Five Signs Your Credentialing Program is (Not) Ready for Accreditation

How vendor credentialing readiness shapes survey success.

Accreditation readiness is no longer a once-every-three-year's event 

Across Joint Commission (JCAHO), DNV, CMS, and state inspections, surveyors now expect continuous compliance, not a last-minute scramble before an audit.   

And one area that can make or break your inspection readiness? Vendor credentialing. 

 Every person who enters your facility - from device reps and contractors to pharmaceutical vendors and service technicians - must meet specific credentialing, access, and safety requirements. If those processes aren’t consistent, documented, and visible in real time, it becomes a major accreditation risk. 

Here are five signs your hospital may not be as “survey ready” as it seems, and how to fix it before the next inspection.

1. Vendor records and training data lives in multiple systems (or inboxes)

If licenses, immunizations, background checks, or policy attestations are scattered across multiple systems or managed manually, that’s a red flag. Surveyors expect hospitals to verify credentials quickly and prove enforcement. 

And credentialing extends far beyond paperwork. Clinical vendors may require OR protocol or aseptic technique training, while service contractors often need safety or facilities-specific certifications. When this training data is tracked separately from credentials, policy acknowledgment, or background checks, blind spots form — and those are what surveyors find first. 

What to do: 
Centralize vendor records in a single system that integrates with your access control process. Automation ensures records stay up to date and accessible for audits without relying on manual follow-ups.

2. You can’t instantly tell who’s onsite and whether they’re cleared to be there

During surveys, inspectors often ask: “Who’s onsite right now, and are they credentialed?” If your team can’t answer confidently, it signals a gap in visibility and control. 
 
Even the most diligent credentialing efforts fall short if your access control system and credentialing platform aren’t connected. Without a bi-directional feed or at least synergy between these systems, vendors and contractors may still be able to enter restricted areas without fully meeting compliance requirements. 

What to do: 
Integrate your credentialing solution with your facility’s access control system so that compliance and access work hand in hand. A real-time dashboard should show every vendor and contractor onsite, their credential status, and zone permissions — automatically updating as badges are scanned. Instant visibility means immediate compliance assurance.

3. Vendor training isn’t standardized or enforced

When vendor or contractor training (HIPAA, infection control, safety, OR protocols) varies by department, gaps form. Surveyors will view this as inconsistent enforcement of hospital policy. 

What to do: 
Standardize training requirements for all vendor types and automate enforcement before access is granted. A strong system flags noncompliance automatically, with no manual tracking required.

4. Your policies are documented, but not practiced

Well-written policies don’t matter if they’re not practiced. Surveyors don’t only care about what’s written; they also care about what’s demonstrated. 

 What to do: 
Use internal spot checks or mock audits to test policy enforcement. Align your vendor credentialing and access policies with infection prevention, HIPAA, and workplace safety standards — and make them visible to staff and vendors alike.

5. Reporting takes hours instead of seconds

If your team is scrambling to compile documentation before an audit, you’re operating reactively, not proactively. Manual reporting creates risk and drains resources that could be used elsewhere. 

What to do: 
Automated credentialing systems generate audit-ready reports in seconds. Survey readiness isn’t a once-a-year event. It’s an ongoing process that’s far more manageable when approached in smaller, focused intervals. Instead of one exhaustive annual review, spread out targeted audits each quarter. This approach keeps readiness top of mind, helps teams focus on specific compliance areas, and allows for meaningful process improvements over time.  

Are you truly ready for accreditation? 

Accreditation success isn’t just about checking boxes; it’s about proving compliance is part of your daily operations. 

That starts with vendor credentialing: ensuring every third party who enters your facility is verified, tracked, and compliant. 

Take our Vendor Credentialing Readiness Self-Assessment Survey to see where you stand. You’ll identify strengths, uncover vulnerabilities, and get a clear action plan for achieving and sustaining daily accreditation readiness: Take the survey.