15 Most Important Healthcare Compliance Policies for Accreditation

There’s no magic bullet to secure and maintain accreditation, but having strong policies provides a good foundation. That’s why I’ve identified the 15 most important based on common deficiencies cited.

Preparing for accreditation or re-accreditation is stressful enough. Take time now to review these 15 policy recommendations so you can avoid penalties and the dreaded corrective action plan. By understanding and implementing these key policies, you can equip your staff to effectively maintain compliance and accreditation, ultimately reducing the stress associated with the accreditation process.

Why Policy Management Is a Pain

Policy management can be particularly challenging for three main reasons. 

1. The multitude of policies requires diligent oversight to ensure they are current and compliant, highlighting the importance of expiration notifications and a structured tracking system. 
2. It’s a complex process that most healthcare organizations (69%) are using two or more tools to manage. According to the same MedTrainer poll, 43% of respondents still collect signatures by people signing a paper.
3. Even with all the policies in place, a lack of employee adherence can lead to gaps in compliance and control. It’s not enough to have policies; your team must actively follow them. 

By addressing these complexities, you can better navigate the accreditation process and maintain your organization’s standing.

See a full-cycle policy management system in action.

Top 15 Healthcare Compliance Policies

Once again, there are so many policies you need to manage as a healthcare organization, but these are the 15 that we think are the most important, as these policies can be the most detrimental to your organization if you are not compliant with them. Keep in mind, each of these policies plays a crucial role in ensuring patient safety, promoting ethical practices, and meeting regulatory standards, all of which are vital for maintaining accreditation and delivering high-quality care. Each policy will have a list with the commissions that require them as well.

1. Care Coordination and Continuity of Care

Required by: 

Among the most common deficiencies noted is the lack of effective care coordination (or communication and information transfer according to TJC), which can lead to fragmented services, poor patient outcomes, and higher risk of readmission. According to the Agency for Healthcare Research and Quality (AHRQ), poorly coordinated care can increase hospital readmissions and drive up healthcare costs.

This policy should include procedures for effective communication among healthcare providers and with patients, including hand-offs and transitions of care. 

2. Behavioral Health Integration

Required by:

Organizations are often cited for having gaps in behavioral health care, a root of which is having inadequate policies and procedures for assessing and treating behavioral health conditions. This should be in place in every facility, but it is especially important for FQHCs where patients are more transient or may be diagnosed.

Your policy should promote collaborative care models that ensure mental health services are accessible and aligned with primary care practices. Effective integration involves training staff to recognize behavioral health issues, implementing standardized screening protocols, and establishing clear referral processes. For example, implementing routine depression screenings during primary care visits allows providers to address mental health concerns promptly and refer patients to counseling or psychiatric services as needed.

TIP: Regularly evaluate the effectiveness of your integration efforts through patient feedback and outcome metrics, and be open to adjusting your approach based on these insights.

3. Infection Control Policy

Required by: 

Effective infection control can save you from a world of problems. That’s why comprehensive policies to prevent and control infections, including hand hygiene, sterilization, and use of personal protective equipment (PPE) are so important. 

Be sure your policy includes collaboration between your Infection Preventionist and all departments to identify any HAI trends or patterns that may occur, as well as identification of opportunities to improve outcomes in the reduction and control of infections. 

TIP: In addition to your policies, make sure you’re conducting and tracking annual N95 fit tests and documenting vaccination declinations.

4. Cultural Competency

Required by: 

A common deficiency is lack of training or policies to ensure culturally competent care for diverse patient populations. This is a standard for most accreditation organizations and many states. 

It helps to prevent minority patients from receiving lower quality care due to cultural misunderstandings or biases among healthcare providers. Your policy should emphasize the importance of training staff to understand and appreciate diverse cultural backgrounds, beliefs, and practices.

TIP: Review your state’s healthcare training requirements closely and consistently. They change more often than federal regulations and, such as in Florida’s Stop Woke Act, prevent mandated cultural competency training.

5. Patient Rights and Responsibilities

Required by: 

Organizations are often cited for insufficient policies regarding patient rights, leading to breaches of patient confidentiality and autonomy. Similar deficiencies include Insufficient procedures for obtaining and documenting informed consent from patients, as well as inadequate processes for managing and resolving patient complaints and grievances. Having effective policies in place, and ensuring staff are following them, can save time and money not just during an accreditation survey. Unresolved complaints and decreased patient satisfaction have hurt many healthcare facilities. 

To prevent deficiencies, your policy should outline patients’ rights, including informed consent, privacy, and grievance procedures. In addition to policies, ensure that patients receive written materials that clearly explain their rights and responsibilities upon admission and during their care.

TIP: Informed consent training is required in many circumstances, but even if it is not required, the best healthcare training softwares offer it and you should consider assigning it to staff. 

6. Safety (Patient and Workplace)

Required by: 

Patient safety is one of the most common deficiencies for organizations, especially those that lack processes for reporting and investigating adverse events, near misses, and sentinel events. This goes hand-in-hand with deficiencies for failure to establish a robust system for incident reporting and analysis. While not one of the top deficiencies, these same processes are critical for workplace safety and maintaining OSHA compliance for accreditation.

Safety in the workplace requires clear safety protocols, training requirements, and emergency procedures to create a safe working environment. Having appropriate policies and procedures in place is the best starting place. But, you’ll also need consistent training to reinforce the policies and an easy-to-use incident reporting system. Bringing incident reports online makes it easier for staff to complete the reports and automatic escalation ensures they get to the appropriate managers more quickly.

