Korea, how many hospitals participate in the accreditation, its effectiveness, and identifying its challenges and issues. This in return can provide insights for countries looking to adopt or enhance accreditation systems. We present this article in accordance with the Narrative Review reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-98/rc).

Methods

Search strategy of this narrative review

Searching PubMed for articles with abstracts containing both “hospital accreditation” and “Korea” yielded 30 articles. On Web of Science, a search for articles including “hospital accreditation” and “Korea” in the “Title/Keywords/Abstract” from 2017 onward returned 32 results. Using Google Scholar, we identified 155 articles published since 2017 containing “hospital accreditation” and “Korea”. On the Korea Citation Index (KCI), 36 open-access articles with the same keywords were identified. Searching DBpia, a Korean academic database, produced 26 articles published since 2020 (Table 1).

Of the 279 articles initially identified, 35 duplicates were removed, leaving 244 articles. After screening titles and abstracts, we excluded articles related to medical education, clinical practice guidelines, laboratory accreditation, and nursing education programs, leaving 74 articles. Finally, after examining the full texts, 11 articles were deemed relevant. An additional 51 references were included, comprising 17 studies cited in the references of the selected articles, 9 research reports jointly conducted by the Korea Institute for Healthcare Accreditation (KOIHA) and academic institutions, and 4 official publications issued by World Health Organization (WHO), OECD, The International Society for Quality in Healthcare (ISQua) and the Korean Society for Preventive Medicine. Additionally, newspaper articles were reviewed to gain insights into societal perspectives on hospital accreditation (Figure 1). We obtained research reports from the website of KOIHA (https://www.koiha.or.kr/web/kr/library/rschReport_board.do).

Figure 1 Flowchart of the search process for this narrative review article. KOIHA, Korea Institute for Healthcare Accreditation.

Definition of terms

Types of hospitals are defined by article 3 of the Medical Services Act based on bed capacity and specialization (26) (Appendix 1). Hospitals are defined as medical institutions with at least 30 beds, including a hospital, dental hospital, Korean medicine hospital and long-term care hospital. A general hospital with at least 100, but not more than 300 beds shall have at least seven specialized departments. The Minister of Health and Welfare may designate a general hospital providing highly specialized medical services for treating serious diseases as a tertiary hospital among general hospitals satisfying the following requirements: “To have at least 20 specialized departments prescribed by Ordinance of the Ministry of Health and Welfare, and have medical specialists exclusively dedicated to each specialized department” etc.

Results

Origins and development of hospital accreditation in South Korea

In South Korea, hospital accreditation began in 1981 as part of the Hospital Standardization Project by the Korean Hospital Association (Table 2). The project initially focused on training hospitals and adapted and implemented a hospital standardization assessment based on the hospital survey profile of Joint Commission on Accreditation of Hospitals (JCAH) (27,28). In 1994, the Health Care Reform Committee, an advisory body to the Minister of Health and Welfare, proposed a hospital evaluation system. The purpose of the hospital accreditation system was to evaluate healthcare services and provide compensation based on evaluation results, aiming to reduce qualitative disparities in healthcare services and deliver higher-quality health care to the public. From 1995 to 2001, the “Healthcare Institution Service Evaluation” was implemented (27,28). In 2002, regulations related to healthcare were established under the Medical Services Act requiring general hospitals and hospitals with 300 beds or more to undergo mandatory evaluation and publicly disclose the results. The “Healthcare Institution Evaluation” was fully implemented from 2004 onwards. However, due to evaluation criteria that emphasized structural aspects such as facilities, equipment, and personnel, many hospitals faced challenges requiring substantial investments in facilities to undergo evaluation. Issues arose including unintended consequences from ranking evaluation results, prompting discussions for system improvement, which led to the conclusion of the program in 2009 (29).

In June 2010, amendments to the Medical Services Act transformed the mandatory evaluation system for healthcare institutions into a voluntary accreditation system. In November 2010, a specialized institution called the “Korea Institute for Healthcare Accreditation (KOIHA)” was established to undertake accreditation tasks entrusted by the Ministry of Health and Welfare. This marked the official start of accreditation evaluation under the new system (28,30).

KOIHA, an exclusive hospital accreditation body in South Korea

In South Korea, the only hospital accreditation agency is KOIHA. Established under the Medical Services Act and designated as the Central Patient Safety Center under the Patient Safety Act, its founding purpose was to integrate and execute various evaluation tasks related to healthcare institution accreditation and other assessments, aiming to enhance the quality of healthcare and patient safety, thereby contributing to the maintenance and promotion of public health (31,32). As of July 19, 2024, during the ongoing 4th cycle (2023–2026) of acute care hospital accreditation, 1,773 hospitals had received accreditation out of 4,228 hospitals in the country (33-35).

