Accreditation Procedure

The first step after applying for an accreditation consists of making a self assessment report by the healthcare organisation that is to be surveyed . On the basis of NIAZ' General Quality Standard for Healthcare Organisations the organisation analyses its organisational set-up (e.g. strategies, policies, procedures, protocols) in order to assess whether is complies with the NIAZ standard. This extensive process usually yields a lot of improvement opportunities, many of which are fairly quickly implemented. As such this is already very illuminating and useful for the organisation.

NIAZ in the mean time puts together a survey team tailored to the organisation that is to be surveyed. This team assesses the self assessment report and decides whether the organisation is ready for having the survey visit performed. Often this stage sees the gathering of more specific information. Or the organisation is advised to work on some organisational aspects before the next steps in the procedure are to be taken. An important demand of NIAZ is that the organisation has an internal survey system. Meaning that each and every department within the organisation must on a regular basis be surveyed by internal surveyors - independent from the department that they survey. NIAZ in its own assessment builds on this internal survey system.

When the survey team gives the green light the survey visit is planned. The survey team will then for a number of days investigate the organisation on site. The size of the survey team and the number of days is dependant on the size and complexity of the organisation that is to be surveyed . Varying from 2 surveyors for 2 days for a very small institution to 9 surveyors for 5 days for a large one. In all cases an extensive investigation is carried out. The survey team beforehand makes a random sample of departments and processes that will be scrutinized. During the survey visit other organisational units may be investigated without prior warning. Safety aspects are always an important issue.

According to the accreditation agreement the healthcare organisation must give the surveyors free and unlimited access to all places and all information deemed relevant for the assessment proceedings. Of course with due respect for privileged information because of privacy concerns. All staff members that the surveyors will want to interview must cooperate.

As soon as possible after the survey visit the survey team draws up a draft survey report. This comprises the findings of the team and identifies opportunities for improvement that need to be addressed by the healthcare organisation. This draft is sent to the organisation for factual correction. After this step the report goes to the College for Quality Certificates. This body will judge whether the healthcare organisation qualifies for being granted an accreditation status. If the decision is negative or if the College decides that a postponement of the decision is in order it advises the Executive Board, which is ultimately responsible.

An organisation that does not agree with a decision taken by NIAZ may appeal to the College of Appeal. This body also deals with other complaints a surveyed organisation might have.

The healthcare organisation makes a mandatory improvement action plan showing what it will do with the suggestions made by NIAZ. About a year after the accreditation decision NIAZ will again visit the organisation with a small survey team in order to assess the progress that is being made.

After four years the entire cycle repeats itself.