Transparency and Trust: How Accrediting Agencies and The Leapfrog Group Shape Hospital Accountability

Hospitals face a constant challenge: keep their Quality programs aligned with the high expectations of regulatory agencies and public reporting entities. From preparing evidence of compliance to maintaining continuous regulatory readiness and overseeing high-risk processes to prevent patient harm, understanding the standards set by rules and regulations of each accrediting agency is essential for achieving consistent reliability and safety.

The accreditation standards and safety practices championed by The Leapfrog Group and the accrediting agencies are more than checkboxes—they are foundational frameworks that shape care delivery and build patient trust. Meeting these standards is not optional; it is essential for credibility, reimbursement, and operational excellence.  

While all accrediting agencies and Leapfrog share a common goal—ensuring the highest level of patient safety and Quality outcomes—each organization brings a distinct focus, methodology and function to the evaluation process.  

The Joint Commission (TJC)

Designed to evaluate the entire care delivery process, TJC’s on-site surveys are data-driven, with a strong emphasis on patient safety and leadership accountability. Using its tracer method, surveyors follow a patient’s care journey to identify potential issues and document areas of noncompliance. This approach allows for real-time evaluation—and correction, if needed—of routine care procedures. TJC’s tracers are not just inspection tools; they are designed to uncover whether hospitals have embedded continuous improvement processes into their daily operations—not just during survey periods. High reliability hinges on an organization’s ability to internally assess and refine its care delivery systems on an ongoing basis, ensuring they consistently meet established standards.  

Accreditation Commission for Health Care (ACHC)

ACHC’s accreditation programs are developed in collaboration with industry experts to be both supportive and educational. Its surveyors bring extensive experience in hospital, critical access hospital, and healthcare lab settings, and they actively share best practices to help organizations identify and address potential compliance gaps. This commitment to education is further reflected in ACHCU, ACHC’s educational division, that offers program-specific resources such as workbooks and free webinars to support hospitals throughout the accreditation process.

Det Norske Veritas (DNV)

DNV’s accreditation approach emphasizes patient safety and encourages hospitals to adopt proactive improvement strategies that drive better patient outcomes. Surveyors closely examine clinical care standards and engage staff at all levels— from leadership to frontline caregivers—to ensure that everyone is aligned with DNV’s recommendations. This inclusive approach fosters a culture of continuous improvement and strengthens hospital-wide Quality initiatives.  

The Leapfrog Group

Although not an accrediting agency, The Leapfrog Group is a nonprofit organization that sets rigorous standards for hospitals safety and transparency. Through its annual Leapfrog Hospital Survey, hospitals voluntarily report their adherence to key safety practices. Additionally, Leapfrog publishes biannual Hospital Safety Grades (A, B, C, D, or F), that are publicly available and widely used by healthcare purchasers and consumers. Hospitals earning an "A" grade demonstrate a strong, organization-wide commitment to proactive patient safety and harm reduction.

Similarities and Differences

While each accrediting body has its own emphasis, they share core expectations around performance improvement, patient safety, quality assessment, and leadership engagement. The differences lie in their focus, methodologies, and evaluation processes.  

• TJC emphasizes organizational systems and continuous improvement.

• ACHC prioritizes education and collaborative knowledge sharing.  

• DNV promotes proactive patient safety strategies.  

• Leapfrog focuses on public transparency and safety practice compliance.  

• Hospitals that understand these distinct approaches are better positioned to drive effective Quality improvement and maintain readiness across all fronts.  

Maintain Compliance Year-Round

• Embed regulatory compliance into daily workflows—not just during survey windows.

• Use proactive monitoring tools to identify gaps before surveys occur.

• Provide ongoing staff education on regulatory standards and evidence-based practices.

• Conduct internal audits with the same rigor as external surveyors.

• Leverage digital Quality Management Systems to integrate compliance evidence, monitor performance, and streamline reporting.

The Vastian Perspective

At Vastian, we help hospitals and labs simplify regulatory compliance by taking a digital, automated approach to survey readiness. Vastian Readiness is the only healthcare compliance software that unites all regulatory Quality into one platform. Our first-of-its-kind solution centralizes all aspects of the survey readiness process—from evidence collection to response storage—allowing hospitals to shift away from a state of constant defense and proactively show their higher standards.

Proactive Readiness in All Areas

Accreditation success isn’t about last‑minute fixes—it’s about sustained readiness. Hospitals that embed compliance expectations into daily operations not only meet survey requirements, but they also strengthen patient safety, staff confidence, and public trust.  

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