What Surveyors Look for in a Hyperbaric Accreditation Survey

Undergoing a UHMS Hyperbaric Facility Accreditation survey represents a major milestone in demonstrating that a facility provides safe, consistent, and clinically appropriate hyperbaric care. Surveyors approach the evaluation with a structured methodology, and although each organization uses its own checklist, their priorities are remarkably similar. In almost every survey, five major areas form the backbone of the review: safety, clinical operations, staff competency, the quality program, and facility standards. Let’s review each one of these areas.

Safety Program and Compliance

Safety is the foundation of hyperbaric medicine, and surveyors devote significant time to ensuring that a functioning, well-maintained safety program is in place. They will look closely at how the facility plans for emergencies, how it manages risk, and whether its written policies accurately reflect what clinicians and technicians do daily.

During the survey, the team will examine how the facility protects patients, staff, and equipment during operations. They often begin by reviewing written safety policies and confirming that they meet NFPA 99 standards. Surveyors expect the facility to have a formal safety program that is reviewed and updated. They may then compare these written expectations to real-world performance by asking staff members how they would respond to specific events—such as a fire inside the chamber, a medical emergency, rapid decompression, or an electrical failure. The goal is not simply that a policy exists, but that every staff member knows and follows it with confidence.

Equipment oversight is another critical component. Surveyors expect to find evidence that chambers undergo regular inspections, maintenance, and calibration. Daily and weekly logs should be complete, up to date, and free of significant gaps in dates. Maintenance tags, service stickers, and inspection records help demonstrate that equipment is actively monitored rather than addressed only when something fails. All of this reflects whether the organization is proactive or reactive in managing patient and staff safety.

Clinical Operations

In addition to examining safety, accreditation surveyors assess how care is delivered. They want to see that hyperbaric therapy is being offered to appropriate patients and that treatment decisions are medically justified. That complete documentation supports the clinical process from start to finish.

This begins with patient selection. Before a patient starts treatment, there should be evidence that a qualified provider evaluated the case and confirmed that the indication is accepted and recognized. A properly completed history and physical assessment should be found in the chart before the start of therapy. Surveyors expect treatment plans to be signed by credentialed physicians or advanced practice providers responsible for supervising the course of care.

Once therapy begins, documentation becomes central. Surveyors will review patient charts for a clear demonstration of progress. They will look for daily documentation describing how the patient tolerated the dive, whether the treatment was completed as ordered, whether therapeutic goals are being met, and whether any complications occurred. If the patient is being treated for a wound, surveyors expect wound evaluations and photographs to be updated regularly. Informed consent must also be present and must meet legal and professional documentation standards. Ultimately, surveyors approach documentation with a simple philosophy: if it is not documented, it is considered not done.

Staff Competency and Training

A hyperbaric service cannot operate safely if staff are not adequately trained. For that reason, surveyors will examine the credentials and competencies of everyone involved in the treatment process. They will review orientation materials for new hires, ensuring that onboarding includes both clinical and safety-related components. Facilities are expected to conduct annual competency evaluations to confirm that each team member can safely operate chamber systems, respond to emergencies, and deliver care in compliance with policies and regulations.

Surveyors may also review documentation of emergency response drills—such as simulated fires, patient issues, rapid decompressions, or chamber malfunctions. They want proof not only that these drills occur, but that staff reflect on them, identify opportunities for improvement, and incorporate lessons learned into practice. Certifications may also be verified, including BLS, ACLS, CHT, CHS, CHRN, and completion of recognized hyperbaric provider training programs. Surveyors understand that a well-prepared team is one of the strongest predictors of patient safety.

Quality Improvement Program

Accrediting organizations expect hyperbaric centers to operate within a structured quality improvement (QI) framework. A QI program is not simply a binder of historical meeting minutes; it should be an active, ongoing system for monitoring performance, identifying opportunities for improvement, and demonstrating accountability.