KOIHA is responsible for providing tailored education and consulting to hospitals to enhance patient safety and healthcare quality. It also enhances the expertise of inspection committee members and establishes accreditation criteria aligned with international standards, ensuring fair and efficient execution of accreditation tasks related to healthcare institution (36).

Legal and institutional framework regulating hospital accreditation

According to article 58 of the Medical Service Act (Appendix 1) (37), the Minister of Health and Welfare has the authority to accredit hospital-level healthcare institutions to enhance the quality of healthcare and patient safety. To deliberate on major policies related to hospitals accreditation, the Ministry of Health and Welfare establishes the Healthcare Institution Accreditation Committee, chaired by the Vice Minister. Accreditation criteria for healthcare institutions must include patient rights and safety, activities to improve healthcare service quality, service delivery processes and outcomes, organizational personnel management and operations of healthcare institutions, and patient satisfaction. The Medical Services Act specifies regulations related to accreditation, including procedures for appeals, issuance of accreditation certificates and marks (16,17), public disclosure and utilization of accreditation, requests for information provision, and cancellation of hospital accreditation (26,38).

Under the Medical Service Act and various other laws (26,39), healthcare institutions must apply for accreditation evaluation to be designated as tertiary hospitals, specialized hospitals, training hospitals, research-oriented hospitals, hospitals attracting foreign patients, rehabilitation medical institutions, or hospice specialty institutions (Appendix 2). According to the Medical Services Act, long-term care hospitals are required to apply for accreditation mandatorily, considering the characteristics of healthcare services and the protection of patient rights and interests. Therefore, they have applied for accreditation evaluations since January 2013 (37,40). Mental hospitals were initially classified under long-term care hospitals and applied for mandatory accreditation evaluations from August 2013 (41). However, mental hospitals were separated and applied voluntary accreditation from 2020. Traditional Korean medicine hospitals began application for voluntary accreditation in September 2013. Dental hospitals started application for voluntary accreditation from June 2014, and rehabilitation medical institutions from December 2019 (42).

The framework for hospital accreditation is based on the following four principles (18,38). All medical institutions should strive to ensure patient safety. The system is designed to enable tracking and investigation of the care process from the patient’s perspective. Efforts are made to improve the quality of medical services and infection control, with an emphasis on supporting high-quality patient care and the expertise of functional and organizational aspects. It includes performance management aspects through indicators. The framework aims to improve the quality of medical care through the organic interaction of the basic value system, patient care system, and organizational management system, as depicted in Figure S1. It also aims for hospitals to achieve results (18,43).

Hospital accreditation standards

In the first cycle of acute care hospital accreditation standards announced by the Ministry of Health and Welfare and the KOIHA in 2011, the basic value system included activities related to patient safety and continuous quality improvement (38). In the 2018 “3rd Cycle Acute Care Hospital Accreditation Standards”, quality improvement activities previously included in the basic value system were moved to the organizational management system (44). The previous “administrative management system” was replaced by the “organizational management system”, with an emphasis on improving the quality of medical services and infection control within the organizational management system. This change reflects improvements made in response to the 2015 MERS outbreak, strengthening accreditation standards of the 2nd cycle and enhancing the system for infection disease response in hospitals (45).

In the basic diagram (37) and framework of the 4th cycle accreditation standards (Figure 2), it can be confirmed that only patient safety activities are included in the basic value system (18). The accreditation standards for acute care hospitals in the 4th cycle (2023–2026) consist of four domains, 13 chapters, 92 standards, and 512 measurable elements (MEs) (Table 3). The survey criteria have been comprehensively developed to ensure uniform application of standards to all hospitals, although the number of MEs may vary between tertiary hospitals, general hospitals and small hospitals (18,26).

Figure 2 Framework of the 4th cycle hospital accreditation standards in South Korea (18).

Hospital accreditation process and methodology

Figure S2 illustrates the accreditation process. Hospitals at the hospital level must complete an application form online through KOIHA’s website. Hospitals can autonomously apply for the accreditation survey by selecting their desired accreditation period. The KOIHA adjusts the survey schedule with the hospital, considering the preferred survey date and application sequence, and provides final notification to the applying hospital within 30 days from the receipt of the accreditation application (37).

The on-site accreditation survey examines whether the hospital adheres to the core values of “patient safety and quality improvement” by having basic principles and procedures in place, ensuring that all staff consistently perform according to these principles, and engaging in continuous quality improvement efforts from the perspective of the patient as a healthcare consumer (18).