TIP: Evaluate your incident report data to identify trends that can help you improve safety and make adjustments to your policies and training programs.

7. Medication Management 

Required by: 

Medication errors affect approximately 1.5 million people in the United States each year, often due to poor communication and lack of standardized processes. Inadequate policies for prescribing, administering, and monitoring medications are common deficiencies, especially when they result in errors. 

Your policy should outline clear guidelines for prescribing, administering, and monitoring medications to prevent errors and enhance care. Conducting regular training for staff who manage medications will help your staff to remain compliant. 

TIP: Remember the five rights of medication administration: patient, drug, dose, route, time.

8. Credentialing and Privileging

Required by: 

Failure to verify and maintain the credentials of providers and lapses in privileges often lead to deficiencies, adverse patient outcomes, and legal repercussions. Having a policy in place and ensuring your credentialers follow the policy can help protect your organization.

Your policy should include comprehensive verification procedures and list of required verifications by location and specialty, since this is an area of high risk. Ensure the policy also specifies where documents, verifications, and provider data will be stored and for how long.

TIP: Use credentialing software to maintain comprehensive records of the credentialing process, including all decisions made, to provide evidence of compliance during audits.

9. Health Literacy & Education

Required by: 

In healthcare, patients with low health literacy are more likely to mismanage their medications, resulting in increased hospital readmissions. Be sure to emphasize the importance of providing clear, accessible information tailored to patients’ literacy levels and cultural backgrounds in the workplace.

Utilizing plain language in written materials, employing visual aids, and offering interactive educational sessions. For instance, a healthcare organization might develop a series of workshops that teach patients about chronic disease management, using relatable scenarios and hands-on activities to enhance understanding.

TIP: Regularly assess the effectiveness of your health literacy initiatives through patient feedback and comprehension tests, and adjust your educational materials and methods to better meet the needs of your diverse patient population.

10. Telehealth

Required by:

Telehealth use skyrocketed during the pandemic and still remains 38 times higher than pre-pandemic levels. While convenient, telehealth compliance adds a layer of complexity that results in deficiencies for organizations who have inadequate policies and procedures. Your policy should outline guidelines for scheduling, conducting, and documenting telehealth visits, as well as ensuring compliance with privacy regulations. Be very clear about the technology and disclosures that are acceptable and not.

TIP: Since many physicians provide telehealth services across state lines, having an online system for credentialing and compliance can help you to meet the added regulations.

11. Emergency Management

Required by: 

Emergency planning is required by multiple federal agencies in addition to your accreditation organization. Deficiencies are common for organizations with incomplete plans for responding to emergencies, including natural disasters or pandemics. 

Your disaster preparedness plan should outline clear procedures for preparedness, response, recovery, and mitigation in the face of emergencies, ideally using a multi-hazard approach. Biannual emergency response drills that simulate various scenarios are required in addition to specific training on your organization’s emergency plan and evacuation routes.

WEBINAR: Plan Like a Pro: Disaster Preparedness 2.0

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12. Quality Assurance & Performance Improvement (QAPI)

Required by: 

Facilities that lack effective quality improvement initiatives and fail to monitor performance are at risk for deficiencies and often experience higher rates of avoidable hospital readmissions and lower overall patient satisfaction scores. 

When you establish a QAPI policy, you should look to outline systematic processes for monitoring quality indicators, identify areas for improvement, and implement changes based on data-driven insights.

TIP: Use this checklist when you report to your governing body to be sure you provide the leaders with the information they need in fulfilling their responsibility for the quality of patient care and safety.

13. Information Management

Required by: 

One of the most common deficiencies cited in healthcare is the lack of a comprehensive information management policy, which can lead to disorganized data handling and compromised patient care. Often, organizations with poor information management struggle with data retrieval, which can delay patient diagnoses and treatment.

Your policy should detail procedures for data entry, storage, sharing, and backup, with a strong emphasis on compliance with HIPAA regulations to protect patient privacy. The policy should also include safeguards for the information entered into the electronic health record (EHR) system.

14. Code of Conduct

Required by: 

A healthcare code of conduct lays the groundwork needed to prevent deficiencies such as non-compliance with regulatory standards and failures in protecting patient information. It plays a critical role in promoting adherence to both human resources requirements and compliance requirements for accreditation.

The code of conduct should be updated regularly and include procedures relating to audits, compliance, training, and more. Including AI and cybersecurity in your code of conduct is also best practice, putting safeguards around your data. 

Download a ready-to-use and customizable Code of Conduct.

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15. Financial Management

Required by: 

While not a common accreditation deficiency, effective financial management is critical in adhering to federal regulations. Monitoring financial performance metrics, engaging staff in financial planning processes, and maintaining billing and coding standards helps to decrease fraud and non-compliance.

Many healthcare organizations without structured financial oversight often face cash flow challenges, impacting their ability to invest in patient care and facilities. Procedures for budgeting, financial reporting, and compliance with regulatory requirements are key factors in creating a solid financial management policy.

Simplify Your Policy Management Process

As you know all too well, these 15 policies are just a fraction of what is required. Managing that volume of policies has become very difficult. Ideally, you would want one system where you can manage the entire policy process from writing to board approval to distribution and organization. This approach not only enhances efficiency but also ensures that everyone in your organization has access to the most current policies, reducing the risk of non-compliance and fostering a culture of accountability.

Stop stressing about accreditation compliance with an all-in-one platform like MedTrainer. All your documents and policies are in together, right alongside your compliance training, incident reports, and credentialing. One login, one interface to learn, one easy path to compliance.

See how MedTrainer can help.