Why More Surgery Centers Are Failing Accreditation

Accreditation isn’t optional—it’s your license to operate.
Yet, with QUAD A tightening their inspection process, more centers are failing to meet compliance in key areas like infection control and documentation.
If you’re relying on outdated forms or old survey prep methods, you’re putting your accreditation—and revenue—at risk.
This post outlines the top reasons facilities are failing inspections in 2025—and what to do now to stay survey-ready.

Inadequate Infection Control Practices

The problem: Lapses in hand hygiene compliance, sterilization tracking, or environmental cleaning protocols can lead to immediate citations—or even shutdowns.

What to do:

Assign a designated Infection Control Coordinator

Train all staff annually (and upon hire) with signed documentation

Surgical Techs must have evidence of sterilization competency and high level disinfection competency

Use checklists and logs to verify daily compliance (and keep them inspection-ready)

Weak Emergency Preparedness & Fire Drill Compliance

The problem: Missing fire drill reports, missing code blue drills, expired emergency contact lists, lack of recent staff drills, or no documentation of tabletop exercises.

What to do:

Schedule and document all emergency drills in your compliance calendar

Review and update your Emergency Operations Plan annually

Train staff using real scenarios—and keep signed attendance sheets

Credentialing & Privileging Gaps

The problem: Expired or missing documents in physician or provider files (licenses, DEA, malpractice insurance, board certifications, health records).

What to do:

Maintain a credentialing matrix for due dates and expiration tracking

Conduct a quarterly audit of all provider files

What To Do NOW To Stay Survey Ready:

Consult with Nicole Brown, owner of Accredia Surgery Center Inspection Preparation.

Purchase accredia.shop ready to download policies and procedures, drill templates and forms.

Subscribe to accredia TV inspection preparation channel and watch surgery center accreditation preparation videos streaming 24 hours a day.

Here’s to your success,

Regulatory Compliance: Consultants help ensure that your surgical facility meets all necessary regulations and standards set by accrediting bodies. This includes understanding and implementing the latest guidelines, which can help avoid deficiencies, fines or legal issues. The objective is to maintain surgical center compliance.

Enhanced Patient Safety: Accreditation often involves rigorous safety protocols and procedures. A consultant prepares your facility to adhere to these standards, which can significantly enhance patient safety and care quality. This is the focus to meeting accreditation requirements for surgery centers, achieving surgery center accreditation .

Operational Efficiency: Consultants assess and streamline your facility’s processes, leading to improved efficiency in operations. This can include optimizing workflows, resource management, and reducing redundancies. You can meet the regulatory standards for surgery centers.

Staff Training and Development: Consultants often provide training for your staff on compliance standards, best practices, and new procedures. This helps ensure that everyone in the facility is knowledgeable and up-to-date with current practices. I’ve noticed some areas where there may be opportunities for improvement in preparation for inspections. To support you in getting up to speed, I recommend utilizing our compliance videos on Accredia TV. The video resources are specifically designed to provide comprehensive training and ensure all team members are well-prepared and aligned with the necessary standards. If you have any questions or need further assistance, please feel free to reach out.

Quality Improvement: Preparation for accreditation involves evaluating and improving various aspects of your facility’s performance. This can lead to better overall quality of care and service delivery, a benefit of surgery center accreditation.

Risk Management: By identifying potential risks and implementing preventive measures, consultants help mitigate issues that could lead to adverse events or operational disruptions.

Financial Benefits: Although there is an initial cost for accreditation preparation, achieving and maintaining accreditation can lead to financial benefits through better reimbursement rates, fewer legal issues, and potential increases in patient volume.

In summary, the preparation provided by a surgical facilities accreditation consultant can lead to improved compliance, safety, efficiency, and quality of care, which ultimately benefits both the facility and its patients. Accredia offers 24/7 access to expert preparation services, accreditation policy and procedures, documentation and video training for surgical facility accreditation and Medicare certification.

Here’s to your success,

Tag: QUAD A Accreditation