Multiple surveyors use the tracer methodology to conduct the survey based on accreditation standards. This method involves tracking “the contents of regulations set by the hospital, the performance processes and results, and improvement activities based on those results” (31,46,47). There are two types of tracer methodology. The individual tracer method involves interviewing service-providing staff (leadership interview), patients (or guardians), reviewing medical records (document review), and observing performance processes (Table 4) (48). This method traces the path that patients experience with the provided services. The system tracer method (Figure S3) involves checking whether the medical institution has a systematic approach to key areas requiring quality management and safety (e.g., medication management, quality improvement and patient safety activities, infection control, human resources management, facility and environment management, medical information/medical record management) through interviews with responsible personnel, checking related documents, and on-site verification (18,31).

The survey methods and results for each standard of Table 3 are as follows: ‘high (10 points)’ is given if the fulfillment rate of MEs is 90% or higher. ‘Medium (five points)’ is given if the fulfillment rate is between 60% and 89.99%. ‘Low (zero points)’ is given if the fulfillment rate is below 60%. ‘Present’ is given if the fulfillment rate of ME is 100%. ‘Absent (zero points)’ is given if the fulfillment rate is below 100% (Table S1) (18).

The accreditation grade is deliberated by the accreditation committee based on assessment results—either granting ‘Accreditation’, ‘Conditional accreditation’, or ‘Denial of accreditation’ (37). KOIHA notifies the hospital of the evaluation results in writing and reports them to the Minister of Health and Welfare. The accreditation status of each hospital is publicly disclosed on KOIHA’s website. Accreditation is valid for 4 years, while conditional accreditation is valid for one year. Hospitals demonstrating a willingness to improve are granted conditional accreditation with the intention of providing opportunities for future corrections and enhancements. They operate as accredited hospitals for one year, during which they make improvement efforts. Afterward, they undergo another accreditation assessment to determine their final accreditation status (37).

The evolution of hospital accreditation standards

Among the accreditation standards, the following 12 standards of Table 3 must have no “absent” or “low” ratings to achieve accreditation. Twelve standards are accurate patient identification, accurate communication among healthcare professionals, correct performance of surgeries and procedures, fall prevention activities, hand hygiene practices, quality improvement and patient safety management system, management of patient safety incidents, infection prevention management system, infection prevention and control education, employee safety management activities, security management (applicable only to advanced general hospitals) and fire safety management activities. Notably, all items in Chapter 1 of the basic value system domain, which pertains to patient safety activities, are mandatory MEs (Appendix 3) (18).

To achieve accreditation, the following conditions should be met (Table S2). The average score of all inspection items must be eight or higher for hospitals and general hospitals, and nine or higher for tertiary hospitals. The average score for each criterion must be five or higher. The average score for each section must be seven or higher for hospitals and general hospitals, and eight or higher for tertiary hospitals. There must be no ‘poor’ ratings (‘low’) in any essential inspection item for hospitals, general hospitals, or tertiary hospitals. Information such as the hospital’s name, type, location, accreditation validity period, licensed bed capacity, and available medical specialties is publicly disclosed on the KOIHA website for accredited and conditionally accredited hospitals (49). Accredited hospitals are allowed to display the accreditation mark at their facilities (Figure S4).

KOHIA obtained international accreditation for ISQua in 2012. In 2015, it achieved international accreditation for ISQua Surveyor Education Program. In 2019, it also received international accreditation for its accreditation standards and surveyor education program from International External Evaluation Association (42). ISQua defines the scope of accreditation as “evaluation criteria used by accrediting agencies to verify the quality and safety of health care provided by healthcare providers to patients and customers”. Quality improvement and safety are included among the six principles that evaluate standards (50). Therefore, The transition of healthcare institution evaluation to accreditation in South Korea is not simply an improvement of the system but marks the beginning of a new system designed to meet international standards (28).

Impact of hospital accreditation in South Korea

Research on whether hospital accreditation improves clinical outcomes for patients in South Korea is still relatively rare. From 2010 to 2017, the study by Lee BY, Chun YJ and Lee YH targeted all acute myocardial infarction (AMI) patients admitted to general hospitals in South Korea, accounting for various patient and hospital factors. The results compared 30-day mortality rates, readmission rates within 30 days after discharge, and lengths of stay between accredited and non-accredited hospitals. The study found that the 30-day mortality rate for patients admitted to accredited hospitals was statistically significantly lower than that for patients admitted to non-accredited hospitals (Figure 3). However, there was no statistically significant difference between accredited and non-accredited hospitals in terms of 30-day readmission and length of stay after admission (51). Another study conducted by the same authors compared the quality of care within the same hospital before and after accreditation. Thirty-day mortality rates for AMI, ischemic stroke (IS), and hemorrhagic stroke (HS) patients in general hospitals newly accredited in 2014 decreased compared to before they were accredited. Specifically, the 30-day mortality rates for AMI decreased from 7.34% to 6.15%, for IS from 4.64% to 3.80%, and for HS from 18.52% to 15.81% (9). Furthermore, the 30-day mortality rates for patients with AMI and HS in hospitals that meet accreditation standards in patient care areas were lower compared to hospitals that did not meet these standards (Figure 4) (9).

