Accreditation readiness has become an ongoing discipline, not an event that comes around every three years. Regulators and surveyors from The Joint Commission (JCAHO), DNV, CMS, and state agencies now expect hospitals to demonstrate continuous compliance with real-time visibility, automated enforcement, and connected systems.
Few areas reveal the gap between policy and practice more clearly than vendor credentialing. The process touches nearly every corner of hospital operations. Everyone – from device representatives, IT contractors, pharmaceutical vendors and biomedical technicians – must meet the same stringent credentialing, access, and safety requirements, yet many hospitals still rely on fragmented or manual processes to manage them.
When that happens, even well-intentioned programs struggle to maintain consistency, and compliance becomes reactive instead of routine. The result is heightened risk for patients, staff, and the organization itself.
There are five common warning signs that a credentialing program may not be as survey-ready as it appears:
1. Credentialing records live in too many places
A hospital’s ability to verify compliance depends on how easily it can access accurate data. When licenses, immunizations, and background checks live across shared drives, departmental systems, or email threads, it becomes nearly impossible to prove enforcement with confidence.
Surveyors expect credentialing, access, and training data to tell a cohesive story. If those records sit in different systems, that story will contain gaps.
Centralized platforms that connect these data points automatically allow compliance leaders to see every vendor’s status in real time. Instead of reacting to missing documents, hospitals can identify and address exceptions before they become findings.
2. You can’t say with certainty who’s onsite
Many organizations still rely on manual lists or outdated sign-in sheets to determine the individuals onsite and to verify their clearance status. That lack of instant visibility signals a deeper problem: disconnected systems.
Credentialing loses its value if it doesn’t inform physical access. Without integration between access-control and credential databases, a vendor could enter a restricted area without meeting all requirements.
Hospitals that link these systems turn compliance into a real-time safeguard. Seeing exactly who is onsite — and whether they’re compliant — turns a vulnerability into an advantage.
3. Vendor training varies by department
When departments define their own standards for HIPAA, infection control, or safety training, inconsistency follows. One area’s definition of “cleared” may not match another’s, which surveyors interpret as uneven enforcement.
Leading hospitals are standardizing training by vendor type and tying access privileges directly to completion status. When education, credentialing, and access operate within one ecosystem, training becomes part of the organization’s culture rather than a periodic compliance task.
4. Policies exist on paper but not in practice
Strong policies are table stakes; execution is what differentiates readiness from risk. Many hospitals maintain detailed documentation but lack a feedback loop to ensure those policies are consistently applied.
Surveyors don’t just review binders — they observe behavior. They notice whether badges flag expired credentials, whether staff can explain policy steps, and whether exceptions are documented.
Hospitals that conduct regular mock audits and align credentialing with infection prevention and workplace-safety protocols treat policy as a living framework — one that’s continuously validated through practice.
5. Reporting requires a scramble
The final test of readiness is how quickly a team can produce evidence. If reports take hours to compile or rely on manual data pulls, compliance has already shifted into reactive mode.
Modern credentialing systems flip that equation. Real-time reporting enables hospitals to prove readiness at any moment, not just during audit season. Many now replace the annual review with quarterly internal assessments to keep compliance top of mind and surface issues early.
Speed and accuracy in reporting are a proxy for system maturity: if readiness can be demonstrated in seconds, compliance is already built into daily operations.
Mickey Meehan
Mickey Meehan is CEO of Green Security.
