Switching AOs: Kettering Health answers why they changed from Joint Commission to HFAP

Briefings on Accreditation and Quality, June 1, 2018

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A large health network’s experience transitioning to a new AO

Editor’s note: This is the first in a new series on changing accrediting organizations (AO). We’ll be talking to hospitals and healthcare organizations on why they changed accreditors, and lessons they learned during the process. If you’d like to share your facility’s experience, please email us at

Kettering Health Network (KHN) is a non-profit network of eight hospitals, 10 emergency centers, and over 120 outpatient facilities in southwest Ohio. In 2016, the network reported more than 1 million outpatient visits, nearly 62,000 patient discharges, and about 315,000 emergency visits. KHN used to be accredited primarily by The Joint Commission, before deciding to switch all its facilities to HFAP in 2011. 

Lisa Seitz, BSBA, CPHQ, CCMSCP, is network director of clinical decision support and accreditation & regulatory compliance at KHN, and Brenda Kuhn, PhD, RN, FACHE, CPHQ, is the network’s chief quality officer. They spoke with BOAQ about why they changed AOs, why they picked HFAP, and lessons they learned during the process. This Q&A has been lightly edited for clarity. 

Q: Why did you decide to change accreditors? And why did you pick HFAP? 

Kuhn: We’ve been developing as a network; we started as two hospitals, then those two joined two, and over time we’ve added three more. Some of our hospitals were HFAP-accredited and others were Joint Commission–accredited.

We have as one of our core strategies “alignment across the network,” and another is “one best practice.” These strategies primarily drive decisions. We decided that we needed to align our accrediting bodies so that work across the network was consistent. For example, if we are looking at the accreditation standards for our emergency departments, the leaders are all speaking the same language and focusing on the same standards. That is what drove us to look at changing accrediting bodies.

Why did we pick HFAP? Well, we have a very large osteopathic residency, and at the time, that residency had a requirement to be HFAP-certified. We contemplated whether we should ask our new hospitals to be both HFAP and Joint Commission–accredited, since most of our hospitals were already Joint Commission–accredited.

But as we started looking at the two organizations, we realized that the CMS standards are core. And our Grandview Hospital had a long history with HFAP and found it a very successful survey process, just as our other hospitals had with their Joint Commission survey process. However, we decided we would align with HFAP in support of the requirement for our residents. 

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