A Practical Framework for Clinical Governance, Staffing, Safety, Documentation, Quality Improvement, and Survey Readiness
Accreditation provides an independent assessment of whether a hyperbaric oxygen therapy program has the systems needed to deliver safe, consistent, and clinically appropriate care. It evaluates far more than the condition of the hyperbaric chambers. The review extends to medical leadership, staff qualifications, patient selection, treatment documentation, fire prevention, equipment maintenance, emergency readiness, and quality improvement.
In the United States, the Undersea and Hyperbaric Medical Society, or UHMS, operates a voluntary specialty accreditation program for clinical hyperbaric facilities. Its evaluation examines the adequacy of the facility, equipment, personnel, training, clinical care, and safety systems. The current UHMS Clinical Hyperbaric Facility Accreditation Manual is the Fourth Edition. (UHMS)
Accreditation should not be treated as a certificate obtained shortly before a survey. The requirements are intended to describe how the program functions every day, including when equipment fails, staffing changes, a patient deteriorates, or a safety concern interrupts treatment.
Accreditation, Licensure, and Regulatory Compliance Are Different
Hyperbaric accreditation is not the same as state licensure, hospital accreditation, Medicare participation, or FDA device clearance.
A facility may be subject to several overlapping requirements:
- State healthcare facility and professional licensing rules
- Local building, electrical, medical gas, and fire codes
- Hospital or ambulatory facility accreditation standards
- FDA medical-device requirements
- CMS and commercial payer coverage policies
- Occupational safety requirements
- Hyperbaric specialty accreditation standards
UHMS accreditation is generally voluntary, although an organization, insurer, contracting entity, or jurisdiction may expect or require accreditation as part of its own standards. Facilities remain responsible for complying with all applicable laws and codes regardless of whether they pursue specialty accreditation. (UHMS)
Medicare coverage is also separate from facility accreditation. CMS defines covered HBOT conditions and establishes requirements for medical necessity, standard care, documentation, and continued treatment. A UHMS-accredited program must still meet every applicable payer requirement for each patient and claim. (Centers for Medicare & Medicaid Services)
The UHMS Hyperbaric Facility Accreditation Framework
The UHMS accreditation process evaluates the program as an integrated clinical system. The Fourth Edition manual includes standards and survey expectations across areas such as:
- Hyperbaric patient care
- Environment of care
- Patient education
- Quality improvement
- Professional performance
- Leadership
- Human resources
- Information management
- Infection prevention
- Medical staff involvement
Survey documentation may include policies, training records, personnel files, medical records, maintenance reports, fire plans, emergency procedures, quality data, meeting minutes, and evidence that the written program is followed in practice. (UHMS)
Accreditation is therefore not achieved by purchasing compliant equipment or adopting a collection of generic policies. Surveyors evaluate whether responsibilities are clearly assigned, staff understand those responsibilities, records support the care delivered, and the program can demonstrate that risks are identified and corrected.
Medical Leadership and Clinical Governance
A hyperbaric program should have a clearly designated medical director with defined authority and accountability. The medical director provides clinical oversight and helps establish the program’s scope of care, patient-selection criteria, treatment protocols, provider privileges, emergency procedures, and quality expectations.
The leadership structure should answer practical questions such as:
- Who determines whether HBOT is clinically indicated?
- Who approves and modifies treatment protocols?
- Who reviews adverse events and questionable treatment continuation?
- Who verifies that physicians and advanced practice providers are appropriately privileged?
- Who coordinates care with surgery, vascular medicine, infectious disease, oncology, and other specialties?
- Who has authority to suspend treatment when a clinical concern is unresolved?
Medical staff participation should be visible in the program’s records. Accreditation documentation may include provider qualifications, hyperbaric education, continuing medical education, privileging criteria, peer-review activities, and evidence of active medical oversight. (UHMS)
The clinical scope should also match the program’s actual capabilities. A center treating stable outpatients requires different personnel and emergency resources from a hospital program accepting ventilated patients, arterial gas embolism, decompression illness, or necrotizing infection.
A facility should not claim emergency or critical-care capabilities simply because its chamber can physically accommodate the patient. The complete medical, respiratory, nursing, technical, and surgical support system must be available.
Staff Qualifications, Training, and Competency
Accreditation requires the facility to define the qualifications and responsibilities of every hyperbaric position. Job descriptions should reflect actual duties, professional scope of practice, reporting relationships, and emergency responsibilities.