Figure 3 Comparisons of three clinical outcomes between accredited and nonaccredited hospitals with multivariate modeling (51). Adjusted for sex, age, insurance type, comorbidity, admission type, health workforce, and hospital ownership and region. Multiple logistic and linear regression were used for 30-day mortality and readmission and lengths of stay, respectively. Nonaccredited hospitals were set as the reference. Black lines in the graph include 95% confidence intervals for percentage outcomes and standards for the length of stay.

Figure 4 Multiple logistic regression analyses for 30-day mortality by three evaluation domains of hospital accreditation program (9). The achievement of each domain was based on the criteria set by Korea Institute for Healthcare Accreditation, that is, 80% or more of the indicators of each domain were satisfied; adjusted for sex, age, insurance type, comorbidity, admission type, health workforce, and hospital ownership and region.

Research involving nurses in general hospitals indicates that the experience of healthcare institution accreditation has a minimal impact on overall patient safety awareness and is unrelated to the hospital’s patient safety grade (52). However, another study found significant improvements in patient safety climate with reduced underreporting of medication errors after healthcare accreditation (53).

Following the introduction of accreditation in long-term care hospitals, there has been a positive impact on patient safety and quality of healthcare. However, hierarchical and production-centered organizational cultures showed moderate changes among the four types of organizational cultures, and hospital management performance, particularly from a financial perspective, exhibited relatively lower changes compared to other perspectives (54).

The greatest achievement of the accreditation system for hospitals is that it provides specialized education on patient safety and quality improvement to healthcare personnel during the preparation for accreditation. When unified regulations are established at the institutional level, all employees perform their duties consistently according to these regulations, standardizing the healthcare service delivery that previously varied among individuals and departments. This allows for more efficient hospital management, including prevention of medical errors and accidents. Research also suggests a positive impact on employee satisfaction and morale enhancement (28). Kim et al. (55) surveyed among accreditation preparation practitioners and general workers at accredited hospitals indicate that both groups reported positive changes in patient safety, quality of care, decision-making processes, hospital organizational culture, and leadership through the process of preparing for the accreditation. Song (56) has also explored factors affecting nursing tasks of accreditation standards for long-term care hospital nurses, including turnover flexibility, marriage, education, and number of accreditations. Table 5 summarize awareness and effects related to hospital accreditation from a review of literature in South Korea from 2011 to February 2015 is worth referring to (57). According to Lee SH’s survey analysis (58), patients who were aware of the healthcare institution accreditation system were more likely to consider the accreditation status when visiting a hospital. This suggests that accreditation status influences hospital selection.

Small and medium-sized hospitals, which have been blind spots in healthcare services, hesitated to apply for voluntary accreditation due to vulnerable finances, staffing issues, and the risk burden of receiving a ‘Denial of accreditation’ grade. Policy coordination measures (Table S1) were proposed to encourage these hospitals to participate in accreditation while addressing their challenges. Most of these policy suggestions have been implemented (59). The current premise of “medical institution accreditation” is the voluntary participation of hospitals. Instead, there are incentive systems associated with the accreditation results. These incentives include the ability to be designated as a superior general hospital, training hospital, specialized hospital, or research-oriented hospital. Accreditation status is included in the evaluation indicators for healthcare quality improvement support funds. Accreditation is a requirement for receiving infection prevention management fees and surgical patient safety management fees.

Rehabilitation hospital accreditation began in 2020 following the public announcement of the “Guidelines for Designation and Operation of Rehabilitation Medical Institutions” in 2019. This marked the commencement of the main program for designating and operating rehabilitation medical institutions. The guidelines specify criteria such as staffing standards for hospital personnel by type of medical institution, classification of relevant diseases, the proportion of patients in recovery-phase rehabilitation, and admission and discharge dates. As a result, concerns regarding additional reductions in hospitalization fees during extended hospital stays, which were highlighted as potentially leading to unnecessary transfers and an increase in total hospitalization days, were mitigated. For instance, if a patient transfers to a rehabilitation hospital within 90 days of a stroke occurrence, they can receive rehabilitation therapy for up to 180 days without reduction in hospitalization fees, even if they do not transfer hospitals during this period (60).

Challenges and limitations

There are criticisms that hospitals are paying excessive costs compared to the evaluation expenses of KOIHA. A tertiary hospital paid 81.93 million won for accreditation from KOIHA, whereas KOIHA incurred only 15.8 million won in expenses related to the hospital. A general hospital also paid 43.46 million won for accreditation, but the KOIHA only spent 11.4 million won, which is about a quarter of the amount. Hospital medical staff are burdened with accreditation duties, leading to turnover and leave, yet there is no compensation for these challenges (61). In surveys, members of accredited hospitals often responded that hospital accreditation did not have a positive financial impact. However, an analysis of financial ratios showed that accredited hospitals performed better than non-accredited hospitals in terms of growth rate (Table S3) and profitability (Table S4) (33). While accreditation systems have significant effects on enhancing hospital efficiency and morale among staff, they do not necessarily lead to increased clinical revenues or cost savings. To encourage voluntary participation in accreditation among healthcare institutions, alternative policies from a financial perspective are deemed necessary (62).

