Medical Staff

Accreditation: Why it matters to physician leaders

Medical Staff Leader Insider, April 26, 2012

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Question: What happens every few years that sort of upsets the hospital’s normal activities and frustrates physicians and caregivers?

Answer: Accreditation. 

Although it can be a stressful time, we need to keep in mind that our patients, staff, and even we physicians benefit. Here’s how.

Hospitals are a very complex mixture of

  • Amazing technology
  • Multifaceted nursing
  • Advanced pharmacology
  • Laboratory and radiology wizardry
  • Hotel services even the best couldn’t top

And all of this is orchestrated and delivered in life and death scenarios and managed by physicians, nurses, technicians, and administrators.

How can we be sure this complex mixture works?

Accreditation is an inspection of the key elements of the organization in action—our actions and those of all the other members of the team caring for our patients and our communities. Those who perform this inspection are health professionals including physicians and nurses.

Invariably, inspectors are looking at our qualifications, our processes, and our habits. How are the meds labeled in the OR?  How are the records kept?  How was this surgeon credentialed? Who maintains this MRI scan? On and on the list goes.  Some feelings are hurt. Decision making is questioned. However, medical staff leaders need to know what is involved and what’s at stake. 

An accreditation survey re-creates the care given, by utilizing the science of inspection. The net result is that care is improved, mistakes are avoided, and, in many cases, liability is mitigated.  As leaders of the medical staff, we need to be in front of the effort, learning and practicing those things that support care excellence (e.g., “time out” two patient IDs, label medications, mark the site, etc).

While it might feel like a physical exam (ouch), we all know that prevention is the best medicine.  Inspection is the “x ray” of the whole hospital, and every hospital that meets those standards supports all the others who also have that model. 

Wherever you see the H sign on the roadways in America, you can be assured that if that hospital is accredited, its providers can care for you and yours, wherever and whenever you need them. Leaders are at the head of that effort. Our families and patients are the beneficiaries.


Richard M. Turbin, MD, FACPE, is a physician healthcare consultant with 15 years of experience as a senior physician executive and eight years of experience as a Joint Commission surveyor.  Turbin is a faculty speaker for The Greeley Company’s medical staff leadership national seminars and onsite education programs.

Turbin practiced family medicine for 11 years in Texas. His senior executive service consisted of 10 years as senior vice president of medical affairs for St. David’s Medical Center, trustee of the Texas Hospital Association, three years as Texas medical director for Blue Cross/Blue Shield Texas and two years as locum tenens vice president of medical affairs for Bayonne Medical Center in New Jersey. In these roles, his responsibilities included physician networking, accreditation, medical affairs management, and statewide oversight for insurance utilization review and quality assurance.

As a Joint Commission physician surveyor, he was responsible for assessing compliance with hospital standards and National Patient Safety Goals, as well as physician credentialing and privileging. In addition to his consulting, he currently practices as a designated doctor for Texas Worker’s Compensation. Turbin holds certifications from the American Board of Medical Management, the American Board of UR/QA Physicians (ABQURP), and the American Board of Family Practice.

In future issues, Turbin will focus on different areas of accreditation.

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