The staffing framework may include:
- Hyperbaric medical director
- Attending hyperbaric physicians
- Advanced practice providers when permitted
- Registered nurses
- Licensed practical or vocational nurses
- Hyperbaric technologists
- Chamber operators
- Inside and outside attendants
- Respiratory therapists
- Hyperbaric safety director or coordinator
- Program leadership and administrative personnel
Personnel files should demonstrate current licensure, certification when applicable, orientation, chamber-specific training, annual competencies, continuing education, and performance evaluation. The accreditation manual specifically calls for documentation of job descriptions, orientation, in-service education, staff-performance review, specialty continuing education, and defined nursing activities. (UHMS)
Completion of a foundational course does not by itself establish operational competence. Staff should demonstrate the ability to prepare patients, operate the specific chamber system, recognize complications, manage prohibited items, respond to alarms, and perform assigned emergency functions.
Competency validation may include direct observation and simulation of:
- Routine compression and decompression
- Ear or sinus pain
- Hypoglycemia
- Oxygen toxicity
- Seizure
- Chest pain or respiratory distress
- Loss of communications
- Power or gas-supply failure
- Emergency decompression
- Fire response and evacuation
The accreditation documentation also expects evidence that the hyperbaric safety leader has completed appropriate hyperbaric safety education. The current manual’s supporting-document list includes verification of an approved safety course and timely specialty certification after assuming the role. (UHMS)
Hyperbaric Safety Leadership
A designated hyperbaric safety coordinator is a central component of the safety program. NFPA 99 identifies this individual as responsible for hyperbaric equipment and the operational safety requirements applicable to the facility. (UHMS)
The role commonly includes oversight of:
- Fire-prevention policies
- Chamber-approved materials
- Prohibited-item controls
- Product and dressing risk assessments
- Preventive maintenance
- Staff safety education
- Emergency drills
- Equipment changes
- Incident and near-miss review
- Coordination with engineering and fire-safety personnel
The safety coordinator should work closely with the medical director, but the positions are not interchangeable. The medical director is responsible for medical governance, while the safety coordinator focuses on the technical and operational risks of the hyperbaric environment.
The safety coordinator also needs sufficient organizational authority. A person cannot effectively protect the program if they are expected to approve equipment and practices but cannot remove an unsafe item, postpone treatment, or take a chamber out of service.
Facility Design and Environment of Care
Accreditation surveyors evaluate whether the physical environment supports safe chamber operation, patient monitoring, emergency access, and staff workflow.
The program should be able to demonstrate compliance with applicable building and fire codes and provide documentation for:
- Chamber installation
- Structural support
- Electrical systems and grounding
- Oxygen and compressed-air supplies
- Ventilation and exhaust
- Fire detection and suppression
- Medical gas alarms
- Emergency power
- Chamber visibility and communications
- Patient and stretcher access
- Emergency egress
- Storage of approved materials
- Environmental monitoring
FDA-cleared hyperbaric chambers are Class II medical devices. The FDA’s device classification references NFPA 99 and ASME PVHO-1 standards associated with hyperbaric chambers and pressure vessels for human occupancy. (FDA Access Data)
The facility must follow the manufacturer’s instructions for the exact chamber model and associated equipment. A device, accessory, or maintenance practice that is acceptable for one system should not automatically be assumed acceptable for another.
The accreditation manual also expects a medical-equipment management plan, hazardous-materials policies, fire-protection planning, and documentation that personnel understand their responsibilities during an evacuation. (UHMS)
Fire Prevention Is a Core Accreditation Requirement
The possibility of fire is one of the most consequential hazards in hyperbaric medicine. Oxygen does not ignite independently, but an oxygen-enriched environment can make materials easier to ignite and cause fire to spread more intensely.
In its August 25, 2025 safety communication, the FDA advised HBOT facilities to follow manufacturer instructions, maintain fire-prevention measures, use appropriate grounding, train staff, monitor patients continuously, perform prescribed maintenance, control electrical and static-producing items, and use hyperbaric-compatible clothing. (U.S. Food and Drug Administration)
An accreditable fire-safety program should address:
- Facility-approved patient clothing and linens
- Cosmetics, lotions, hair products, and alcohol-containing products
- Wound dressings
- Electronic and battery-powered devices
- Implanted and external medical equipment
- Static electricity and grounding
- Oxygen leaks and local oxygen enrichment
- Chamber cleaning
- Emergency gas shutoff
- Fire suppression
- Patient evacuation
Every item introduced into the chamber should be approved through a documented process. Routine hospital availability does not establish hyperbaric compatibility.
The program should also conduct and document realistic emergency drills. Staff should know who controls the chamber, who stops oxygen flow, who manages decompression, who contacts emergency responders, and who protects other patients in the department.
