Clinical Competency and Regulatory Compliance: Bridging the Gap to Prevent Failures

Accreditation Regulatory Affairs

By: AORN Staff

Published: 3/28/2025

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A single mistake in the OR—whether in infection prevention, patient positioning, or sterile technique—can have serious consequences, not just for the patient but also for a hospital’s compliance and accreditation status.

“An adverse event that could occur due to a lack of competency could be a pressure injury that a patient acquires during the perioperative period,” said Colleen Becker, PhD, MSN, RN, CCRN-K, Director of Nursing Education at AORN.

“Education and competencies around positioning and care of the patient and their skin can decrease or eliminate this pressure injury adverse event."

When perioperative teams lack proper training, patients face a greater risk of preventable complications such as pressure injuries and surgical site infections. These incidents not only compromise patient safety but can also lower a hospital’s quality scores, threaten accreditation, and reduce financial reimbursements. 

Regulatory Compliance Risks: The Consequences of Competency Gaps

Hospitals and ambulatory surgery centers (ASCs) must meet strict competency and compliance standards set by regulatory bodies such as the Centers for Medicare & Medicaid Services (CMS), and accreditation agencies such as The Joint Commission, Accreditation Association for Ambulatory Health Care (AAAHC), and Magnet. Failing to do so can lead to lower quality scores, financial penalties, or even loss of accreditation.

“Hospitals and ASCs that participate in the Medicare program are required to have a Quality Assurance and Performance Improvement (QAPI) program,” said Jeanine Watson, MSN, RN, CNOR, Senior Manager for Ambulatory Surgery at AORN. “This program requires facilities to set clear objectives, implement evidence-based interventions, and continuously monitor outcomes.”

If perioperative teams lack competency in critical areas—such as infection control, patient positioning, or instrument sterilization—facilities risk:

  • Increased adverse events related to preventable complications.
  • Lower quality scores that impact Medicare reimbursement rates.
  • Compliance violations that put accreditation at risk.

How Quality Scores Directly Impact Medicare and ASC Reimbursements

Hospitals and ASCs must meet Medicare certification requirements to participate in the program and be reimbursed for services. Facilities can achieve certification in two ways:

1. Directly through CMS via a full Medicare survey.

2. Through a third-party accrediting body like The Joint Commission or AAAHC, which grants “deemed status.” This means meeting these accreditation standards also satisfies Medicare certification requirements.

Beyond certification, quality scores play a major role in reimbursement:

  • Hospitals: Under Medicare’s Value-Based Purchasing (VBP) Program, hospitals with high-quality scores earn financial rewards, while low scores result in penalties.
  • ASCs: The ASC Quality Reporting (ASCQR) Program requires ASCs to report quality data on specific measures like COVID vaccinations among healthcare providers on a quarterly basis. Other quality measures submissions are collected between Jan. 1 and mid-May, from the previous year. Unlike hospitals, they aren’t penalized for poor scores—only for failing to report. ASCs that fail to submit quality data may face a 2% payment reduction.

“Hospitals are rated based on quality measures,” Becker said. “Medicare and Medicaid reimbursements, as well as ASC reimbursements, are often tied to these quality scores. 

Evidence-Based Practice: The Key to Compliance and Preventing Surgical Errors

Many preventable surgical complications—such as infections, pressure injuries, and anesthesia-related errors—are directly linked to competency gaps.

  • Following evidence-based protocols reduces risk for complications and improves patient outcomes.
  • Failing to follow best practices can lower quality scores, reduce reimbursement, and increase financial penalties.

“Quality measures are based on evidence-based practice and research on the best care available for patients,” Becker said. “Hospitals and ASCs that fail to follow evidence-based practices may have complications that could have been prevented, leading to lower quality measure outcomes.”

Watson emphasizes that adhering to evidence-based practices isn’t just about compliance—it’s about delivering the highest level of patient care.

“Certain interventions—such as infection prevention protocols for surgical procedures, urinary catheters, and central line insertions—have proven to reduce the risk of complications,” Watson said. “Hospitals and ASCs that fail to follow these best practices are more likely to experience preventable patient harm and lower overall quality scores, which can impact financial reimbursement.”

AORN Training Solutions: Closing Competency Gaps for Compliance Success

Preventing adverse events and compliance failures starts with equipping perioperative teams with the right education and resources. Without standardized training, competency verification, and real-time clinical support, hospitals and ASCs risk increased patient harm, lower quality scores, and financial penalties.

AORN’s perioperative education solutions help facilities bridge competency gaps and maximize regulatory compliance.

How AORN Solutions Support Patient Safety and Compliance

Hospitals and ASCs can reduce risk and maintain accreditation by providing their teams with:

  • Structured competency-based training – Periop 101 delivers a standardized, evidence-based curriculum for both new and experienced nurses, ensuring staff meet required competency standards.
  • Instant access to evidence-based best practices – eGuidelines Plus provides perioperative teams with the latest AORN Guidelines and step-by-step visuals to support real-time decision-making. The Accreditation Assistant aligns accreditation standards from The Joint Commission and AAAHC with specific AORN Guideline recommendations, policies and procedures, competencies, and other relevant tools to save you time when preparing for a survey (available as add-on subscriptions to eGuidelines Plus).
  • Ongoing skills reinforcement – The AORN CineMed Video Library and Perioperative Clips offer quick access to a library of high-quality, evidence-based videos, allowing teams to increase competency, review procedures, and implement evidence-based practices as needed.
  • Leadership and regulatory training – ASC Academy: Administrator Essentials provides comprehensive training on the skills required to successfully run an ASC, while the instructional Ambulatory Leadership Guides help leaders navigate quality reporting, credentialing, and privileging, among other responsibilities that affect regulatory compliance. The ASC Academy: Infection Prevention Course reviews the CMS Infection Control Surveyor Worksheet, teaches vital competencies to keep patients and staff safe, and provides teams in ASCs the tools they need to meet CMS’s annual training requirements. 

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