Healthcare accreditation is often framed as a binary exercise where the outcome is pass or fail, compliant or non-compliant, or varying degrees of right and wrong. Accrediting Organizations like the Joint Commission, DNV, AAAHC, CIHQ, etc., uphold rigorous CMS standards intended to ensure on-going patient safety and operational reliability. Yet, as we assist organizations in preparing for their surveys, we routinely see the same compliance findings surface year after year. Although policies are updated, education modules are completed, and mock surveys are performed, the underlying behaviors in nursing units, in operating rooms, and in ancillary departments remain inconsistent. This is where the gap occurs between learning what is right vs. embedding sustained behavioral change. The very real pressures of workload, staffing, competing priorities, and financial performance all have the effect of eroding compliance habits over time. When accreditation is viewed as an event rather than a way of operating, there is a much higher likelihood of regression. We believe there is a strategic opportunity for healthcare organizations to move beyond readiness at a single point in time to an organization-wide behavioral commitment to doing the right thing at any and all points in time.
Sustained behavioral change must begin with senior leadership as culture has a cascading effect. Studies have shown that when boards, CEO’s and leadership teams start to frame accreditation as an operational discipline tied to patient safety and financial stewardship, priorities begin to shift. Leaders must be operationally present by rounding on units, asking compliance-based questions and creating a sense of ‘safe’ transparency when gaps are identified. In addition, compliant behavior needs to be the path of least resistance and not something more difficult than everything else.
One proven technique is known as environmental nudging, which is the process of subtly designing the physical environment in a way that makes the desired behavior easier, more automatic, and more likely without forcing it. Some illustrative examples may include 1) embedding infection prevention checklists directly into electronic health record prompts, 2) placing visual management boards in medication rooms or 3) redesigning supply rooms so expired products are physically segregated to reduce accidental errors. Behavioral science has demonstrated that having the correct environmental cues drives more reliable and desirable outcomes than education alone. This is especially true in a fast paced, high work-load environment where clinicians are juggling admissions, discharges, emergencies, and documentation.
A second technique is unit-level ownership through peer accountability structures. Rather than centralizing compliance within a quality department, organizations can establish ‘accreditation champions’ or rotating compliance stewards within each clinical area. These individuals are not auditors but peer coaches who may conduct brief weekly tracers, review documentation completeness, or facilitate safety huddles. Behavioral change has been shown to be more psychologically effective in peer-to-peer reinforcement than top-down directives. From a day-to-day perspective, this might look like a charge nurse leading a quick review of restraint documentation accuracy before shift change or respiratory therapist validating equipment logs during morning rounds. The goal here is to normalize compliance by embedding it in routine conversations.
Third, organizations should implement an ‘experiential learning’ program rather than the usual annual competency refreshers. We find that traditional learning programs often overwhelm staff with broad regulatory language disconnected from frontline realities. A better approach is to foster scenario-based learning that occurs during daily routines. By linking a compliance standard to a real patient situation or a near-miss event with the organization, leadership creates an emotional connection and stickiness. For example, an educational program might state that “hand hygiene compliance must be at 95%.” However, if a patient develops sepsis after a preventable infection linked to inconsistent hand hygiene, that can be a far stronger behavioral learning tool. This can be accomplished either through real patient situations or through examples that feel very real. Over time, these repeated micro-interventions build muscle memory.
Finally, it is important to align incentives and recognition with compliance reliability. We find that financial performance and patient throughput often dominate dashboards which may not signal what the organization truly values: delivering the highest quality of patient care. When units demonstrating sustained documentation accuracy, environmental safety or tracer performance are publicly recognized, the behavioral message strengthens. This recognition can be conveyed through leadership communications, performance evaluations or even through modest financial incentives. The key to this recognition is ‘sustained consistency’ and not a one-time effort to be compliant. This integration of compliance indicators into management scorecards coupled with recognition sends a powerful message: compliance is a part of operational excellence.
Accreditation, at its core, is about safeguarding patients and strengthening operational discipline. When healthcare organizations invest in behavioral change through environmental nudging, peer accountability, experiential learning, and incentives/recognition, they shift from reactive preparation to continuous readiness. The return on that investment is very measurable through lower regulatory risk, smoother operations, stronger staff engagement, and ultimately improved patient outcomes. Courtemanche & Associates stands ready to help your organization achieve a higher level of behavioral excellence so that compliance is ingrained, consistent, and sustained.
For questions or to learn more, contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
