Accreditation Terms
Accreditation - a review process of the organization’s execution of performance
standards as defined by an accrediting body.
Accreditation Manager - the person(s) at a law enforcement organization seeking to be
accredited responsible for managing the accreditation process. In healthcare, this person
is known as a Survey Coordinator/ Regulatory Compliance
Coordinator/Manager/Director.
Accredited - an organization that has met the standards of performance set by an
accrediting body.
Accrediting Body - an organization that establishes performance standards for its
members then monitors how its members meet those standards.
Assessment - an organization’s formal presentation of compliance to performance
standards through examples of policies, reports, interviews, and observation of the
organization’s facilities and operations to external assessors during a prescribed time
period.
Auditor - a representative of an accrediting body that conducts the virtual and/or onsite
evaluation of an organization seeking to be accredited. In healthcare, this representative
is known as a Surveyor.
Conditional Accreditation - when an organization seeking accreditation has not provided
enough proof to meet the quality standards. They are given a period of time to meet the
standard and then will be accredited or denied accreditation.
Corrective Action Plan - step-by-step plan of action developed for healthcare
organizations to address performance that did not meets the standards of the
accrediting body.
Deeming Status - the United States government acknowledgment that an accrediting
organization has met and/or exceeds federal expectations in the realm of accrediting
healthcare organizations. The Centers for Medicare & Medicaid Services (CMS) granted
Deeming Status to The Joint Commission (TJC) to accredit healthcare organizations on
their behalf.
Designated - a healthcare term that identifies an organization that has gone above and
beyond general accreditation in a specialty area.
Enrollment - when an organization seeking accreditation joins an accrediting body and
gains access to a standards manual.
Accreditation Definitions
4/2022
Evidence of Compliance - evidence provided by an organization that they meet a
performance standard determined by the accrediting body. In law enforcement, the term
Proof is used.
Policy - is a set of guidelines used to set direction in an organization. It is typically a guide
to decision-making that allows flexibility and situational decision-making.
Primary Source Verification - terminology used for license verification in a healthcare
setting.
Procedure - a set of step-by-step instructions on how to perform a specific task.
Proof - evidence provided by an organization that they met a performance standard
determined by the accrediting body. In healthcare, the term Evidence of Compliance is
used.
Reaccreditation - when an organization begins the accreditation process again. At a set
cadence, depending on the accrediting body an organization is evaluated for
reaccreditation.
Review and Decision - when the leaders of an accrediting body review the assessment
and awards or denies accreditation.
Self-assessment - when the accreditation manager/surveyor reviews the stands manual
and compiles evidence that they meet a standard.
Standard - a statement of the level of quality or achievement that is acceptable/desirable
to obtain accreditation.
Survey Coordinator/ Regulatory Compliance Coordinator/Manager/Director - the
person(s) at an organization seeking to be accredited responsible for managing the
accreditation process. In law enforcement, this person is known as an Accreditation
Manager.
Surveyor - a representative of a healthcare accrediting body that conducts the onsite
evaluation of an organization seeking to be accredited. In law enforcement, this
representative is known as an Auditor.
Written Directive - a written order given authority by the organization to provide
employees with guidance related to the expectations of the agency. (Policy, General
Orders, Standard Operating Procedures, Administrative Memo, etc.)
Accreditation Definitions
4/2022