According to the survey conducted twice by the healthcare union 2015, the most pressing issue identified as a top priority (62.3%) was the need for staffing expansion. Many members reported working overtime for several months without compensation, solely to prepare for accreditation, and there were instances of preparing through temporary methods (63). Issues highlighted included insufficient education and communication during accreditation, memorization-focused preparation, excessive overtime work, superficial preparations complaining that the purpose of accreditation is cleaning, lack of interest from physicians, evaluations focused mainly on nursing departments, and authoritative attitudes from some evaluation members. Despite these challenges and criticisms, hospital accreditation received a score of 5.5 out of 10 in terms of its impact on improving healthcare service quality and patient safety (63). There are voices from the field suggesting the need for several improvements, including effectively mandatory consulting system improvements, expanding participation of medical institutions, introduction of unannounced evaluations, management of surveyors’ histories (64).

As of the end of 2022, the participation rate in accreditation evaluations was 100% for tertiary hospitals, whereas for hospitals with over 30 beds but less than 100 beds, it was 11.1% (Table S5). General hospitals had a participation rate of 63.3%. There is a need for research and measures to increase participation rates among hospitals with less than 100 beds (33).

Future directions and recommendations

It is necessary to estimate the adequate staffing of nurses by department directly involved in patient safety and healthcare quality at hospitals according to their size, and to reflect these staffing standards and fees. To ensure patient safety and enhance healthcare quality, the calculation of the additional healthcare workforce needed beyond the current staff is as follows (65).

Estimation formula for nursing workforce for accreditation preparation:

0.45(hourday)×365(days)×currentnumberofnurses1784(hours)[1]

Additional work hours for maintenance of accreditation system and meeting accreditation criteria:

0.56(hourday)×365(days)×currentnumberofnurses[2]

Based on quantitative and qualitative evaluations of the performance of the accreditation system, the following improvement measures have been proposed for future accreditation inspections and data analysis (66). First, broaden the scope of objective assessments and specify criteria more concretely when determining accreditation standards. Consider diversifying accreditation levels (such as satisfactory, excellent, outstanding) to serve as reference points for consumers’ choices. Second, there is a need to diversify accreditation standards considering the characteristics of hospitals. Third, strengthen compensation for accredited hospitals. Fourth, enhance the consulting services currently provided by KOIHA to ensure that hospitals do not lack accreditation preparation solely through consulting. Furthermore, it is desirable to operate ongoing educational support programs, ensuring that employees of accredited hospitals complete training to develop their own capabilities in patient safety and healthcare service quality improvement. Fifth, enhance the selection process and post-selection training for evaluation commissioners, ensuring they have rich field experience across various types of hospitals and different working areas. Sixth, establish an integrated system for connecting accreditation inspection with evaluations from other institutions to facilitate effective performance analysis (66). To fundamentally address the recurring issues of temporary measures, superficial accreditations, and regression to prior states after accreditation, it is essential to resolve the workforce shortage (63).

Patient safety and the improvement of healthcare quality represent the purpose and direction of healthcare institutions; thus, they will naturally advance alongside hospital accreditation systems. For the accreditation system to develop, it is essential to establish accreditation standards through relevant research and to undergo a process where healthcare providers and patients fully empathize with the necessity and rationale behind accreditation. The hospital accreditation system will advance in proportion to the financial investments and efforts dedicated to research and dissemination (25).

Conclusions

In South Korea, KOIHA established under the Medical Service Act, has been conducting hospital accreditation since 2011. KOIHA evaluates hospitals based on their performance in patient safety activities, patient care systems, organizational management, and performance management. Accreditation is renewable every 4 years. Long-term care hospitals are mandated to obtain accreditation, while certain types of hospitals, such as tertiary hospitals, specialized hospitals, training hospitals, and hospitals for foreign patients, are also required to participate in the accreditation process. However, the participation rate among general hospitals and small hospitals, where accreditation is voluntary, remains low.

A study utilizing big data from the National Health Insurance Service, encompassing the entire population, revealed that accredited hospitals had lower 30-day mortality rates for AMI patients and shorter hospital stays compared to non-accredited hospitals. Another study analyzing profitability ratios of hospitals that disclosed financial information found that accredited hospitals outperformed non-accredited hospitals in terms of growth ratios and profitability per 100 beds.

