Perioperative Accreditation: Standards, Challenges, and Resources

• NV Healthcare's focus on quality management systems requires a deep dive into process improvement and data-driven decision-making. Perioperative leaders must demonstrate a culture of continuous improvement, which can be challenging to implement and maintain across diverse teams. 

Perioperative Accreditation Challenges and Solutions  

• Maintaining Consistent Compliance: “Facilities need to teach, train and continuously educate the interdisciplinary team on numerous protocols, techniques, and technologies,” said Colleen Becker, PhD, MSN, RN, CCRN, Director of Nursing Education at AORN. “Consistency is one of the most challenging aspects to maintaining compliance for the healthcare leader because it’s so pervasive. As a perioperative leader, you must ensure consistency across many teams and different aspects of the facility.”
• Staff Education and Competency: “When an accreditation body comes into a facility, leadership has to demonstrate that they continue to develop each and every member of their team on a routine basis,” said Becker. “And annually, leaders have to show that they have gone through their competencies—the ones that they’ve identified as high risk for their patient population.”
• Resource Allocation: “It can be a delicate balancing act for leaders,” said Becker. “They must advance their teams’ competencies, which requires greater investment in education, but they also must be good stewards of resources. So that means leaders must be skilled in collaborating with the finance, human resources, and other departments in the facility.” 
• Interdepartmental Collaboration and Proper Equipment Maintenance: “Accreditation bodies come on site and can pick any piece of equipment they want, and you must have the tag or the sticker on it to show that it has been maintained and updated by the appropriate department,” said Becker.
  
  “Perioperative leaders must collaborate with facilities engineering, clinical engineering—whatever department that might be—so that they can give other departments access to all their equipment,” she continued.
  
  “When your facility is reviewed for accreditation, all departments must demonstrate that they've got that interdepartmental collaboration, and that the facility can show the outcome of all of those reviews.”
  
• Emergency Procedures: “Depending on the area of the country where a facility is located—the natural surroundings and the infrastructure of the nearby communities—leaders must put together competency and emergency procedures, which can, in some cases, be dictated by the natural surroundings and the community’s infrastructure,” said Becker. “Two examples of some of the competencies that are considered high risk regardless of the facility’s location are fire and power outage, but leaders may also need to be prepared for scenarios like earthquakes, tornadoes, and chemical and plant explosions.”
• Policy Changes and Staff Training Prior to a Visit: “When you set up a routine schedule, whether it be staff meetings around your surgeons, or anything else, it gives you the opportunity to build in those routine updates and clinical competencies that may be required by accreditation bodies,” said Becker. “Having this routine schedule, whether it be every two weeks, once a month, whatever works best for that organization, is great to put in front of that accreditation body to say, ‘I have time with my team on these routine schedules, and if you give me additional updates, this is where we build it in.’”
  
  However, Becker continued, “Successful facilities build a culture of continuous learning and adaptability. When last-minute policy changes arise, they leverage existing communication channels, utilize readily available resources like online modules or quick huddles, and focus on practical, hands-on training to ensure staff comprehension and compliance, even under tight deadlines."

AORN Resources for Accreditation Success  

• Standardized Staff Education: Periop 101 provides a consistent, comprehensive understanding of perioperative nursing principles, ensuring all novice nurses receive the same core knowledge of evidence-based best practices. This standardization helps facilities demonstrate competency and compliance with accreditation standards related to staff training. 
• Ongoing Training: Newly released program features now include continuing education opportunities for both novice and experienced RNs on the periop team, displaying a facility’s commitment to the continued development of periop skills.
• Demonstrated Competency in Core Skills: By covering essential topics like sterile technique, infection prevention, and patient safety, Periop 101 equips perioperative staff with the skills necessary to perform their duties according to best practices. This directly supports a facility's ability to prove staff competency during accreditation surveys. Clinical tools in the program’s recently expanded features include access to downloadable and customizable Competency Verification Checklists to confirm the understanding of key perioperative guidelines.

How AORN CineMed Video Library and AORN CineMed Perioperative Clips Helps Your Facility with Accreditation 

• Standardized Training and Competency Verification: The AORN CineMed Video Library provides over 40 in-depth educational courses to help reinforce critical skills learned in Periop 101 and help verify competency in the OR. Each course includes an engaging and accessible video, a study guide to help retain complex information, and a test to assess and verify competency. This ability to assign standardized training and validate competency with successful test results can help support competency verification efforts, a key component of accreditation surveys.
• Visual Demonstration of Best Practices: AORN CineMed Perioperative Clips provides over 90 high-quality, evidence-based video clips on how to perform critical perioperative procedures including surgical prepping, draping, positioning, tourniquet care, and more. All videos are based on AORN Guidelines, evidence-based practice, and research. This visual evidence can be used to demonstrate commitment to staff competency and compliance with accreditation requirements related to procedural techniques.

How eGuidelines Plus Helps Your Facility with Accreditation 

• Access to AORN Guidelines and Crosswalk to Standards: The eGuidelines Plus subscription platform provides facility-wide access to the latest AORN Guidelines, implementation tools, and resources, which demonstrates a commitment to evidence-based care, a critical factor during accreditation reviews. In addition, the Accreditation Assistant aligns TJC Standards and AAAHC Standards with the 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).
• Templates to Help Maintain Consistent Compliance: eGuidelines Plus includes hundreds of downloadable and customizable tools to help ensure consistency with compliance. Each AORN Guideline within eGuidelines Plus includes associated audit tools, competency verification tools, gap analysis tools, and policy and procedure templates. These tools are essential to help busy perioperative leaders and educators maintain consistent training, competency verification, and standardized procedures – all key to a successful accreditation.

Accreditation serves as a powerful validation of a healthcare facility's dedication to quality and safety. It demonstrates to patients, staff, and the wider community that rigorous standards are consistently met. This commitment fosters trust and ultimately drives continuous improvement, ensuring the highest level of care for every patient. 

However, a perioperative team’s work isn’t done after achieving accreditation. Optimal OR efficiencies, robust clinical competency, and strict regulatory compliance form the critical foundation for high-performing perioperative teams. Simultaneously, maintaining a highly skilled and competent staff ensures patient safety and minimizes errors, while adherence to evolving regulatory standards safeguards both patients and the facility from potential legal and financial repercussions. In essence, these three pillars are not isolated goals but rather interconnected elements that drive superior patient outcomes and sustainable operational success within the perioperative environment. 

Perioperative Education Solutions 

AORN offers a variety of facility solutions to support your team's goals. Take advantage of three essential resources—Periop 101, eGuidelines Plus, and the CineMed Video Library—to discover how they can positively impact your team's surgical practice.