Process · Timeline · What to expect

From first enquiry to accreditation granted.

Your guide to the full AAA healthcare accreditation process — the four formal stages, how long each phase realistically takes, and exactly what your team needs to have ready at each point.

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3–6 monthsPreparation phase
1–2 monthsPre-survey preparation
28 daysDecision after survey
3 yearsAccreditation validity

The formal process

Four stages, fully documented

Every AAA healthcare accreditation follows the same four stages, with a dedicated advisor assigned from stage one.

Accreditation stages

PreparationA dedicated advisor is assigned · You receive the self-assessment tool · An action plan is set for implementing the standards · The AAA advisory team provides training and technical support
Document reviewFinalize the self-assessment tool · Submit the required documents and evidence · AAA Surveyors review the documents
Onsite / hybrid surveyAAA Surveyors conduct an onsite or hybrid survey (2 to 5 days) · The AAA team sends the final report within 2 weeks · The facility implements corrective actions, if required
Accreditation decisionThe accreditation committee reviews the surveyors' final reports · The accreditation certificate is prepared · Accreditation is granted, valid for 3 years

Accreditation certificate valid for 3 years

AAA surveyors reviewing records with hospital staff during an on-site accreditation survey — Surveyors review documents, walk the facility, and interview staff and patients.On-site or hybrid, 2–5 days

Timeline & what to expect

Phase by phase, with realistic durations

This is AAA's planning guide for facilities preparing for accreditation. Use it to schedule internal work, brief your board, and set expectations with your team.

3–6 months

01. Preparation phase

Assess readiness: Evaluate your current healthcare practices, policies and systems to determine how they align with the accreditation standards, once you receive your healthcare manual.
Gather documentation: Collect the policies, procedures and records that demonstrate compliance, and separate what must be sent before the survey from what will be demonstrated during it.
Form an accreditation team: Appoint the individuals who will lead the process — typically staff from quality management, clinical services and administration.
Education & training: Educate your staff about the accreditation standards, the process, and their roles in achieving compliance.

Within preparation

02. Self-assessment & gap analysis

Conduct a self-assessment: Review your existing processes, systems and services against the accreditation criteria.
Identify gaps: Identify the areas that need improvement or modification to meet the accreditation standards.
Develop an action plan: Create a detailed plan to address the identified gaps — revising policies, improving clinical practices or enhancing patient safety protocols.

Within preparation

03. Implement changes & improvements

Make necessary improvements: Begin implementing the changes in your action plan: updating protocols, training staff and improving facilities.
Monitor your progress: Continuously monitor the effectiveness of the changes and confirm the improvements align with the accreditation requirements.
Conduct internal mock surveys: Identify any remaining issues and address them before the official survey.

1–2 months before

04. Prepare for the on-site survey

Review documentation and records: Ensure all required documents and records are up to date and available for review by the surveyors, and send what needs to be sent beforehand.
Prepare your staff: Make sure everyone understands their role during the survey and the expectations of the compliance agenda.

3 days – 1 week

05. On-site / hybrid survey

Schedule the survey: Set the date for the official accreditation survey.
Host the surveyors: A team of surveyors visits your facility, reviews documents, and interviews staff and patients.
Receive initial feedback: After the survey you have a debriefing meeting outlining any areas for improvement or suggestions from the surveyors.

Within 28 working days

06. Post-survey & accreditation decision

Corrective actions: If issues are identified during or after the survey, implement corrective actions and submit evidence of compliance — especially where a conditional accreditation is followed by another survey.
Final decision: Once concerns are addressed, the Accreditation Decision Committee makes the final decision on your accreditation status.
Accreditation awarded: If you meet all the necessary standards in accordance with the AAA manual, you are granted accreditation.

Continuous

07. Ongoing maintenance

Regular reviews: Conduct regular internal audits and assessments to ensure ongoing compliance with the accreditation standards.
Prepare for self-assessment: A self-assessment is conducted after 18 months for the organization to review its own compliance.
Prepare for re-accreditation: Accreditation is valid for a set period — typically 3 years. Begin preparing for re-accreditation well in advance.

Optional stages

You do not have to walk this on your own.

AAA provides consulting services if you need help preparing. You are assigned a dedicated healthcare consultant who guides you through the process step by step — whether you are at the very beginning of the journey or close to the end.

Gap analysis against the standards before you commit to a survey date
Policy development and documentation support
Staff training on the standards and their role in the survey
Internal mock surveys before the official visit

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FAQ

Questions about the process

How long does the whole process take?

It depends where you start. AAA's timeline guide allows 3 to 6 months for the preparation phase, 1 to 2 months of focused preparation before the survey, an on-site or hybrid survey, and an accreditation decision within 28 working days of the survey being completed.

How long is the survey itself?

AAA Surveyors conduct an onsite or hybrid survey lasting two to five days; AAA's planning guide advises reserving three days to one week for the visit. A debriefing meeting follows immediately, and the final report is sent within two weeks.

What happens if we do not meet a standard?

If issues are identified during or after the survey, you implement corrective actions and submit evidence of compliance. This is especially the case where a conditional accreditation is followed by another survey. Once concerns are addressed, the Accreditation Decision Committee makes the final decision.

Do we have to do this alone?

No. Consulting services are available if you need help preparing. You are assigned a dedicated healthcare consultant who guides you through the process step by step, whether you are at the beginning of the journey or near the end.

What happens after we are accredited?

Ongoing maintenance is continuous: regular internal audits and assessments, a self-assessment after 18 months for the organization to review its own compliance, and preparation for re-accreditation well before the three-year certificate expires.

Keep reading

Start the clock.

The sooner a dedicated advisor is assigned and the self-assessment tool is in your hands, the sooner your three to six month preparation phase begins.

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