Criticism has been raised regarding hospitals that fail to meet workforce standards but attempt to create the illusion of an adequate workforce during the accreditation period by discharging as many patients as possible and recalling personnel from leave. Additionally, concerns persist about the superficial evaluation of appropriate workforce levels—an essential factor for ensuring patient safety and improving healthcare quality—during accreditation surveys. This issue arises because submitting an improvement plan alone may suffice to pass a re-survey, even without implementing actual changes. Research on calculating appropriate workforce levels required for maintaining accreditation and meeting standards is available, and integrating these findings into hospital workforce criteria could potentially increase participation in the accreditation process.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-98/rc

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-98/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-98/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Nicklin W, Fortune T, van Ostenberg P, et al. Leveraging the full value and impact of accreditation. Int J Qual Health Care 2017;29:310-2. [Crossref] [PubMed]
2. Heidemann EG. The ALPHA program. Agenda for Leadership in Programs for Healthcare Accreditation. Int J Qual Health Care 1999;11:275-7. [Crossref] [PubMed]
3. Walshe K, Wallace L, Freeman T, et al. The external review of quality improvement in health care organizations: a qualitative study. Int J Qual Health Care 2001;13:367-74. [Crossref] [PubMed]
4. Bergholt MD, Von Plessen C, Johnsen SP, et al. Accreditation and clinical outcomes: shorter length of stay after first-time hospital accreditation in the Faroe Islands. Int J Qual Health Care 2022;34:mzac015. [Crossref] [PubMed]
5. Braithwaite J, Westbrook J, Pawsey M, et al. A prospective, multi-method, multi-disciplinary, multi-level, collaborative, social-organisational design for researching health sector accreditation BMC Health Serv Res 2006;6:113. [LP0560737]. [Crossref] [PubMed]
6. El-Jardali F, Jamal D, Dimassi H, et al. The impact of hospital accreditation on quality of care: perception of Lebanese nurses. Int J Qual Health Care 2008;20:363-71. [Crossref] [PubMed]
7. Almasabi M, Thomas S. The impact of Saudi hospital accreditation on quality of care: a mixed methods study. Int J Health Plann Manage 2017;32:e261-78. [Crossref] [PubMed]
8. Avia I, Hariyati RTS. Impact of hospital accreditation on quality of care: A literature review. Enfermería Clínica 2019;29:315-20. [Crossref]
9. Chun YJ, Lee BY, Lee YH. Association between Accreditation and In-Hospital Mortality in Patients with Major Cardiovascular Diseases in South Korean Hospitals: Pre-Post Accreditation Comparison. Medicina (Kaunas) 2020;56:436. [Crossref] [PubMed]
10. Mansour W, Boyd A, Walshe K. The development of hospital accreditation in low- and middle-income countries: a literature review. Health Policy Plan 2020;35:684-700. [Crossref] [PubMed]
11. Falstie-Jensen AM, Bogh SB, Johnsen SP. Consecutive cycles of accreditation and quality of in-hospital care: a Danish population-based study. Int J Qual Health Care 2021;33:mzab048. [Crossref] [PubMed]
12. Alhawajreh MJ, Paterson AS, Jackson WJ. Impact of hospital accreditation on quality improvement in healthcare: A systematic review. PLoS One 2023;18:e0294180. [Crossref] [PubMed]
13. Mansoor T, Wan Puteh SE, Aizuddin AN, et al. Challenges and Strategies in Implementing Hospital Accreditation Standards Among Healthcare Professionals in Healthcare Systems in Yemen: A Phenomenological Study. Cureus 2024;16:e59383. [Crossref] [PubMed]
14. Roberts JS, Coale JG, Redman RR. A history of the Joint Commission on Accreditation of Hospitals. JAMA 1987;258:936-40. [Crossref] [PubMed]
15. Greenfield D, Braithwaite J. Health sector accreditation research: a systematic review. Int J Qual Health Care 2008;20:172-83. [Crossref] [PubMed]
16. KOIHA. Program Overview: Accreditation results: KOIHA; 2020. Available online: https://www.koiha.or.kr/web/en/program/accResult.do
17. KOIHA. Assessment & accreditation: Accreditation mark: KOIHA; 2020. Available online: https://www.koiha.or.kr/web/kr/assessment/accMark.do
18. KOIHA. 4th Cycle Acute Care Hospital Accreditation Standards and Standard Guidelines. Ministry of Health and Welfare; 2021. Available online: https://www.koiha.or.kr/web/kr/library/establish_board.do
19. Korean Society for Preventive Medicine. Preventive Medicine and Public Health III. 4th edition. Gyechuk Cultural Publishing House; 2021. Available online: https://ebook-product.kyobobook.co.kr/dig/epd/ebook/E000003119162
