We Already Have Policies and Procedures. Will They Work for Accreditation?
Keep them if they describe how you actually operate. Map each element to a policy and a record, and rewrite only where the policy misses what the element requires. Three separate questions are in play: whether your policy says what the element requires, whether the process it describes meets the element, and whether you can produce records showing it was followed. A policy binder can answer the first. It does not answer the second or the third.
The framework below, three failure modes and five dispositions, is this page's own. URAC and ACHC are cited only where named.
The gap is one of purpose. A manual written for internal operations tells staff what to do. An accreditation manual must also let a reviewer see that a published requirement is met.
Will our existing policies work for accreditation, or do we have to start over?
Map what you have against the element language. Keep the policies that already carry the substance. Rewrite the ones that leave a requirement missing or unclear, and write new ones only where nothing covers the requirement. If the operations your policies describe are sound, the work is closing the distance between how your manual describes the work and how the standard describes it.
ACHC makes the dual role of these documents explicit. In a March 3, 2026 article on developing policies and procedures for ambulatory surgery centers seeking ACHC accreditation, ACHC wrote that these documents do two jobs: they guide staff in daily work, and they are what a surveyor reviews to judge compliance. A manual written only for the first job will underperform at the second.
What makes an existing policy fail an accreditation review?
Existing policies fail in three distinct ways, and the fix for each is different. Either the policy does not clearly show what the element requires, or the policy is accurate and there is no evidence of implementation to produce, or the policy accurately describes a process that is followed but does not itself meet the element. Diagnose which one you have first. Rewriting a policy that was never the problem uses up the schedule and fixes nothing.
Language mismatch. What a reviewer would find: A term, timeframe, approval authority, or role the element names is absent from your policy, even though the underlying process is sound. What fixes it: Rewriting the policy against the element's own text.
No evidence of implementation. What a reviewer would find: The policy is correct, but the minutes, training records, audit results, or case files that would show it operating cannot be produced. What fixes it: Nothing in the policy. The gap is operational and dated, and drafting now does not close it.
Process falls short of the element. What a reviewer would find: The policy accurately describes what staff do, staff follow it, and the records show it, but the process itself does not deliver what the element requires. What fixes it: Changing both the process and the policy. Rewriting the policy alone would describe a process that still falls short.
Only the first failure mode is a writing problem. The second is an implementation problem: either the work was done and the records are missing, or the procedure was not followed. A binder can look complete until someone asks for the file behind it. A policy states the intention. A record shows whether it happened. Neither substitutes for the other.
The third failure mode is a process-design problem, and faithful execution does not cure it. A policy that is accurate and consistently followed can still fail if what it prescribes is not what the element asks for. An illustration, not a cited element: the element names a particular approval authority, your policy accurately says a different role approves, and everyone follows it. Complete records of that practice show the gap clearly. That is this page's inference, not a cited rule.
The first failure is a content-and-clarity problem. An illustration, not a cited element: the element names a 30-day timeframe and your policy says "promptly." A reviewer reading against the element text can miss the required component and score the element not met. That is this page's inference, not a cited rule.
URAC made the point about implementation in a 2022 URAC webinar. It warned that an organization whose practice departs from the procedures it filed for Desktop Review can fail at Validation Review.
Do we need a separate policy for every standard?
For URAC, no: one policy can satisfy several elements at once. In a September 28, 2022 URAC webinar on policy and procedure writing, URAC said organizations need not write one policy per standard; a single document can cover several standards or elements.
A large program does not need a proportionally large manual. Make every element traceable to a policy and to evidence that the activity happens, and identify any missing activity for correction. Make each required component easy to find in the document. Using the element's own terms helps with that.
How do we tell which policies to rewrite and which to keep?
Work element by element, not policy by policy. For each element, find the policy language that satisfies it. Then ask whether the process the policy describes meets the element, and separately what record would prove it happened and whether that record exists. For each element, one or more of five dispositions applies:
policy and evidence are both adequate: keep them and map them;
the policy is the gap: rewrite it;
the policy accurately describes a process that is followed but does not meet the element: change both the process and the policy;
the work was done and the records are missing: locate the missing records;
the procedure was not followed: correct the operation, then build the record going forward.
This mapping decides whether the rest of the work is drafting, records recovery, process redesign, or operational correction. What makes it hold up:
Match the element's own words, including defined terms, timeframes, and named approval authorities. That way the reviewer does not have to infer that your wording is equivalent.
Name the artifact that would evidence each element and who owns producing it, before you touch the prose.
Read every document you plan to submit against each element it is meant to cover. In the same webinar, URAC advised checking each submitted document against the intent of every standard it is offered for.
Apply the reviewer's question to every document. URAC frames it from a staff member's seat: reading the document, would one of your employees understand the task and the organization's expectations?
A policy a new employee could not act on gives a reviewer little to score.
What this is NOT
Not a claim that your policies are worthless. If your policies describe sound operations, starting over discards what already works.
Not a formatting exercise. Reformatting a manual or standardizing templates addresses none of the three failure modes described above.
Sound operations are not enough on their own. A sound operation still risks being scored not met when the documentation or the evidence is missing. Where a procedure was not followed, the operation itself needs correcting.
Not legal advice, and no substitute for your accrediting body's current standards documentation.
Not universal rules across accreditors. Every requirement and element citation here is scoped to the body, program, and document cited. The URAC and ACHC material cited here comes from different programs and documents, and each body sets its own review structure.
Not a statement of any body's fees, file-sample sizes, or submission deadlines. None appear here because no source consulted for this page published them.
Sources
Each source below was retrieved on October 17, 2026. Standards change; confirm any requirement with your program's current documentation or the body itself.
URAC, "Getting Started with Policy and Procedure Writing: Practical Tips for Success," webinar, September 28, 2022 (PDF), https://www.urac.org/wp-content/uploads/2022/09/URACPolicyProcedureWorkshopSlideDeck.pdf
ACHC, "Developing Comprehensive ASC Policies and Procedures," March 3, 2026, https://achc.org/developing-comprehensive-asc-policies-and-procedures/
Sources retrieved October 17, 2026. Text revised October 28, 2026.