Mastering the Credentialing Journey: Expert Insights from Dr. David Shapiro on Streamlining Healthcare Facility Accreditation

Jessica Puente

In today’s rapidly evolving healthcare facility accreditation landscape, facilities face immense challenges in achieving and maintaining accreditation. Striving for excellence while navigating complex regulatory requirements and rigorous survey processes can be daunting for even the most seasoned professionals.

In a recent webinar on accreditation, we spoke with Dr. David Shapiro, an esteemed accreditation surveyor, who shares his wealth of knowledge on provider credentialing and facility accreditation.

Delve into our enlightening Q&A session as Dr. Shapiro offers practical advice, best practices, and a roadmap to overcome the obstacles and thrive in healthcare accreditation.

Q: The past few years, we’ve seen an upheaval in the healthcare industry. What does this mean for ASC administrators or healthcare facility administrators generally?

Unfortunately, it means they have a lot more they are responsible for and a lot more work to do. The pandemic and the temporary standards that have occurred on the federal level have really broadened the amount of work that has to be conducted for a facility to remain compliant with all of the new regulations and administrative requirements that have been promulgated, especially at the federal level.

Q: What are some of the specific challenges that you tend to see facilities experience in terms of accreditation and or surveys?


The only thing that a surveyor can really do to check a lot of things in your facility is to look at your documentation, so please be aware that your documentation tells a good story of all the great things that you’re doing to remain compliant, but also to take good care of your patients.

Emergency Preparedness

As far as the emergency equipment, we really want it to be something that all of your staff are very familiar with, not just the location of your code chart, but how to work it. Other things that are super important are fire safety. All of those things need to be well documented so that you have made everyone feel comfortable and secure in the fact that they know what your procedures are.

Infection Prevention

One of the things that we really want to make sure you have documented that all the employees understand is the importance of one syringe and one needle, how to use multi-dose vials, and all the things that you build into your infection prevention. This includes the way that you clean all of your equipment, not only the equipment that you sterilize or disinfect.

Risk Management

We want you to consider really doing a risk management evaluation or environmental scan to take care of things in advance to try to prevent any patient loss or any financial loss to your facility. Near the top is the whole issue of making sure that your employees recognize, understand, and can implement the confidentiality and privacy of your patients.

These are questions I recommend asking yourself in a risk management evaluation:

  • How well have you configured your facility to make sure that both your patients and your employees are safe?
  • Do you have an eye wash station for your employees?
  • Do they know what to do if there’s a spill of some substances?
  • Have you created a safe environment for them?
  • Are there places where they can easily trip over ports that you may have extended from a wall socket?


There’s the confidentiality of patient medical records but also their physical privacy when they’re within your facility. How do you handle the fact that patients are often very close to each other in terms of treatment areas? You really want to make sure that you’ve been able to accommodate as high a level of privacy as you can.

Credentialing and Privileging

One of the most common deficiencies is credentialing and privileging. Things that have tripped up organizations in terms of surveys are making sure that the privileges granted to a practitioner in your facility are for procedures that can be done in your facility. Do not bring the privileging and credentialing files over from another institution and leave them as-is.

Q: As a surveyor, what’s the number one thing you’re looking for when you visit a facility? And what’s the number one thing that causes facilities to lose accreditation or not get accreditation in your experience?

A surveyor is going to not only look at documents but also observe. We’re really looking to see if patients are being taken care of. And also, do you have the documentation to support that?

When you’re talking about infection prevention, one thing that is probably going to weigh pretty heavily against you getting accredited is seeing someone misusing syringes, needles, or multi-dose vials.

Q: What should administrators be thinking about in terms of documentation and staying organized?

One of the most frequent places that I’ve seen facilities run aground is being able to access their documentation, especially those written policies and procedures. We really want to make sure that those written policies and procedures don’t just stay on a shelf and collect dust, but are easily organized and easily accessible. Electronic is even better because it can be easily done at a computer terminal, rather than trying to find a big three-ring notebook and scan through maybe a couple of hundred pages to find the policy that you need.

As a surveyor, I really want to look at your policies and procedures and make sure that they are:

  • Specific to your facility
  • Customized to your facility
  • Updated regularly
  • Current
  • Approved by your governing body

Q: What are a few ways that you’ve seen technology, specifically automation, help in terms of surveys or accreditation to help ease that burden on staff?

I think the best thing that electronic automation can do is create a checklist for things that need continual massaging, like credentialing, compliance, and training.

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About Dr. David Shapiro

David Shapiro, M.D. is an anesthesiologist from Florida who has had extensive experience serving as a department chair, medical director, and board member of several ambulatory surgery centers. He is the Chair-Elect of the Board of AAAHC and conducts healthcare facility surveys on behalf of AAAHC and Medicare.