Evaluating Initial Site Visit Pass Rate Across American College of Surgeons Accreditation Programs.

Abstract

The American College of Surgeons (ACS) accreditation programs establish evidence-based, consensus-driven standards to improve surgical quality. Although the criteria are publicly available for self-assessment, limited data exist on initial pass rates and the effectiveness of remediation after a failed site visit. This study evaluated outcomes of initial ACS accreditation visits to determine whether accreditation primarily validates hospitals already meeting standards or serves as a driver for systemic quality improvement. This retrospective cohort study used the ACS quality database to identify hospitals undergoing first-time comprehensive accreditation visits from 2017 to 2023 across 7 ACS quality programs. The primary outcome was the initial accreditation pass rate; secondary outcomes included re-evaluation, domain-level, and standard-level pass rates. Multivariable logistic regression identified factors associated with first-attempt success. Subgroup analysis evaluated the effect of earlier system-level accreditation experience in multihospital systems. Of 833 initial site visits, 61% of hospitals achieved accreditation on their first attempt. Pass rates varied substantially by program, ranging from 31% to 86%. Among hospitals that failed initially, 94% of hospitals that pursued re-evaluation achieved accreditation. The most common areas of deficiency involved the quality domains "personnel and services resources" and "patient care: expectations and protocols." In a subgroup analysis, hospitals in systems with earlier accreditation experience had higher first-attempt pass rates (odds ratio 1.69, 95% CI 1.09 to 2.65, p = 0.021). Findings demonstrate that many hospitals pursuing accreditation initially face challenges in meeting core patient safety and quality standards. However, through remediation, most ultimately achieve accreditation, underscoring accreditation's role as a driver for systemic improvement.