20. Shaw CD, Groene O, Botje D, et al. The effect of certification and accreditation on quality management in 4 clinical services in 73 European hospitals. Int J Qual Health Care 2014;26:100-7. [Crossref] [PubMed]
21. Brubakk K, Vist GE, Bukholm G, et al. A systematic review of hospital accreditation: the challenges of measuring complex intervention effects. BMC Health Serv Res 2015;15:280. [Crossref] [PubMed]
22. Ho MJ, Chang HH, Chiu YT, et al. Effects of hospital accreditation on medical students: a national qualitative study in Taiwan. Acad Med 2014;89:1533-9. [Crossref] [PubMed]
23. e-Country Indicator: Trends in the number of hospital beds graph Statistics Korea [updated Dec 28, 2023]. Available online: https://www.index.go.kr/unity/potal/main/EachDtlPageDetail.do?idx_cd=A0007
24. OECD. Health at a Glance 2023 OECD Indicators. 2024. Available online: https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2023_7a7afb35-en
25. Yeom HG. KOIHA 10th Anniversary White Paper - Celebrating the 10th Anniversary of the KOIHA and Looking Forward to the Next 10 Years: Korea Institute for Accreditation of Medical Institutions; 2020. Available online: https://www.koiha.or.kr/web/kr/koihaPR/prPaper_board.do
26. Medical Services Act of the Republic of Korea. Korea Ministry of Government Legislation; 2024. Available online: https://www.law.go.kr/LSW/eng/engLsSc.do?menuId=2&section=lawNm&query=medical+service+act&x=20&y=38#liBgcolor18
27. Park JH. Understanding of the new Korea Healthcare Accreditation System. J Korean Med Assoc 2011;54:142-5. [Crossref]
28. Lee KS, Shin MK. Goals and assignments of healthcare accreditation program in Korea. J Korean Med Assoc 2012;55:7-16. [Crossref]
29. Lee S. Healthcare Accreditation in Korea: The Current Status and Challenges Ahead. Health Policy and Management 2018;28:251-6.
30. Lee HR. The role of the Korean Hospital Association in Korea's healthcare accreditation system. J Korean Med Assoc 2012;55:23-30. [Crossref]
31. KOIHA. Accreditation Procedures: Tracing survey methodology. 2024. Available online: https://www.koiha.or.kr/web/kr/assessment/accResearch.do
32. KOIHA. About KOIHA: Mission and Vision. 2024. Available online: https://www.koiha.or.kr/web/en/about/mission.do
33. Lee KS, Kim CB, Yoon SJ, et al. Analysis of the Achievements of the Medical Institution Accreditation System and Development of Strategies for Utilizing the Results. Korea Institute for Health and Social Affairs; 2023. Available online: https://www.koiha.or.kr/web/kr/library/rschReport_board.do
34. KOIHA. Accreditation Status. 2024. Available online: https://www.koiha.or.kr/web/kr/assessment/accStatus.do
35. KOSIS. Current status of medical institutions by province and type. 2024. Available online: https://kosis.kr/search/search.do
36. KOIHA. Assessment & Accreditation: Accreditation system. 2024. Available online: https://www.koiha.or.kr/web/kr/assessment/accditation.do
37. KOIHA. Accreditation Procedure: Accreditation Process. 2024. Available online: https://www.koiha.or.kr/web/en/program/accStep.do
38. KOIHA. Healthcare Accreditation Standards Manual. 2010. Available online: https://www.koiha.or.kr/web/kr/library/establish_board.do
39. KOIHA. Assessment & accreditation: Application for accreditation. 2024. Available online: https://www.koiha.or.kr/web/kr/assessment/accStep.do
40. WHO. Republic of Korea health system review. 2015. Available online: https://iris.who.int/handle/10665/208215
41. Moon SH. Success in Separating 'Types' of Mental Hospitals. No Need for Mandatory Accreditation. Medical Times [updated May 11, 2020]. Available online: https://www.medicaltimes.com/Users/News/NewsView.html?ID=1132486
42. KOIHA. Organization Overview - History 2024. 2024. Available online: https://www.koiha.or.kr/web/kr/about/history.do
43. KOIHA. Governmental Programs: Accreditation Standards. 2016. Available online: https://www.koiha.or.kr/web/en/assessment/accStandard.do
44. KOIHA. Assessment & accreditation: Accreditation standards. 2018. Available online: https://www.koiha.or.kr/web/kr/assessment/accStandard.do
45. KOIHA. Announcement of 3rd cycle acute care hospital accreditation standards (standard glossary added). 2018. Available online: https://www.koiha.or.kr/web/kr/library/establish_board.do
46. Magnarelli F. What one facility learned from the tracer methodology. Biomed Instrum Technol 2005;39:202-3. [PubMed]
47. Murphy-Knoll L. Nurses and the Joint Commission tracer methodology. J Nurs Care Qual 2006;21:5-7. [Crossref] [PubMed]
