Initial survey

Foundation for Achieving Accreditation and Continuous Improvement

The Initial Survey is a comprehensive, on-site evaluation designed to assess the implementation, effectiveness, and readiness of a healthcare organization’s systems for AACI accreditation. This assessment verifies the organization’s compliance with the International Accreditation Standard for Healthcare Organizations and ensures that core systems, processes, and outcomes meet the required level of performance.

Scope of the Initial Survey

The survey is conducted at the organization’s location(s) and includes an in-depth review of the following critical areas:

• Conformity to AACI Standards
  Verification of documented evidence demonstrating compliance with all applicable AACI requirements.

• Performance Monitoring and Analysis
  Evaluation of the organization’s methods for monitoring, measuring, analyzing, and reporting key performance indicators, objectives, and outcomes.

• Compliance with Statutory and Regulatory Requirements
  Review of the organization’s ability to meet relevant national laws, regulatory mandates, and industry-specific obligations.

• Operational Control
  Assessment of systems and controls that ensure safe, consistent, and effective operations throughout the organization.

• Internal Surveys and Management Reviews
  Examination of internal audits and management review processes to confirm their contribution to continuous quality improvement and alignment with accreditation standards.

Survey Outcomes

Upon completion of the initial survey, the organization will receive:

• A comprehensive survey report, including detailed findings, strengths, and areas for improvement

• A Corrective Action Plan (CAP) recorded in iAuditor, outlining all identified nonconformities and required actions

• A summary of next steps, including timelines for addressing findings and guidance on the follow-up process

• Expert recommendations regarding the organization’s accreditation status, based on the overall level of compliance and effectiveness of its quality and safety systems

This structured approach ensures transparency, accountability, and a clear path toward performance enhancement and sustained accreditation.

Surveyor Team Composition

AACI will assign a multidisciplinary team of experienced professionals to conduct the accreditation survey. The team typically includes:

• Clinical Surveyor – evaluates the quality and safety of clinical services and care delivery

• Generalist Surveyor – reviews organizational governance, administrative systems, and overall operations

• Physical Environment & Life Safety Surveyor – assesses facility safety, infrastructure, infection control, and compliance with environmental and life safety standards

The team conducts the survey through document reviews, direct observations, interviews, and process tracing to verify:

• Full compliance with AACI accreditation standards

• Professional competence across services and departments

• The effectiveness and efficiency of the organization’s management system

Corrective Action Plan (CAP) Requirements

Upon receiving the written survey report, the healthcare organization is required to prepare a Corrective Action Plan (CAP) to address identified nonconformities. The CAP must be submitted to AACI within a maximum of thirty (30) days from the last date of the survey.

The healthcare organization is expected to implement the corrective actions as outlined in the CAP within the prescribed timeframe. If implementation within the standard timeframe is not feasible, AACI will review the specific circumstances and may approve an adjusted timeframe. However, such extensions will be granted only in exceptional cases, and the extended timeframe for implementing corrective actions will rarely exceed six (6) months.

The CAP must comprehensively address the following:

• Root Cause Analysis – clearly identify the root cause(s) that led to the nonconformity;
• Corrective Actions – specify the actions taken to correct the nonconformity in the affected areas and/or processes;
• Preventive Measures – outline process or system changes that will be implemented to prevent recurrence of the nonconformity;
• Implementation Timeframe – provide a detailed timeline for the implementation of the corrective actions;
• Responsible Parties – identify the individual(s) responsible for carrying out the corrective actions;
• Performance Monitoring – define performance measures and/or other supporting evidence that will be used to monitor and validate the effectiveness of the corrective actions.

This structured approach ensures that nonconformities are addressed effectively and sustainably, minimizing the risk of recurrence and enhancing overall compliance with AACI standards.