Preventive Maintenance and Equipment Management
Accreditation requires evidence that chambers and related systems are maintained according to manufacturer instructions, applicable standards, and facility policy.
The maintenance program should include:
- Preventive maintenance schedules
- Inspection records
- Corrective maintenance
- Calibration and functional testing
- Chamber door and seal evaluation
- Relief-valve testing
- Grounding-system checks
- Communication testing
- Gas-system inspection
- Alarm verification
- Fire-suppression maintenance
- Return-to-service authorization
The FDA specifically advises facilities to follow manufacturer-recommended cleaning procedures, maintenance intervals, and safety checks for each HBOT device. (U.S. Food and Drug Administration)
Maintenance records should show what was inspected, who performed the work, what findings were identified, which corrective actions were completed, and who authorized the chamber’s return to clinical service.
A defect should not be normalized because the chamber remains operational. Unusual sounds, pressure instability, damaged seals, communication failures, oxygen-delivery discrepancies, or alarm problems require documented evaluation.
Patient Selection and Hyperbaric Clinical Care
Accreditation surveyors examine whether patient care is organized, evidence based, and consistent with the program’s stated scope.
The medical record should support:
- A recognized or clinically defensible indication
- Relevant diagnostic findings
- Previous standard treatment
- Patient-specific risks and contraindications
- The treatment prescription
- Informed consent
- Pre-treatment assessment
- Monitoring during treatment
- Treatment response
- Adverse events
- Continued medical necessity
- Coordination with other treating clinicians
The treatment prescription should identify the pressure, oxygen duration, treatment frequency, air breaks when applicable, and planned reassessment. Deviations should be documented and clinically explained.
For qualifying diabetic lower-extremity wounds, CMS requires documentation of diabetes, a Wagner grade III or higher wound, failure of an adequate course of standard care, and continued use of vascular assessment, offloading, debridement, glucose management, infection treatment, nutrition, and appropriate wound care. CMS also requires periodic reassessment and does not support continued coverage without measurable healing during a 30-day treatment period. (Centers for Medicare & Medicaid Services)
This illustrates why accreditation and payer compliance must function together. An excellent chamber operation cannot compensate for weak patient selection or insufficient clinical documentation.
Patient Monitoring, Rights, and Education
Patients should receive understandable information about why HBOT is being recommended, what treatment involves, what alternatives exist, and what risks may occur.
Patient education should address:
- Pressure sensations and ear-clearing techniques
- Expected treatment duration
- Chamber communication
- Fire-safety restrictions
- Approved clothing
- Medication and glucose instructions
- Potential adverse effects
- Circumstances that may interrupt treatment
- Symptoms that should be reported immediately
The accreditation manual includes a dedicated patient-education section and expects written policies or procedures addressing how education is provided. (UHMS)
Education should be documented in the medical record and adapted to the patient’s language, cognitive ability, developmental level, and health literacy. Patients should be encouraged to report ear pain, anxiety, congestion, medication changes, glucose symptoms, or newly introduced devices and dressings.
A patient should never feel pressured to remain silent because stopping compression or interrupting treatment is inconvenient for the schedule.
Infection Prevention and Medication Management
Hyperbaric departments should be integrated into the organization’s infection-prevention system while addressing chamber-specific issues.
The accreditation manual calls for documentation describing the facility’s infection-prevention program. (UHMS)
Policies may address:
- Chamber and stretcher cleaning
- Reusable oxygen-delivery equipment
- Linen handling
- Isolation precautions
- Wound drainage
- Indwelling lines and catheters
- Respiratory infections
- Multiplace chamber exposure
- Blood and body-fluid events
- Equipment shared between patients
Medication policies should clarify which medications may be administered before or during treatment, how medications are stored, and how chamber compatibility is assessed.
Special attention may be required for insulin, oral glucose agents, sedatives, anticonvulsants, intravenous infusions, vasoactive medications, and drugs that may influence oxygen-toxicity risk or cardiorespiratory stability.
Medical Records and Information Management
Accreditation requires more than complete individual treatment notes. The program should demonstrate an organized information-management process that supports continuity of care, quality review, and regulatory compliance.
Records commonly include:
- Hyperbaric consultation
- Treatment order
- Informed consent
- Daily pre-treatment assessment
- Chamber treatment log
- Oxygen and air-break periods
- Monitoring data
- Post-treatment evaluation
- Adverse-event documentation
- Wound or condition-specific progress
- Communication with referring clinicians
- Discharge or treatment-completion summary
The accreditation manual’s information-management requirements include review of hyperbaric records for documentation quality and timely completion. Survey documentation may include reports and summaries demonstrating that this review has occurred over the preceding year. (UHMS)
A documentation audit should evaluate substance, not merely whether a note exists. The record should make clear why HBOT was appropriate, what treatment was delivered, how the patient responded, and why treatment should continue.