48. KOIHA. KOIHA 10th Anniversary White Paper. 2020. Available online: https://www.koiha.or.kr/web/kr/koihaPR/prPaper_board.do
49. KOIHA. Assessment & accreditation: accreditation status by region. 2024. Available online: https://www.koiha.or.kr/web/kr/assessment/accStatus.do
50. International Society for Quality in Healthcare. Guidelines and principles for the development of health and social care standards. 4th edition. 2015. Available online: https://www.koiha.or.kr/web/kr/assessment/accStatus.do
51. Lee BY, Chun YJ, Lee YH. Comparison of Major Clinical Outcomes between Accredited and Nonaccredited Hospitals for Inpatient Care of Acute Myocardial Infarction. Int J Environ Res Public Health 2021;18:3019. [Crossref] [PubMed]
52. Kwan MR, Seo HJ, Lee SJ. The association between experience of hospital accreditation and nurses' perception of patient safety culture in South Korean general hospitals: a cross-sectional study. BMC Nurs 2021;20:195. [Crossref] [PubMed]
53. Lee E. Safety climate and attitude toward medication error reporting after hospital accreditation in South Korea. Int J Qual Health Care 2016;28:508-14. [Crossref] [PubMed]
54. Seo YH. Change of patient safety, medical service quality, organization culture and hospital management performance after the execution of healthcare accreditation system for convalescent hospital. Daegu: Graduate School of Public Health, Kyungpook National University; 2016. Available online: https://www.riss.kr/link?id=T14184407
55. Kim YH, Kwon SC, Kim KJ, et al. Analysis of effectiveness on hospital management by accreditation system. Korean Society for Hospital Management; 2011. Available online: https://www.koiha.or.kr/web/kr/library/rschReport_board.do
56. Song EH. Factors affecting nursing performance, one of the accreditation standards for long-term care hospital nurses. Changwon: Changsin University; 2019. Available online: https://www.riss.kr/link?id=T15050729
57. Park IT. Review of Awareness and Effects Related to Healthcare Facility Accreditation. Korea Institute for Healthcare Accreditation; 2015 [updated 2015.10.26]. Available online: https://www.koiha.or.kr/web/kr/library/publication_review_popup.do?fileId=FILE_ID00004291&fileRefId=BRD_ID0000033
58. Lee SH. Recognition status of healthcare accreditation among hospital outpatients. Kyeongsan: Graduate School of Environmental Health, Yeungnam University; 2020. Available online: https://www.riss.kr/link?id=T15514673
59. Kim YH, Kim HS, Woo JS. Policy Integration Strategies for Participation in the Accreditation System for Small and Medium-sized Hospitals. Industry-Academia Cooperation Foundation, Eulji University; 2011. Available online: https://www.koiha.or.kr/web/kr/library/rschReport_board.do
60. Bang MS. Launching of the accreditation system for rehabilitation facility in Korea. 2020. Available online: https://snucm.elsevierpure.com/en/publications/launching-of-the-accreditation-system-for-rehabilitation-facility
61. Park YM. Accreditation Body Profiting from Hospitals? Controversy Over Excessive Certification Fees for Medical Institutions. 2022 [updated October 12th, 2022]. Available online: https://www.medicaltimes.com/Main/News/NewsView.html?ID=1149915
62. Woo JS. The effects of accreditation program to the leadership, organizational culture, hospital management activities and performances: focused on perception of accredited hospital professions. Daejeon: Eulji University; 2013. Available online: https://www.riss.kr/link?id=T13161862
63. Lee JH. Accreditation Systems: The Key to Transforming South Korean Healthcare after the MERS Outbreak-Patient Safety and Accreditation are the Answer! Korea Institute for Healthcare Accreditation; 2015. Available online: https://www.koiha.or.kr/web/kr/library/publication_review_popup.do?fileId=FILE_ID00004288&fileRefId=BRD_ID0000033
64. Park KY. During hospital surveys, they only increase the number of nurses and reduce the number of patients, creating a 'facade accreditation'. 2017 [updated Dec 26th 2017]. Available online: https://www.hani.co.kr/arti/society/health/825042.html
65. Yeom HG, Kang JY, Kim MS, et al. Research on Determining Adequate Staffing to Meet Healthcare Facility Accreditation Standards. Industry-Academia Cooperation Foundation, Inje University; 2021. Available online: https://www.koiha.or.kr/web/kr/library/rschReport_board.do
66. Seo YJ, Lee KS, Yu GB, et al. Study on Analytical Framework for Measuring the Performance of Healthcare Facility Accreditation Systems. Industry-Academia Cooperation Foundation, Yonsei University; 2019. Available online: https://www.koiha.or.kr/web/kr/library/rschReport_board.do