Obtaining accreditation is a crucial milestone for healthcare facilities. It demonstrates your commitment to quality care, safety, and regulatory compliance. However, the road to accreditation can be filled with challenges. Even the most well-prepared facilities can encounter avoidable pitfalls.
Here are the top 10 accreditation mistakes facilities make—and how you can avoid them:
The Problem: Policies and procedures that don’t reflect current standards can lead to non-compliance.
How to Avoid It: Review and update your policies annually or when standards change. Governing Body must review and accept any additions or changes to current policies as reflected in regular meeting minutes.
The Problem: Inspectors need evidence of compliance. Missing or disorganized documentation raises red flags.
How to Avoid It: Conduct regular audits of your documentation. Ensure files are complete, current, and easily accessible. This includes, but is not limited to, credentialing files, safety logs, previous accreditation information, policies, etc.
The Problem: Untrained staff are a common reason facilities fail accreditation. When asked pertinent questions about safety plans, staff may fumble with appropriate response due to lack of appropriate education about facility operations.
How to Avoid It: Schedule regular training sessions and keep records of attendance. Ensure every team member understands their role in emergency protocols and with maintaining compliance.
The Problem: Without practice and knowledge of the accreditation process, small issues can snowball into major problems during the actual survey.
How to Avoid It: Perform mock surveys to simulate the accreditation process. Identify and resolve gaps before the real inspection.
The Problem: A strong Quality Assurance (QA) is often overlooked but is essential for accreditation.
How to Avoid It: Implement a QA program that regularly monitors, evaluates, and improves your facility’s performance. Designate a responsible staff to take charge of its oversight.
The Problem: Sterilization failures are a frequent audit issue, endangering patient safety and accreditation success.
How to Avoid It: Validate sterilization processes with biological and chemical indicators. Follow best practices for cleaning, sterilizing, and storage. Ensure adequate documentation is available and that routine inspections of sterilization devices are conducted.
The Problem: Contaminated or poorly stored sterile items can lead to compliance failures leading to deficiencies cited during inspection.
How to Avoid It: Adhere to storage guidelines: maintain proper temperature, humidity, and airflow. Keep sterile items off the floor and away from sprinkler heads.
The Problem: Inspectors look closely at your readiness for emergencies for patient safety compliance, and gaps here can jeopardize accreditation.
How to Avoid It: Develop a comprehensive emergency preparedness plan. Train staff on their roles and conduct drills regularly. Document all interactions pertaining to the plan, like revisions or education.
The Problem: Failing to maintain and document equipment inspections can result in non-compliance.
How to Avoid It: Establish a routine maintenance schedule. Keep detailed records of all inspections and repairs. Confirm credentials of contracted service providers to validate their expertise.
The Problem: Rushing to prepare for accreditation increases the likelihood of oversight and potentially disastrous consequences from your onsite survey.
How to Avoid It: Treat accreditation as an ongoing process, not a last-minute task. Start preparing well in advance and address potential issues proactively.
At Universal Healthcare Consulting, we’ve helped countless facilities navigate the accreditation process successfully. Here is how Universal Healthcare Consulting adds value to your facility’s operations:
Accreditation is more than a certification—it’s a commitment to excellence. Let us help you achieve it with confidence.
