Accreditation Theater: The Illusion of Rigor in Healthcare Accreditation
Posted: September 11, 2025
In the post-9/11 era, the term “Security Theater” emerged to describe over-the-top yet ineffective airport security procedures designed more to make travelers feel safe than to actually increase safety. Today, healthcare accreditation faces its own version of this phenomenon: Accreditation Theater.
What is Accreditation Theater?
Accreditation Theater is the use of excessive, showy, and often punitive survey practices to create the illusion of a more prestigious or rigorous accreditation experience. In reality, these actions do little to improve patient outcomes—instead, they redirect focus and resources toward surviving the survey process rather than delivering better care.
How did it take hold?
- AO uncertainty: For years, Joint Commission (JC) occupied the majority of mindshare, and many providers weren’t sure what alternatives existed. This gave JC the perceived authority to define what “high quality” accreditation should look like—even if it came with excess burden.
- Customer anxiety: Punitive survey processes, an ever-expanding list of proprietary standards, and intimidating scoring matrices reinforced the idea that more pain equals more prestige.
- Misplaced focus: The obsession with preparing for and surviving the survey became the goal, rather than improving care or outcomes. Survey readiness became a full-time job—not because of CMS requirements, but because of layered demands from legacy accrediting organizations (AOs).
What does Accreditation Theater look like?
- Punitive survey practices: Instead of partnering with providers, some accreditors focus on “gotcha” findings, rigid scoring, and performative enforcement.
- Non-essential standards: Requirements that go far beyond CMS Conditions of Participation (CoPs) but add little to no value in care delivery.
- Subtraction by addition: Adding layers of complexity or duplicative standards, only to later remove them for PR credit—without actually simplifying the provider experience.
- Engagement window dressing: Repackaging basic support services as bold innovations, while still charging top dollar for what ACHC includes for all customers.
- Transparency confusion: Using selective performance metrics and dashboards that obscure real accountability or value.
- Updated, but outdated: Modernizing standards language without changing the outdated, top-down survey approach that alienates provider teams.
What’s the risk?
- False sense of security: The illusion of quality through procedural rigor, without advancing meaningful change.
- Wasted resources: Staff time, labor, and funds spent preparing for excessive survey expectations instead of improving patient outcomes.
- Burnout and mistrust: Repetitive and competitive processes leading to staff disengagement and skepticism about accreditation overall.
What healthcare actually wants (and deserves)
Organizations and clinicians are demanding more from accreditation—not in volume, but in value. They want:
- Clear alignment with CMS Conditions of Participation/Conditions for Coverage.
- Collaborative, respectful, educational survey experiences.
- Support for continuous improvement—not just compliance policing.
- Accreditation that fits their reality—not an inflated checklist.
ACHC: Built for the moment others are chasing
ACHC never needed to pivot—because we never imposed the burdens others are now trying to walk back.
With ACHC you get:
- Standards tied directly or indirectly to CMS.
- No duplicative reporting or proprietary scoring matrices.
- Built-in engagement with an ACHC Account Advisor and education team.
- Access to clinical and life safety experts.
- Surveys rooted in partnership, not punishment.
- Clarity and consistency from the moment you engage.
The question in 2025 is not, ‘Who is reducing burden?’ but ‘Who never imposed it to begin with?’”
Real accreditation leads to real progress
Accreditation should empower, not encumber. While others market changes as innovation, ACHC continues to lead with clarity, consistency, and commitment to meaningful quality improvement.
Let’s leave Accreditation Theater behind—and move healthcare forward, together.