HCAC, Jordan's Health Care Accreditation Council, accredits hospitals against its Hospital Accreditation Standards, 5th Edition, which adds 40 new standards, revises 60 and applies to hospital evaluations from October 2025. Medical laboratories are accredited against HCAC's separate Medical Laboratories Accreditation Standards, a set of 85 standards in seven clusters built on the WHO Laboratory Quality Stepwise Implementation tool.
This guide is for quality directors, accreditation coordinators and laboratory managers in Jordanian hospitals and standalone laboratories.
Which HCAC standards apply to hospitals and laboratories?
HCAC runs separate programmes for each type of facility. Its own site lists accreditation or certification for hospitals, primary health care centres, medical laboratories, ambulatory centres, dental clinics, community pharmacies, medical transport, breast imaging units, and diabetes and cardiac care programmes.
The hospital standards cover the hospital laboratory within the diagnostic services cluster. A standalone laboratory applies to the medical laboratory programme. The table compares the two sets as HCAC describes them in October 2026.
| Point | Hospital Accreditation Standards | Medical Laboratories Accreditation Standards |
|---|---|---|
| Current edition | 5th Edition, announced January 2025 | The edition in use at the time of writing. Confirm the number with HCAC |
| In use since | Hospital evaluations on the 5th Edition from October 2025 | Accredited by ISQua EEA from March 2026 to March 2030 |
| Structure | Clusters from ethics and patients' rights to research. HCAC's page still shows the 4th Edition's 15 clusters and 426 standards | Seven clusters, 85 standards |
| Classification | Critical, core and stretch (4th Edition: 69, 317 and 40) | Critical, core and stretch (12, 63 and 10) |
| Who can apply | All hospitals that offer health care services | Licensed laboratories with at least six months of service before the survey |
What changed in the Hospital Accreditation Standards 5th Edition?
HCAC announced the 5th Edition in January 2025. It said hospital evaluations against it would start from October 2025, and it planned workshops for accredited hospitals, surveyors and consultants in April 2025.
The edition introduces 40 new standards and revises 60 existing ones. HCAC lists seven areas of change.
Person-centred care widens the earlier patient-centred focus to the whole needs of each person. Leadership excellence adds leadership development programmes. Patient advocacy strengthens advocacy programmes.
Digital transformation covers digital governance and the growing role of telehealth. Climate resilience asks for environmental sustainability plans. Just culture promotes accountability and learning rather than a blame-free approach. Clinical outcomes puts health outcomes at the centre of quality and safety work.
For a hospital accredited under the 4th Edition, the new and revised standards are the first gap list. Each of the seven themes needs a visible owner, a written process and records that show it running.
How are HCAC standards organised and classified?
Both sets follow the same pattern. The standards are grouped into clusters. Each cluster opens with an intent statement and a list of key documents that surveyors review. Each standard is followed by its measurable elements and a survey process.
HCAC says the survey process is exactly what surveyors look for when they score the standard. Read it before you write a policy, because it tells you which documents, interviews and observations will be used.
Standards fall into three classes. Critical standards cover laws and regulations, or could cause death or serious harm if not met. Core standards cover the systems, processes and policies important for patient care. Stretch standards matter but are hard to implement because of time, resources or the need for culture change.
HCAC also states that its standards are not prescriptive. They say what to achieve and leave the method to the facility, provided practice is evidence-based.
What do the HCAC medical laboratory standards cover?
The medical laboratory standards have seven clusters: governance and leadership, human resources management, laboratory operations, facilities and premises, client rights, quality improvement, and laboratory information management.
Laboratory operations is the largest. It covers the pre-analytical, analytical and post-analytical workflow, equipment, quality control, and procurement and inventory. Facilities and premises covers laboratory safety, infection prevention and control, and emergency management.
HCAC built the set on the WHO Laboratory Quality Stepwise Implementation tool. In June 2026 it announced that the ISQua External Evaluation Association had accredited the laboratory standards from March 2026 to March 2030. If your laboratory also works toward ISO 15189, our ISO 15189 guide covers that standard, and our JCI laboratory guide covers JCI's two laboratory programmes.
Why does every measurable element count?
A standard is judged through its measurable elements, so one weak element can pull down a standard you thought was in place. The exact scoring thresholds and decision rules are set out in HCAC's standards manual and survey guidance, not on its public pages. Get them from HCAC before you plan.
In practice, audit yourself at measurable-element level, not standard level. For each element, ask whether there is a written process, a record that it ran, and staff on duty who can explain it. An element backed only by a written process is unlikely to score well.
Start with the critical standards. They cover legal requirements and the risks of serious harm, so a gap there carries the most weight with surveyors. Our guide to JCI hospital accreditation shows how another survey body handles element scoring, if you run both programmes.
What should a hospital or laboratory prepare before the survey?
Begin with the key documents list at the start of each cluster. It is HCAC's own statement of what surveyors will review, so build your document register around it.
For the 5th Edition themes, hospitals should expect to show an environmental sustainability plan with data, a digital governance arrangement covering telehealth, and a just culture process for incident review. Add patient advocacy records, a leadership development programme and clinical outcome measures that leaders actually review.
Laboratories should be able to trace one sample from request to report. That means specimen acceptance and rejection records, internal quality control with action taken on failures, equipment calibration and maintenance logs, and result release and critical value records. Staff files with credentials and competency assessments complete the picture.
How AGS can help
AGS sells two editable Microsoft Word kits to support HCAC requirements, each with a compliance matrix:
- Hospital Person-Centred Quality & Patient Safety Management System - HCAC 5th Edition: 117 documents, including a quality manual, policies, procedures, forms, a tracer worksheet and a mock survey checklist.
- Medical Laboratory Quality Management System - HCAC 2nd Edition (2021): 90 documents, including a laboratory quality manual, procedures, forms and logs, audit checklists and a readiness guide.
Frequently asked questions
Is HCAC accreditation the same as a hospital licence?
No. HCAC accreditation is a separate, quality-focused assessment. The laboratory programme, for example, requires a valid licence before a laboratory can apply.
Does a hospital laboratory need separate HCAC laboratory accreditation?
The hospital standards include the laboratory within the diagnostic services cluster. Ask HCAC whether a separate laboratory accreditation adds value for your scope.
Where can we get the full HCAC standards?
From HCAC itself. Its website has a link to request the standards and a published price list.
Does buying documentation mean we will be accredited?
No. Documents are a starting point. Accreditation depends on how the system is implemented and on HCAC's survey findings.
AGS provides independent documentation toolkits. This guide and the referenced kits are prepared to support HCAC requirements. They are not affiliated with, endorsed by or approved by the Health Care Accreditation Council, and they do not guarantee any survey or accreditation outcome.
Reviewed October 2026. Facts checked against the sources current at publication.
