Background: Healthcare accreditation has grown rapidly since the 1980s but critics question the value of accreditation rather than certification or inspection. Research has focused more on evidence of impact on provider institutions than on health systems; little has been published on the determinants of growth or decline of accreditation organizations and programmes. Objective: To describe the development of national accreditation organizations in Europe in relation to incentives, funding and market position in 2009; to identify trends over time using data from previous surveys. Methods: Contacts in 24 countries, identified by previous surveys, were invited to complete a web-based questionnaire comprising 183 items seeking numerical data or posing multiple choice options. Preliminary results were verified with respondents and agreed for publication. Main Outcome Measures: National healthcare environment, incentives, government policy, legislation, regulation; programme governance, development, funding. Results: The survey identified 18 active national accreditation organizations in Europe. Older ones tend to be independent, profession-dominated and self-financing; they have shown little growth in activity and coverage of the potential market. Newer ones have broad stakeholder governance, support from government policy and growth sustained by legal or financial incentives-giving wide coverage across the healthcare system. The traditional collegial model of accreditation is moving towards a semi-regulatory model of external assessment which could integrate minimal standards of licensing, public safety and accountability with aspirational standards for organizational development and improvement. Conclusions: The principal challenges to sustainable accreditation appear to be market size, consistency of policy support, programme funding and financial incentives for participation.