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Accreditation Readiness: What Hospitals Need to Know to Stay Survey-Ready Every Day

By Bill Ledger, AIA, ACHA, NCARB, EDAC, LEED AP, LSSGB

May 5, 2025
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For hospitals, accreditation is more than a one-time event—it’s a continuous commitment to delivering safe, high-quality care. Understanding accreditation readiness is essential to maintaining compliance and protecting the healthcare organization’s reputation.

In this article, we’ll break down what accreditation means, why it matters, and how hospitals can stay prepared—not just for surveys, but for everyday excellence.
Van Wert Surgery and Inpatient Expansion - Operating Room
Van Wert Surgery and Inpatient Expansion - Operating Room

What Is Hospital Accreditation?

Hospital accreditation is a formal evaluation process conducted by independent organizations to assess a hospital’s adherence to nationally recognized standards. These standards cover many areas of performance from patient safety and infection control to staff training, facility operations, and beyond.

The Purpose of Accreditation

  • Promote patient safety and high-quality care
  • Drive continuous improvement and operational excellence
  • Support regulatory compliance and Centers for Medicare and Medicaid Services (CMS) participation
  • Enhance public confidence and organizational reputation

The accreditation process results in official recognition (or accreditation status) that a hospital meets or exceeds the standards. However, accreditation is about more than passing a survey. It’s about integrating quality and accountability into every aspect of hospital operations.

Who Accredits Hospitals?

Several organizations are approved by the Centers for Medicare and Medicaid Services (CMS) to accredit hospitals, including:

Hospitals can choose the accrediting organization that aligns best with their culture and goals. Accreditation by these bodies grants what’s known as “Deemed Status,” meaning CMS accepts their survey in place of its own, as long as federal requirements are met. This streamlines compliance and helps hospitals maintain uninterrupted access to Medicare and Medicaid reimbursement.

Is Accreditation Required?

Accreditation is technically voluntary at the federal level, but in practice, it’s often essential—especially for hospitals that want to receive Medicare or Medicaid reimbursement.

In some states or for certain specialty healthcare facilities (e.g. behavioral health), it may be mandatory for licensure or insurance participation. For example, a state health department might require accreditation for hospital licensure, or an insurance provider might only contract with accredited facilities.

Core Responsibilities for Accreditation Readiness

To remain accredited and survey-ready, hospitals must:

  • Meet or Exceed Standards – Hospitals must comply with CMS Conditions of Participation (CoPs), which set the baseline for operating a safe and effective facility. Most accrediting organizations go further than that by incorporating clinical best practices, evidence-based practices, and quality frameworks like ISO 9001.
  • Adopt a Continuous Readiness Mindset – Accreditation isn’t a once-every-three-years event. Hospitals that rely on “survey prep mode” often scramble to update documents and coach staff last minute. The best-performing organizations build compliance into daily routines for continuous readiness—engaging staff regularly, updating policies, and using data to drive improvement. This creates a culture where being ready for a survey is a byproduct of doing the right thing every day.

Use Accreditation to Drive Better Outcomes

Beyond compliance, accreditation improves:

  • Care Quality – Achieving accreditation requires holding staff to high standards for patient care.
  • Operational Efficiency – A survey conducted by the Harvard Business Review found that management issues were the biggest challenges facing healthcare providers.
  • Liability Insurance Risks – Preparing for accreditation requires a comprehensive review of how your organization functions, and lets you see the areas where you are most at risk.
  • Community Trust – Accreditation shows your patients that they can trust your organization to take care of them.
  • Competitive Advantage – Since accreditation improves the quality of care, it also improves patient satisfaction.

The Survey Process: What to Expect

Surveys typically occur every 36 months and can be:

  • Unannounced (most common)
  • Announced (some specialty or initial surveys)
  • Virtual (typically used during emergencies or follow-ups)

Surveys may occur more frequently based on findings or complaints. Being survey-ready every day—not just every three years—will make the process go smoother.

Surveyors Focus On:

  • Documentation and Records: Policies, audits, incident reports, credentialing files
  • Staff Knowledge: How well team members understand policies, apply standards, and describe safe practices
  • Physical Environment: Life safety compliance, infection control, cleanliness
  • Performance Improvement: Use of data for safety and quality
  • Patient Safety Culture: Transparency, reporting mechanisms, leadership engagement

The survey is not just a paper trail—it’s a full-system evaluation, assessing how well your people, processes, and environment align with your policies and accreditation standards. The survey validates both your systems and your culture.

Tools for Continuous Readiness

To stay accreditation-ready, consider implementing these tools into your everyday practices.

Mock Surveys

Simulate the accreditation visit to identify blind spots and prepare staff for interviews.

Internal Audits

Ongoing reviews of policies, documentation, and compliance, often led by internal quality/risk teams or external consultants.

Best Practices

  • Rotate departments and surveyors through the mock surveys and include realistic walkthroughs and questions
  • Offer real-time feedback and coaching
  • Debrief after audits and track follow-up actions

Remember: Practice doesn’t make perfect—practice makes prepared.

Common Accreditation Issues

General Hospital Challenges:

  • Incomplete documentation (patient records, policies, and staff training records)
  • Infection control lapses (improper hand hygiene and sterilization, ventilation system inefficiencies)
  • Medication errors (storage, labeling, and administration)
  • Environmental safety hazards (blocked fire exits, improper storage of hazardous materials)

Facilities-Specific Issues:

  • Improper maintenance of utility systems (HVAC, electrical, and medical gas)
  • Blocked or unsafe egress routes
  • Deficiencies in the building’s physical condition (damaged walls, ceilings, and floors)
  • Fire protection system failures (fire alarms, sprinkler systems, and fire doors)
  • Incomplete or missing life safety documentation and record keeping
  • Medical gas storage, handling, and ventilation problems
  • General life safety code violations (improper storage of hazardous materials, inadequate fire drills)

Final Thoughts: Keys to Accreditation Success

Accreditation readiness is a team sport—and a year-round effort. To stay ahead:

  • Stay up-to-date with changing standards
  • Train and empower your teams
  • Embed compliance into daily routines
  • Learn from mock surveys and internal audits
  • Keep documentation current and accessible

Ultimately, a culture of continuous readiness is what sets great hospitals apart. It’s not just about passing a survey—it’s about making safe, high-quality care your standard every day.
Rush Memorial ICU Patient Room
Rush Memorial ICU Patient Room

Want to have a deeper conversation about accreditation and how your hospital is staying prepared? Contact us to talk to one of our healthcare experts.

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