Accreditation Procedures

KOIHA hosts the Accreditation Program for Healthcare Organizations, performing work designated and entrusted by the Ministry of Health and Welfare, with aims to secure reliability of the quality of medical services and patient safety.

Accreditation Process
인증조사 진행과정
Application for accreditation
  • The hospital-level medical institutions can voluntarily apply for the accreditation survey at their convenience. Yet, the desirable survey date can be designated after 60 days from the date of application.
  • The general hospitals seeking to become designated as a tertiary general hospital should receive the accreditation survey since the accreditation is a requirement for tertiary general hospitals. (Article 3 (2) of the Medical Service Act, Article 2 of the Regulations on the Designation and Appraisal, etc. of Tertiary General Hospitals)
  • Care hospitals and mental institutions, however, are mandated to apply for the accreditation since 2013 in accordance with the Medical Service Act, considering the characteristics of the medical services provided and protection of patients’ rights (Article 3(2)-3, Medical Service Act)
  • Hospitals and oriental medicine hospitals seeking to be designated as specialized hospitals should receive the accreditation since the accreditation result is a mandatory requirement (Article 2 (1), subparagraph 1 and 2, Regulations on the Designation and Appraisal, etc. of Specialized Hospitals, Ministerial Decree Number 38 of the Ministry of Health and Welfare,)[Enforcement date: Jan 13, 2014]
  • The costs required for the accreditation survey should be borne by the institution itself.
Accreditation survey
  • The survey schedule is notified to the institution which applied for the accreditation within 1 month from the date of receipt of the application.
  • The survey schedule is determined after consultation is made between the institution and KOIHA, based primarily on the desirable date suggested by the institution.
  • Once the survey date is determined, it cannot be changed since the surveyor selection process and survey plan start immediately after the survey date is confirmed.
  • The accreditation survey is conducted considering the type and the number of beds of the institution.
Category Tertiary General Hospital General hospital Hospital
Number of beds 1000 beds or more Less than 1000 beds 300 beds or more Less than 300 beds 100 beds or more Less than 100 beds
Survey period 4 days
Surveyors 7 surveyors 6 surveyors 5 surveyors 4 urveyors 4 surveyors 3 surveyors
Granting of the rating by the Accreditation Deliberating Committee
  • The accreditation rating is deliberated by the Accreditation Deliberating Committee based on the survey result.
  • The accreditation rating determined by the Accreditation Deliberating Committee is notified to the institution in writing.
  • There are three accreditation ratings granted to the institution: Accreditation, Conditional Accreditation, and Denial of Accreditation. The effective period for the accreditation is 4 year, and that of the conditional accreditation is 1 year.
Objection to and final confirmation of the accreditation result
  • An institution having an objection to the rating granted may make an official objection to the result within 30 days from the date on which the accreditation result is notified. In this case, the institution should fill in the Statement of Objection to the Accreditation Rating (Form 23-8, Enforcement Regulation of Medical Service Act) and submit it to KOIHA within 30 days along with other supporting documents.
  • KOIHA may utilize the subcommittee for the objection settlement in order to review the validity of the grounds for the objection.
  • The Accreditation Deliberating Committee should deliberate the adequacy of the objection submitted based on the Statement of Objection or the review of the subcommittee, and then determine the final accreditation rating.
Notification and declaration of the accreditation rating
  • KOIHA notifies the final accreditation rating to the institution and reports to the Minister of the Ministry of Health and Welfare.
  • The accredited institutions (Accreditation or conditional accreditation) are given the accreditation certificate and accreditation mark and are allowed to use those.
  • The accreditation ratings of the accredited institutions (Accreditation or conditional accreditation) are announced on the official KOIHA website.
  • The accreditation certificate and mark shall not be used after the effective period of the accreditation.
Interim self-survey
  • In order to maintain the ‘accredited’ status, the accredited institutions should conduct the interim self-survey every year and submit the result to KOIHA.
  • The result of the interim self-survey does not affect the next accreditation survey (survey application, implementation of survey, and the survey result, etc.) while it can be used as reference materials.