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5 Tips for Effective and Lasting Accreditation Readiness
We can still remember that night.
The fluorescent lights buzzed overhead as our team scrambled through hospital corridors at 2 AM—replacing outdated policies, locking medication rooms, and double-checking crash carts.
The Joint Commission surveyors were arriving in six hours, and anxiety was in the air."
Did you update the fire safety logs?"
"Are the hand hygiene signs posted in every room?"
"Does everyone know their emergency codes?"
"Can you describe the improvement work going on?"This last-minute frenzy—what many call the "Joint Commission Shuffle"—is exactly what accreditation efforts shouldn't be: reactive, chaotic, and unsustainable.
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Too often, accreditation is treated like a test to pass, not a mission to fulfill.
When the goal becomes "get through the survey," organizations lose sight of why the standards exist in the first place—to protect patients and employees and deliver excellent care.This “check-the-box” mindset leads to real risks:
Minimum compliance instead of continuous improvement
Heightened stress and resource waste during survey windows
Poor integration of quality into everyday operations
Drift from mission: healing and protecting patients
The Solution: Perpetual Readiness, Not Episodic Panic
What if accreditation wasn’t a crisis event—but simply how we operate every day?
Here are 5 ways to make that shift happen:
What if accreditation wasn’t a crisis event—but simply how we operate every day?
Here are 5 ways to make that shift happen:
1. Standardize and Centralize Accreditation Efforts
Don’t silo Joint Commission, CMS, DNV, and specialty-specific accreditations.
Create a system-wide accreditation inventory that gives everyone a "common operating picture" and include in your health system’s governance structure.
Benefits:
- Cross-functional collaboration
- Smarter resource sharing and prioritization
- Consistent compliance and staff education
- Clearer view of system-level gaps and strengths
2. Embed and Practice High Reliability Principles
High-reliability organizations thrive in high-risk settings—and healthcare can too.
Adopt both pillars and principles of high reliability:
Three Pillars:
- Leadership commitment to zero harm
- Culture of safety and trust
- Robust process improvement capability
Five Core Principles:
- Preoccupation with failure
- Reluctance to simplify
- Sensitivity to operations
- Commitment to resilience
- Deference to expertise
Focus on why standards exist—not just on passing audits.
3. Proactively Identify and Fix Flaws
Don’t wait for audits to tell you what’s wrong. Find risks early—and fix them fast.
Tactics:
- Daily leadership rounds in high-risk areas
- Psychologically safe incident reporting systems and meaningful organizational learning
- Practice tracers and tiered safety huddles
- Centralized data tracking tools
Relentless curiosity about vulnerabilities creates safer systems.
4. Share Knowledge, Don’t Hoard It
Silos kill readiness. Sharing fuels learning.
How to spread knowledge fast:
- Use safety huddles to share real-time updates and promote horizontal and vertical communication
- Deliver targeted staff education (not one-size-fits-all) with open discussion and reflection
- Use technology platforms to spread best practices and create visual queues
- Recognize teams who find and fix risks
When everyone owns readiness, it becomes part of the culture—not a side project.
5. Tell a Compelling Story that Resonates
People don’t commit to compliance. They commit to purpose.
Tips for powerful messaging:
- Share real patient stories that bring standards to life
- Use simple language and metaphors to cut through complexityInfuse the mission into onboarding, huddles, and leadership communications
- When standards are tied to emotional truth, people stop doing them for surveyors—and start doing them for patients.
When standards are tied to emotional truth, people stop doing them for surveyors—and start doing them for patients.
Accreditation doesn't have to be a 2 AM scramble.
When we embrace continuous readiness, accreditation becomes a catalyst for excellence, safety, and trust.
Measure success through real outcomes:
- Increased reporting to include near misses and employee concerns
- Fewer preventable harm events- Improved quality and safety scores
- Better patient experiences
Perpetual readiness isn’t just good practice—it’s what delivers better care.The goal isn't just to avoid citations.
It's to honor the trust that patients place in us, every single day.By treating standards as the floor—not the ceiling—we deliver what patients deserve: safety, quality, and dignity.
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