Surveyors want to see that the facility tracks meaningful performance indicators, such as adverse events, patient outcomes, delayed or missed treatments, equipment failures, and patient satisfaction trends. The program should include regular meetings, typically monthly or quarterly, during which data are reviewed and discussed by leadership and clinical staff. If something goes wrong—such as a safety breach, a medical emergency, or a significant equipment failure—the facility should conduct a root-cause analysis, determine how the issue occurred, and develop corrective actions to prevent it from happening again.

Peer review may also be examined. Surveyors will look for evidence that physicians and advanced practice providers periodically review clinical cases, reflect on care quality, and document these activities. A mature quality program demonstrates that the facility is continually learning, improving, and adapting—not just preparing for accreditation day.

Facility Standards and Environmental Safety

Surveyors will conduct a physical site tour to ensure the treatment environment supports patient and staff safety. They will examine the placement of chambers to ensure adequate clearance for safe ingress and egress. Ventilation, grounding, alarm systems, and overall cleanliness will be inspected. Surveyors will also ensure that oxygen cylinders and related materials are stored securely and in accordance with applicable codes and regulations.

Emergency exit pathways should be unobstructed and clearly marked. Patient care areas should be orderly and free of unnecessary clutter. A clean environment does more than present well; it reflects attentiveness, discipline, and proper operational control.

Preparing for a Successful Survey

Preparing for a hyperbaric accreditation survey is best done gradually, through consistent maintenance and continuous reinforcement of expected practices. Facilities typically benefit from conducting internal mock surveys, ideally conducted by someone not involved in everyday operations. A fresh set of eyes often reveals risks or compliance gaps that busy staff may overlook.

Documentation plays a significant role in helping surveyors navigate the program. Many facilities maintain an accreditation binder or digital folder containing policies, procedures, training files, maintenance logs, drill reports, QI summaries, and credentialing files. When documentation is well organized and readily available, surveyors can complete their work more efficiently, and the facility appears disciplined and prepared.

Training and staff confidence are equally important. Surveyors often ask employees direct questions about safety processes, emergency responses, or clinical protocols. Staff members who provide clear, accurate responses demonstrate mastery of their environment, which reflects positively on the facility.

What a High-Quality Hyperbaric Quality Program Looks Like

A strong quality program is data-driven, consistent, and connected to both patient care and operational performance. It includes a written QI plan describing how performance is evaluated, who is responsible for monitoring progress, and how corrective actions are developed. The program should demonstrate measurable results—trends over time, improvements made, and issues resolved. In mature programs, staff at every level understand the QI process, and participation is not limited to management.

A credible quality program reviews not only adverse events but also near misses, recognizing that preventing harm before it occurs is a sign of a well-functioning safety culture. Leadership engagement is also essential. When administrators, medical directors, and clinical staff regularly interact with performance data, the program becomes an active tool for shaping daily operations—not an exercise performed only when surveyors arrive.

Conclusion

Hyperbaric Facility Accreditation is not simply a review of regulatory requirements; it is a structured measure of whether a facility has a culture of safety, accountability, and professionalism. By maintaining strong clinical oversight, training competent staff, proactively managing risk, and documenting all aspects of patient care and operational performance, hyperbaric centers can not only succeed during surveys but also elevate the quality of care they provide every day.

Congratulations to these Facilities!

July 2025

Reaccredited:
Methodist Dallas Medical Center
Dallas, TX 

August 2025

Reaccredited:
Holy Cross Hospital-Jordan Valley
West Jordan, UT

September 2025

New:
*Essentia Health*
Fargo, ND

The Brain & Performance Centre
Dubai, UAE

Reaccredited:
*AdventHealth Orlando*
Orlando, FL

*Aurora Medical Center in Grafton*
Grafton, WI

*Aurora Medical Center-Manitowoc County*
Two Rivers, WI

*Aurora Medical Center-Oshkosh*
Oshkosh, WI

*Essentia Health Fargo*
Fargo, ND

Nuvance Health Danbury Hospital
Danbury, CT

Nuvance Health Norwalk Hospital
Norwalk, CT

*NYU Langone-Long Island*
Mineola, NY

*With Distinction*