• Gap analysis against accreditation standards

• Identification of high-risk deficiencies

• Review of current documentation

• Written readiness report with corrective action steps

• Emergency preparedness & drills

• Infection Control Program

• Medical Records

• Provider credentialing & privileging

• Personnel files

• Patient rights and safety policies

• Quality studies design, data collection and analysis with corrective action recommendations

• Internal and external benchmarking

• Risk assessments

• Incident and adverse event tracking & reporting process

• Emergency preparedness

• Emergency drills

• Anesthesia safety and monitoring standards

• Medication / controlled substances requirements                                                                                                                                                                    ​

• Onboarding checklists

• Ongoing training  documentation

• Clinical competencies

• Accreditation standards interpretation

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• Assistance with application process

• Documentation requirements

• Survey expectations & guidance

• Mock surveys with real-time coaching​

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• Quarterly compliance check-ins

• Monitoring of accreditation standards updates

• Policy updates 

• Monitoring of documentation requirements

• QI program support

• Reaccreditation preparation

• Assistance with application process

• Documentation requirements

• Survey expectations & guidance

• Mock surveys with real-time coaching                                                                                                                   ​