By Deanna Scatena, RN
In surgical environments, ensuring patient safety isn’t just a goal, it’s a baseline expectation that depends on systems designed to support consistency, accountability and excellence.
This is where accreditation plays a pivotal role. As a program leader with the Accreditation Commission for Health Care (ACHC), I can attest that achieving and sustaining the standards associated with accreditation is more than meeting regulatory requirements. We provide hospitals and surgical centers with a trusted partner to support the creation of a sustainable culture of safety, quality and accountability.
ACHC Standards are organized in chapters and while it may be tempting to limit your review to those specific to surgical care (e.g., anesthesia services, surgical services), successful surgical outcomes depend on a process that begins well before the patient arrives in the OR. Whether the period from pre-admission assessments to discharge occurs in under 24 hours in an outpatient setting, or over a longer period in an inpatient setting, it is essential to align each step with evidence-based protocols.
Accreditation serves this need as an organization-wide commitment. Beginning with your leadership and administrative structure, recognizing your physical plant as your biggest piece of “medical equipment,” and continuing to specific, department- and function-level requirements, the standards as a whole reflect an integrated, facility-wide commitment to patient care quality.
Within the OR, each regulation is designed to reduce risk, improve outcomes, and support clinical best practices across all roles in the operating room. Accreditation standards for the floor plan, utility and equipment set-up, use of sterile technique, infection prevention and other risk reduction strategies such as surgical site verification and defined team roles work together to foster an efficient, predictable, well-managed environment. This serves your surgical teams just as much as it does your patients. When every member of the team knows and follows the same procedures, collaboration improves, and the risk of complications decreases. Any deviation that occurs will be immediately noted and responded to.
Data consistently demonstrate that accredited organizations adhering to best practice guidelines are associated with reduced complication rates and decreased average lengths of stay compared to facilities lacking accreditation.
I am biased based on my role, but I have seen accreditation from the provider side as well as from the perspective of several accrediting organizations. In my view, ACHC Accreditation is a shared promise, a pledge from every member of my team and of the surgical teams we serve to uphold the highest standards of care. Accreditation isn’t a box to be checked. It’s not a periodic hassle to be avoided. It’s not about compliance for the sake of compliance. At its core, accreditation is about delivering the kind of care we want for ourselves and our families – intentional, consistent and collaborative.
– Deanna Scatena is the associate program director for acute care and critical access hospital accreditation at ACHC. She has worked in accreditation since 2017, guiding product development for specialty care certification and providing standards interpretation before moving into her current leadership role.
