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

Background: The American College of Surgeons (ACS) accreditation programs establish evidence-based, consensus-driven standards to improve surgical quality. While 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 evaluates 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.

Study design: This retrospective cohort study utilized the ACS Quality Database to identify hospitals undergoing first-time comprehensive accreditation visits from 2017-2023 across seven 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 prior system-level accreditation experience in multi-hospital systems.

Results: 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 prior accreditation experience had higher first-attempt pass rates (OR: 1.69; 95% CI: 1.09-2.65; P=0.021).

Conclusion: 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.