Accreditation of Healthcare Facilities

The main purpose of accreditation is to determine compliance with the national standards of excellence, coaching health care facilities to improved performance as a quality improvement philosophy.

After an organization has passed the licensing process, it can then proceed into the accreditation process. Information collected and stored in the licensing inspection reports can be passed to the accreditation department within the Ministry of Public Health, allowing potential trouble areas to be identified and the appropriate level of examination during the accreditation survey. In addition, in the event that a facility loses its license, the licensing department can inform the accreditation department so that appropriate steps can be taken.

National Accreditation Standards:

The accreditation standards are standards of excellence that identify those practices that contribute to safe, quality, and effectively managed patient care. The standards serve as the foundation for the National Accreditation Program.


High Priority Criteria and Required Organizational Practices

The accreditation standards include two special types of criteria:

  1. High priority criteria:

  2. High priority criteria are related to safety, ethics, risk management, and quality improvement. They are identified in the standards by an exclamation mark (!). In the accreditation decision, high priority criteria are weighted more heavily than other criteria.

  3. Required Organizational Practices (ROPs):

  4. ROPs are essential, evidence-based practices that mitigate risk and contribute to improving the quality and safety of health services and are analogous to the High-Risk Requirements of the Licensing program.

ROPs are organized according to six key patient safety goal areas:

  •  Safety culture,

  •  Communication, 

  •  Medication use, 

  •  Work life/workforce, 

  •  Infection control

  •  Risk assessment.

Accreditation Process:

The accreditation process follows a three-year cycle that includes key phases and interactions with the health care facility on an annual basis for its licensing. The licensing process is designed to feed into the accreditation process and functions as outlined below.


The accreditation process has four (4) primary components that sub sequentially:

  1. Education:

    Orientation sessions, which are customized to meet the health care facility’s needs, introduce the accreditation program to leaders and staff at the beginning of their accreditation journey. Sessions may also be used as refreshers, most particularly where health care facilities have undergone high staff turnover or when there are significant changes to standards.

  2. Self-Assessment:

    In preparation for the on-site visit, staff within the health care facility assess performance against standards by answering (anonymously) questionnaires that are based directly on the standards. Through the self-assessment process, health care facilities identify areas requiring review and follow-up, as well as develop and prioritize action plans to address them. One of the strengths of the self-assessment process is that it enables the health care facility to focus on its own priorities.

  3. On- site Survey:

    The on-site survey allows a health care facility to showcase its commitment to quality care and its compliance with the accreditation standards. It is an opportunity for peer surveyors to share their knowledge and expertise with the health care facility’s staff and leadership, as well as to discuss areas for improvement identified during the self-assessment. The integration of the licensing process is fully-realized at this stage, as information collected from the most recent licensing report is examined prior to the visit. This allows for planning to occur around areas of concern highlighted by the licensing inspectors.

  4. Accreditation Decision:
    An Accreditation Report is shared with the health care facility, this report documents the findings of the facility’s on-site visit and provides guidance for future quality improvement activities and initiatives. It provides specific information on key findings, strengths, areas for improvement, as well as highlights areas that will minimize risk and improve overall performance. The Accreditation Decision is provided with the Accreditation Report. Upon achieving accredited status, the health care facility is provided with an award letter and a certificate of accreditation.

Levels of National Accreditation

The Qatar National Accreditation Program has three accreditation levels: 3 Star; 4 Star and 5 Star. These levels allow flexibility to adapt the program to various types of services and settings, encourage health care facilities to build capacity, and provides a step-by-step approach to accreditation and quality improvement. Each criterion within the standards is tagged to a level and performance is assessed to determine the health care facility’s accreditation award:

  • 3 Star level: Addresses basic structures and processes linked to the foundational elements of safety and quality improvement.

  • 4 Star level: Builds on the foundational elements of quality and safety, and emphasizes key elements of client-centered care.

  • 5 Star level: Focuses on achieving quality by monitoring outcomes, using evidence and best practice to improve services, and benchmarking with peer facilities.


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