Quality Improvement Must Produce Measurable Results
A facility seeking accreditation should maintain a hyperbaric-specific quality-improvement program. General hospital quality activity is not enough when it does not evaluate the risks and outcomes unique to HBOT.
Potential measures include:
- Middle-ear barotrauma
- Oxygen-induced seizure
- Hypoglycemia
- Unplanned decompression
- Treatment interruption
- Chamber downtime
- Prohibited-item interception
- Emergency transfer
- Documentation compliance
- Treatment completion
- Clinical outcome by indication
- Patient complaints
- Near misses
The accreditation manual expects documentation showing the scope of quality-improvement initiatives and the results produced. Leadership should also be able to demonstrate how recommendations are assigned, acted upon, and communicated to staff. (UHMS)
A quality project should move beyond identifying a problem. The facility should define the baseline, implement an intervention, measure the result, and determine whether the change was sustained.
Near misses are particularly valuable. An unapproved item discovered before treatment, an incorrect profile caught during the safety pause, or a maintenance discrepancy identified before chamber use may reveal a system weakness without patient harm.
The UHMS Application and Survey Process
The UHMS process begins with an application, presurvey questionnaire, and supporting documentation submitted through its accreditation platform. UHMS reviews the program’s materials before the formal survey. (UHMS)
The survey may include:
- Review of policies and personnel records
- Inspection of the physical environment
- Evaluation of equipment and maintenance records
- Interviews with leadership and staff
- Review of clinical records
- Observation of patient preparation and treatment
- Assessment of emergency readiness
- Review of quality and safety activities
UHMS surveyors collect information and report their findings, but the survey team does not make the final accreditation decision during the visit. (UHMS)
Programs may be asked to address identified deficiencies through corrective action. The safest approach is to treat each finding as a clinical or operational risk rather than as paperwork needed only to satisfy the accrediting body.
Accredited facilities must also maintain compliance after the survey. Material changes in chamber systems, facility location, leadership, clinical scope, or ownership may affect accreditation status and should be communicated according to current UHMS requirements. (UHMS)
Accreditation With Distinction
UHMS also provides an advanced “With Distinction” pathway for facilities meeting additional criteria beyond core accreditation.
Current guidance includes enhanced expectations related to medical-director qualifications and other markers of professional engagement and program excellence. Some criteria must be active at the time of survey, while others may be demonstrated through activity completed during a defined period before the survey. (UHMS)
This designation should be approached after the facility has built a stable foundation. Strong daily operations, reliable safety systems, complete records, and measurable quality performance remain more important than pursuing an advanced designation before core processes are mature.
Common Accreditation Readiness Gaps
Programs often struggle when written policies do not match actual practice.
Common vulnerabilities include:
- Expired credentials or incomplete personnel files
- Generic policies that do not match the chamber system
- Missing competency validation
- Inadequate safety-director documentation
- Poorly defined provider privileges
- Incomplete maintenance records
- No formal product-approval process
- Fire drills that are undocumented or unrealistic
- Weak medical-necessity documentation
- Quality projects without measured results
- Inconsistent review of treatment continuation
- Staff who cannot explain emergency responsibilities
Survey readiness should include direct observation. Leadership should watch the complete process from referral and consultation through patient preparation, chamber treatment, documentation, billing, and follow-up.
The most revealing question is often not, “Do we have a policy?” It is, “Can the staff demonstrate the policy without being coached?”
Building a Sustainable Accreditation Program
A practical readiness plan should begin with the current accreditation manual and a detailed internal gap assessment.
The program should then:
- Assign responsibility for each standard.
- Review facility, personnel, and clinical documentation.
- Correct physical and equipment deficiencies.
- Update policies to reflect actual operations.
- Validate staff competencies.
- Conduct realistic emergency drills.
- Audit patient records and medical necessity.
- Complete measurable quality-improvement projects.
- Perform a mock survey.
- Maintain the system after accreditation is awarded.
The goal is not a survey-day performance. It is a program that operates safely and consistently when the surveyors are not present.
For patients, accreditation provides an additional level of assurance that the center has subjected its clinical and technical systems to external review. For hospitals and healthcare organizations, it establishes a structured framework for managing a specialized service with significant medical, pressure, oxygen, and fire-safety risks.
